Addiction is a terrifying breakdown of reason. People struggling with addiction say they want to stop, but, even with the obliterated nasal passages, scarred livers, overdoses, court cases, lost jobs, and lost families, they are confused, incredulous, and above all, afraid. They are afraid because they cannot seem to change, despite the fact that they so often watch themselves, clear-eyed, do the very things they don’t want to do.
Fisher connects that eloquent description of addiction with the Greek word akrasia (“often translated as ‘weakness of the will’”). I’ve never dealt with substance abuse, but that last sentence perfectly captures a significant part of my teenage years and early twenties—it’s exactly the relationship that I, and many other devout Christian boys, had with pornography. At the end of the book, Fisher compares his own alcoholism with his patients who are “struggling with food, work, cheating, power, money, or anger”, seeing these problems as related:
We all suffer from a divided self, and we all have too much confidence in our judgment and our ability to exert power over our environments and ourselves.
Fisher favors a nuanced view of addiction: it has many causes and manifests in many ways and degrees; no single criterion can define the problem and no single solution is right for everyone. (Even the akrasia conception of addiction is not the whole story, he notes: it’s focused on the individual’s subjective perception of internal conflict, but substance use sometimes leads to problematic behavior even in people who feel no desire to change their habits at all.) Among other things, he argues:
It is misleading to draw a boundary between “physical” and “psychological” addiction, especially because that notion has long been used to suggest that a so-called psychological addiction is not a “real” addiction, often to the benefit of market interests and people in power.
Just shy of 20 percent of the men had been addicted to heroin in Vietnam … but only 1 percent were addicted during their first year back. In other words, 95 percent of people addicted to what was supposedly the most powerful drug in the world had simply stopped using. Over a longer time horizon, no more than 12 percent of the people who had been addicted in Vietnam relapsed at any time in the three years after their return.
heritability of addiction … ranges from about 25 percent to 70 percent
The book provides a taxonomy of “four broad approaches that have recurred throughout history” in society’s handling of addiction: “prohibitionist”, “therapeutic”, “reductionist”, and “mutual-help”, and discusses how these have been applied in several so-called drug “epidemics” throughout history (like 18th-century England’s “Gin Craze” and the 19th-century American opioid epidemic). It’s unsurprising to see harsh, moralistic responses in the past, but I was encouraged to see that more compassionate approaches have also been with us for a long time. (In its early years, for example, the prison and treatment center called the United States Narcotics Farm, which opened in Kentucky in 1935, was apparently quite enlightened.)
Ultimately Fisher advocates for a combined approach. Unsurprisingly, he thinks prohibitionism is too influential in the US. He also thinks our healthcare system is too prone to viewing addiction as outside the scope of ordinary mental health care and pushing addicts into a separate addiction treatment system.
One of the most eye-opening things for me in the book was the discussion of how industries that cater to people’s addictions, such as alcohol producers, can have a vested interest in propaganda and legislation that frames substance abuse as a moral failure on the part of a small subset of users, because this hurts their profits less than approaches that might actually lead to a widespread reduction in consumption.
…in the 1980s, industry groups funded organizations like Mothers Against Drunk Driving and Students Against Driving Drunk—groups that focused on individual responsibility and advocated retributive legal penalties rather than the systemic change, such as advertising reform, which was being championed by other consumer protection groups.