George Santayana’s aphorism “Those who cannot remember the past are condemned to repeat it” doesn’t make an appearance in this book. But it could well serve as the subtitle. For if ever a field should heed the lessons of history it is the making of policy on alcohol and other drugs, and their associated addictions. Carl Erik Fisher takes the reader on a vivid tour over several thousand years of multiple cycles of science, medicine and literature, woven together by the thread of the author’s own alcohol and amphetamine addiction and treatment. It is made even more emphatic and moving because he is also a psychiatrist who treats such patients.
At the end of 2021, the British government set out a “once in a lifetime” policy for tackling drug crime and drug use. It was a remarkable document not least because it contained no references to any previous research in this field – as if the last two millennia had taught us nothing. The authors of that report should now read this book and realise how wrong most of their ideas are, how their new vision will probably repeat a relentless cycle of failed policy approaches. Given that they are unlikely to do so, I will try to summarise the key messages from Fisher’s book.
Those are, first: don’t conflate drug use with addiction or even with harm – heed the research by Lee Robins on Vietnam vets, for example, which showed that most of those who used heroin in that war stopped once they returned to a normal life. Punitively extending the tentacles of drug-testing is harmful, because many will fail at some point, become marginalised and be driven from legal work into crime.
Second, abstinence isn’t the only – or even necessarily the safest – goal of treatment. We know this because of the major contribution of methadone and, more recently, buprenorphine to opioid addiction treatment, though neither of them are yet fully utilised. Third, do not “wage war” on drugs, because that instantly becomes a war on drug users, with poor, non-white and disadvantaged people the most likely victims.
Of course, none of these insights will be a surprise to experts in this field – they are established facts. But this book is not a polemic, and one of its pleasures is the succession of historical nuggets it serves up, many of which were unknown to me. For example, the word “addiction” was used for the first time in reference to chocolate. I was also unaware of the deliberate use of cheap alcohol to undermine Native American communities by the early white settlers. This led to the Code of Handsome Lake, the first mutual support group explicitly focused on addiction recovery in America, predating Alcoholics Anonymous by almost 150 years, and surviving to this day. Though I was familiar with the presumed role of cannabis and ephedra in the origins of Hinduism, I had not realised that gambling addiction appeared so early in literature, in the Rig Veda: hearing the sound of dice, the gambler rushes to them “like a girl with her lover”. He “goes to the hall of play asking himself, ‘Will I win?’ puffing himself up with ‘I will win!’”
The book is rich with similarly potent quotations, among them two that capture the different faces of alcoholism. This one from Edgar Allan Poe, who died very young from the effects of drinking, sums up the paradox of self-destructiveness: “the unfathomable longing of the soul to vex itself, to offer violence to its own nature, to do wrong for the wrong’s sake”. Whereas Caroline Knapp describes how “liquor occupies the role of a lover or constant companion”. William Burroughs recounts that “heroin is momentary freedom from the claims of the ageing, cautious, nagging, frightened flesh”. Which of us hasn’t had similar longings to escape?
And then there’s Fisher’s own remarkable story, which includes an amphetamine-induced manic episode during which he was Tasered by the police before being forcibly taken into detox. Months later, on his first weekend leave from rehab, he describes walking back into his lonely apartment and finding the Taser wires “tangled on the floor, like a loose, copper bird’s nest”.
The child of two alcohol and smoking addicts, he explores the reasons for both their and his vulnerability, though he cautions that “it is rarely useful to attempt to arrive at one major ‘cause’ of anyone’s addiction”. His mother, he writes, learned from her stressed immigrant father that “alcohol was a way to cope with a difficult world”. Even when she is dying from lung cancer she still drinks, though it messes with her treatments, and has an expert doctor as a son trying to stop her. His parents’ denial of their addictions translated into his own failure to recognise when his drinking had become out of control.
Fisher is now working as an addiction psychiatrist and medical ethicist, but still undergoes regular alcohol and drug testing that he feels helps keep him clean – though it hasn’t been as successful among other medical professionals in his treatment group. If testing often fails among these people, what hope has it with those who have little or no incentive? Fisher argues that non-judgmental encouragement and understanding is the right approach.
The book is thorough and revealing. It is largely US-centric, but, given the overwhelming influence that country has had in driving global drug policies, the narrative is still internationally relevant. Fisher’s personal saga, together with case studies of his patients, lend it an additional human depth. Pulling it all together is this final reflection, a mature view of the topic from someone with immense experience of it. “Addiction is profoundly ordinary: a way of being with the pleasures and pains of life, and just one manifestation of the central human task of working with suffering. If addiction is part of humanity, then, it is not a problem to solve. We will not end addiction, but we must find ways of working with it: ways that are sometimes gentle, and sometimes vigorous, but never warlike, because it is futile to wage a war on our own nature.” One can only hope the British government – and others like it around the world – is listening.
• David Nutt is professor of neuropsychopharmacology at Imperial College London and the former chair of the UK’s Advisory Council on the Misuse of Drugs. To buy a copy of The Urge for £14.78 go to guardianbookshop.com
