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Hi, it s Elise Lunen, host of Pulling the Thread.
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Today is a special episode, the second of a four-part series on addiction.
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I m joined by addiction MD Carl Eric Fisher, who is also in recovery himself.
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Hi, it s Elise Lunen, host of Pulling the Thread.
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On this show, we pull apart the web in which we all live to understand who we are and why we re here.
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Pulling the Thread is about big questions.
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Why we do what we do, how we can understand our own experiences within a larger spiritual and historical context,
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the ways in which we might begin to understand ourselves and each other better, and what s required to heal ourselves and our world.
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I ll be joined in conversation by luminaries and wise elders, those who have laid tracks on their work and lives to help us bring meaning and understanding to a world that often feels chaotic and overwhelming.
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My hope is that these conversations spark moments of resonance and plant tiny seeds of awareness so that we might all collectively learn and grow.
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I want to say that it s not just some idea about suffering, it s also a function of social and economic systems that are deliberately weaponizing an individualized view of suffering as a technique.
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As a strategy, the thing I found across eras and eras and eras in the book is that addiction supply industries, which is what one scholar calls them, like the alcohol industry, the tobacco industry, they constantly come back to this hyper-individualization as saying, you know, like, the problem is not in the bottle, the problem s in the person.
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If so many people can drink, quote-unquote, normally, that means the problem is really with these sick people over here.
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And that happened with tobacco, and then
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Very directly and deliberately, things like the processed food industry and other modern addiction supply industries have used the same language.
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So says Carl Eric Fisher, an addiction psychiatrist, bioethics scholar, author, and person in recovery.
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Carl is also an assistant professor of clinical psychiatry at Columbia University, where he teaches law, ethics, and policy relating to psychiatry and neuroscience, particularly where they converge with substance use disorders and other addictive behaviors.
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He hosts a podcast called Flourishing After Addiction and is launching a substack where he ll organize his thinking around treatment paths and modalities.
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Most pertinent to our conversation today, Carl is the author of The Urge, Our History of Addiction, which is a fascinating deep dive into our long cultural fascination with addictive substances interlaced with his own story and stories from his practice.
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In fact, the book opens in Bellevue, where Carl is not functioning as a doctor.
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In this case, he s the patient, after suffering an addiction-induced manic episode that put him into recovery.
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Carl is brilliant and kind, and also fluent in all the prevailing science about addictive behavior, science that really hasn t ruled the day until recent years.
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Instead, the addiction space has been one of binaries,
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You re compulsive or you exercise choice.
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You re normal or an addict.
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You have no control to stop or you have all the control and refuse to use it.
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And on and on and on.
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We get into all of this in today s conversation.
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First, thank you.
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I mean, I learned so much about the history of addiction, and I loved watching your mind in the process of writing this book.
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And we re primarily going to talk about the beginning of the book and the end of the book and how you think about addiction as a practitioner and someone in recovery today.
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But I do want to know, as you explored the history of addiction, was that really to understand your own mind?
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Were you looking for examples of people who you could map your own experience to?
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More the former than the latter, I would say.
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It was definitely to understand my own mind and my own situation and the problems I was confronting.
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It was less to find models.
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I did find models and there were interesting people throughout history that I identified with.
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And I think a lot of their stories are beautiful grounds for hope and the prospect of change and the prospect of living with and working through addictive behaviors, you know, like,
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Chinese scholars in the 16th century and the funny pre-AA, 12-step, like pre-modern era mutual help groups.
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Those are really beautiful stories, but it was more the first part of what you said.
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It was more about just understanding the intellectual history of addiction.
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What is this idea of addiction?
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How do I make sense of the notion of addiction?
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What does addiction mean to the extent that I have an addiction?
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What does that say about me?
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Because I saw in myself and in the people around me and in some of the problems I was navigating, just a lot of different ideas about what addiction was.
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And very early on in the process of making sense of my own addiction felt like it would be useful to go back
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and to sort through some of those messy, conflicting, you know, sometimes in like direct opposition to one another ideas.
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Yeah.
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I mean, you start with this essential binary, right, which creates certainly confusion and also probably inhibits a lot of people from
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seeking help or pursuing moderation or even engaging in that introspective question of is this too much or do I have a problem, right?
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Which is the way that our culture characterizes people as either addicts or somehow safe or more complete or is it called a crisis?
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Yeah, I ve heard professional philosophers describe it both ways, which makes me feel more comfortable about my own pronunciation, Akraja.
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But yeah, that weakness of the will, that sort of loss of control, yeah.
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Yeah, which is this idea that an addict is somehow an aberrant or deviant individual who lacks all self-control, rather than I think we re getting to the place where we can acknowledge that we all live on this spectrum.
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It s still so bound, yeah?
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Like, you are or you re not.
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And it s still a concept that escapes an easy definition.
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So I got into recovery because, and I m grateful for the fact that this happened to me safely, and it s a function of privilege that it happened to me safely.
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But I was psychiatrically hospitalized for a substance-induced manic episode during my psychiatric residency.
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And so I was brought to NYU, and I was hospitalized there.
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where I d interviewed for a residency.
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And so up to that point had been thoroughly baked in the notion that I was one of the healthy normals, and I was always on the other side of that glass or the other side of that interviewing table.
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And then all of a sudden, I was one of them.
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And so I met that essential binary.
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And
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It really helped me to break down that binary because I saw very quickly how it wasn t working.
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It wasn t working for me or for other people to have this clear, bright dividing line between, you know, there s lots of things you could put in opposition to addiction.
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Addiction versus healthy, addiction versus safe, addiction versus free.
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But I think the most toxic form of that binary is addiction versus normal, as if there is a normalcy apart from addiction.
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Because as you mentioned,
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ancient times up to the present, the most nuanced and thoughtful philosophy says that we all have this thing inside of us that we have some impairment to control.
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Our control is not unlimited.
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It s actually a modern fantasy.
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It s a neoliberal notion of like the perfect economic actor in some ways, that we should be able to perfectly control all of our
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little actions and plans.
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That s one of the ways that looking at the history helped me to unravel ideas about addiction, that I needed that historical context.
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It was very helpful for me, not just in understanding the nuts and bolts and the logic of it all, but to get a really clear, heartfelt, visceral sense that something had gone wrong in the way we think about humans as agents, as people who are struggling with something.
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Yeah, that s a beautiful way to think about it and so helpful.
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Because it s interesting, I think you note that denial is not part of any sort of DSM.
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I don t know how helpful the DSM is really anyway, but it s not part of a criteria of diagnosis.
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But this was a stunning statistic.
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in your book that only 5% of people with substance use admit or acknowledge it?
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And some of the stories are just stunning.
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The young, I think he was in his 30s, the man who ultimately died from hypothermia but had been in the ER hundreds and hundreds of times.
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Is the denial entrenched simply because the binary exists and there s no room for people to explore the question without feeling like they re stepping into an identity that they
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don t want.
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That s a big part of it.
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I don t think it s all of it.
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I think that denying
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can certainly be exacerbated by overly reductionistic essentialist idea that there are sick people over here and healthy people over there.
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So when there is a really strong focus on normalcy, and when
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having an addiction or another form of mental suffering is held up as some sort of awful outcome, then yeah, people will cling really tightly to a story of themselves about normalcy.
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They ll say, I couldn t possibly identify as somebody with an addiction problem because that ll be terrifying.
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That feels life-ending.
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It s a fate worse than death.
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And that s a function of stigma.
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And even more fundamentally, it s a function of that really clear
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division between us and them.
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But I don t think in some perfect future, if we somehow arrived at a much more compassionate view of addiction, that nobody would have denial.
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I think there are many examples of people struggling with denial, including at times where I would say, in the past, there was a more nuanced and thoughtful view of addictive problems.
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And I think that s just basic human delusion that people can have a sense that they are engaging in a harmful behavior that is really hurting them.
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And yet they see no other option.
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And it feels unsafe to even look at the pattern.
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You know, I see that over and over again as a clinician.
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And you have to be deeply, deeply compassionate about that.
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That s just part of the self that s just like clinging on to some sort of imagined safety, even if it s not actually safe.
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I m Rachel Martin.
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Your exploration of sort of choice and choosing I think is so beautiful because sometimes there s this idea of like sort of automatons, right?
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I think it s Susan.
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I can t remember the name of the woman, the patient that you write about.
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And you write about her in the context of just like the desperation that she feels as she s watching herself choose something that she doesn t want.
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Can you talk a little bit about choice here?
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And you tease this out.
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Is it compulsion?
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Is it choice?
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Is it somewhere in between?
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And how do you think about that?
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Yeah, thank you.
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I think that s a key starting point that I ll never get tired of reiterating, is that we have this tendency to create another essential binary between total choice and completely hijacked compulsion.
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And that means total freedom on one end, total enslavement on the other.
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And I use that word intentionally.
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And that s harmful too.
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That s a misleading binary too.
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Because as anybody with addiction will attest to, it s not as if you just woke up one morning and you got zombified by the drug.
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There is an intimate relationship with addiction.
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choice and planning and thought and lots of ambivalence.
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People can feel one way and then act the other way.
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And to paint it as choice versus compulsion is just so oversimplified and misleading.
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I think it s really dangerous.
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It s not a matter of having no choice or being choiceless.
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It s a matter of misguided choice or choice that s been misled or warped in some way.
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And that patient you mentioned, Susan, described this really well, but it s something I felt in myself.
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It s something I ve seen countless times since where somebody says, I m very clear on what I want to do and very clear on what I don t want to do.
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And yet I see myself doing the thing I don t want to do.
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And I can t get myself to do the thing I want to do.
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I know in my heart, sure, I might have like an urge or a craving or whatever, but I know in my heart that I want to stay abstinent from drinking.
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And yet I see myself walking down to the corner store and drinking.
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Why is that?
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This is the mystery.
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I think it s a mystery at the heart of human life.
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That s the thing that all those ancient philosophers were pointing toward, but it is the key mystery at the heart of addiction is that kind of misguided choice.
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Why do we do the things that we know not to be good, that we know not to be what our hearts truly want?
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In a way, that s sort of what the nuance and the useful and the thoughtful writers about sin are writing about.
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When we look at
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certain elements of St.
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Augustine and others that followed.
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That s what sin is about.
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Sin is not about doing a bad thing versus doing a good thing in the true philosophical theological sense.
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Sin is about why do I do the bad even though I feel called toward the good?
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What is that about me that gets twisted up?
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Listen, I studied neuroscience at Columbia and I m big on neuroscience.
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There s some neuroscience in the book and I think neuroscience is useful.
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But one legacy of focusing only on neuroscience and reducing it only to the brain level is that we miss out on all those human nuanced, rich psychological factors and people get painted as a cartoon of just automata.
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Either you re choiceless or you re totally free.
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Yeah, I m also very interested in sin.
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I wrote a whole book about it.
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But this and St.
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Augustine too writes about lust, someone who has a sexual compulsion, which is also very interesting.
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But yeah, it is human.
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I mean, as you re talking about Susan, who is this, I think, at times functional sort of corporate business person, you write about her one time drinking like tons of vanilla extract.
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That s right.
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I mean the other day it s like the internal Conversation I had with myself at like 11 a.m.
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Over whether to eat an ice cream sandwich or not, right?
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Like this is alive and all of us like I recognize like it s not a great choice, but I really wanted it the more I denied myself The more I ate the ice cream sandwich.
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I did it not to minimize
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Susan, but we all have, this is human, this idea of some sort of ability to self-regulate in the face of highly tempting, sometimes dissociative, sedating, numbing, enlivening substances.
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And more than ever, it feels like we all need to understand and come to peace, not to reduce
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what is a very complex issue to sort of, oh, if we could find peace in ourselves, we would never have any addictions.
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But part of it is like understanding these drives and appetites and not denying them, but to recognize that this is who we are, right?
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Exactly, yeah.
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I think there s a lot of low-hanging fruit in addiction prevention.
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Like if we didn t horrifically traumatize people or expose them to abject poverty or fail to provide for their basic needs, that would be a very good addiction prevention program.
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And I know that s exactly what you re speaking to when you say that the self-love and the recognition of the internal conflict is not the whole story.
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But that s one thing I write about toward the end of the book, is even if we did everything perfectly,
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Even if we had all the right programs and we did all the supposedly right things, there would still be addiction.
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There s no cure for it.
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It s not like we cure it through the perfect social planning or we cure it through the perfect medicine, that there s something in us and it comes out in different ways for different people, sometimes severely and sometimes in a really subtle and almost kind of funny way.
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You know, like I had ice cream.
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I had two servings of ice cream last night.
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I write about ice cream in the book.
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I finalized that edit, I guess, two years ago now, more than two years ago.
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And, you know, probably there was a part of me that was like, Oh yeah, sure.
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By 2023, I ll have cracked the ice cream nut.
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And I haven t cracked it, but it s also not, it s not actively killing me today.
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So that s something, you know, but it s there.
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It s in all of us.
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We need that compassion toward that essential human vulnerability.
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It s there.
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Yeah.
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So you write about your own recovery throughout the book, which I thought those parts were quite fascinating.
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And you sort of locate what happened to you in the context of a family system, or I don t know if they talk about themselves in this way, but both of your parents have.
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alcohol, substance use, but didn t work programs, et cetera.
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When you talk about going to an AA meeting as a med student and refusing, again, like you were refusing almost a binary, which is interesting.
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And you write about how it was clear you weren t like those people or your parents and that you thought your problem, to quote you, was more sophisticated, something more complex and existential than a quote unquote disease like alcoholism or a psychiatric disorder like suicidal depression or debilitating OCD.
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You sort of talk about how those patients are the ones who are suffering.
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You re just medicating yourself through burnout.
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But that I think also gets in the way is particularly in the US where we re very alive and awake to levels of oppression, privilege, who has access to what can be sort of a like, I m fine, don t worry about me.
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I don t know how much, it seems like that was somewhat alive in you unless that was more of a defense mechanism.
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But can you talk a little bit about your own denial
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Yeah, that s exactly right.
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I mean, if I m hearing you right, you re talking about not just the core of the denial in terms of protecting the addictive behavior, but also
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the discomfort in fully owning whatever suffering I had.
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Yes.
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I think those can be distinguished.
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The latter is that if I have all the externals and have good friends and I m in a good med school and things seem to be going well for me, and my parents had their problems, but I was never beat or horrifically abused, then how dare I claim some sort of suffering?
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I should be able to just tough it out and go,
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harder and solve my own problems.
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That for sure was there.
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I had this feeling that I didn t deserve it.
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I didn t deserve to consider myself somebody who had struggled.
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And the cause doesn t matter.
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It s not because of my parents or because of genetics or whatever.
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It s just whatever brought me to that point, there was a notion
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This can t be that bad.
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I don t deserve to call this like real suffering.
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So that was part of the denial too.
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And that s a thing that is not 100% within me.
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I think that kind of waxes and wanes across history.
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That s a legacy of some of our more recent messaging around addiction.
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It s one of those negative byproducts of really focusing too much on a broken brain
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sort of disease idea.
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If it really is like a broken brain disease, then it doesn t make sense that somebody who s going to Columbia University Medical School, and otherwise functioning reasonably well, could have an addiction.
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But I certainly did.
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And I really had to work with that denial, not just to accept my identity that I identify with today of being a person with addiction and recovery, but to do the recovery part too.
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It s not just about admitting to, or not even admitting, because admitting is sort of a loaded and stigmatized term, but it s not even about recognizing the addiction, but it s also continuing on the process of recovery, that to really own
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my suffering and say, you know, like I had it hard in significant enough ways, or that I continue to have it hard in significant enough ways.
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Even while there s unimaginable pain and sorrow and devastation around us, certainly today, and also every day, the full catastrophe living that Jon Kabat-Zinn wrote about.
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There s an unimaginable suffering way worse than what I m going through.
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And also I get to wake up to my own suffering.
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Like I get to acknowledge my suffering as real suffering.
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That s a big one.
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I think it s especially big for people with addiction because shame is such a big part of addiction.
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It s really one of those powerful universals that, you know, I ve never met somebody with a significant addiction who didn t have a powerful experience of shame as well.
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And I think it s so beautiful, because what I do see, high-functioning addiction in our culture obviously is rampant, right?
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If 95% of people, a significant margin, I would imagine, of those people are still sort of moving through life functioning.
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But the way that, and I understand this instinct, and I have loved ones who are very much
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part of what you talk about that refuse to sort of acknowledge that anything could possibly be wrong.
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You know, Gabor Maté talks about this a lot, like, tell me you had a good childhood and let me ask you a few questions and sort of take it apart.
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really quickly.
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And I probably live in this world of quote unquote self-help, which is, you know, has its own stigma.
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And of course, we can sort of laugh at it.
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But there s a lot of it that s really important.
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I just would like it to be rebranded toward like personal responsibility, or something like this, which is,
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particularly for those of us who want to work toward bettering or serving the world, there s a fair amount of emotional hygiene, mental hygiene that s required, right, to attend to your own suffering on the regular.
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So you re not pushing it into some sort of shadow or suitcase and carrying it around and projecting it onto other people or asking them to carry it for you.
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And I don t know what the twist
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that s required is that allows, or how we move out of this, like who s got it bad, you know?
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I don t know how we move past that as not oppression Olympics, but this sort of like constant comparison or weighing our experiences against other people who we perceive to have it worse.
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But it seems like a big hurdle.
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Yeah.
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I want to say that it s not just some idea about suffering, it s also a function of social and economic systems that are deliberately weaponizing an individualized view of suffering.
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as a technique, as a strategy.
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The thing I found across eras and eras and eras in the book is that addiction supply industries, which is what one scholar calls them, like the alcohol industry, the tobacco industry, they constantly come back to this hyper-individualization.
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They re saying, you know, like the problem is not in the bottle, the problem s in the person.
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If so many people can drink quote unquote normally, that means the problem is really with these sick people over here.
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And that happened with tobacco and then
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Very directly and deliberately, things like the processed food industry and other modern addiction supply industries have used the same language.
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Not to mention the fossil fuel industry has too, and that s not even a psychoactive chemical, it s just a way of conveniently putting all the responsibility and the onus
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on the individual.
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And so it s not just a matter of like, oh, if we get the right psychological messaging, society will wake up and we ll have an awakening.
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SPEAKER_00
It s part of like Holly Whitaker s work too, which is how you and I got connected is just to wake up to the fact that there are extremely powerful forces that have a vested interest in making us feel like we are the problem, that I am the problem.
2
SPEAKER_00
And if only I toughened up a little bit, then I should be able to solve this.
2
SPEAKER_01
I want to talk to you a bit now about the way that our recovery ecosystem is set up and I want to talk to you about you sort of methadone and I know that there are a lot of prescriptions that I don t think people really even know about for
2
SPEAKER_01
alcohol and to help with cravings and sort of functional nutritional programs, etc.
2
SPEAKER_01
And maybe I m just oblivious because I m not in recovery.
2
SPEAKER_01
And this is certainly true that, and Holly and I talked about this at length as well, but there s so much anxiety and or control in the world of recovery that it wants to insist that it has to be a certain way.
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SPEAKER_01
And if you deviate from that,
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SPEAKER_01
you ll die.
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SPEAKER_01
And if you explore other options or ask questions about it, that you are going to cause someone else to die because you will implant in their head the idea that moderation or harm reduction or that there are other potential avenues to explore that would lead them back to the substance that they can t touch.
2
SPEAKER_01
So where do we start?
2
SPEAKER_00
I mean, we could start with a sort of knee-jerk stereotypical image that most people on the street probably have of entering recovery and getting help and getting treatment.
2
SPEAKER_00
You know, that 95% statistic you mentioned earlier, that s a really important statistic.
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SPEAKER_00
95% of people with a substance use disorder don t think they have a problem and don t want treatment.
2
SPEAKER_00
And so there s a lot of denial baked into that, but also baked into that could be the totally appropriate hopelessness about our existing treatment systems.
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SPEAKER_00
Maybe people don t want treatment because they ve been poorly served by our existing treatment systems.
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SPEAKER_00
There are some real problems.
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SPEAKER_01
Yeah.
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SPEAKER_01
Can t go to rehab for 30 days.
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SPEAKER_01
I invested in this company called North Star, which is a different way of doing it, where you can continue your life without going away.
2
SPEAKER_00
That s great.
2
SPEAKER_00
Yeah, because there are financial interests baked into that stereotypical idea, too.
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SPEAKER_00
It didn t necessarily start that way.
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SPEAKER_00
Yeah, the stereotypical idea people have is exactly what you say.
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SPEAKER_00
You go away for 30 days, you get cured, you come back.
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SPEAKER_00
You have some sort of transformative experience, which enables you to come back to your home and get a sponsor, get a home group, do a 90-90, you know, do all the traditional AA stuff.
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SPEAKER_00
And then people rightly say it s just an extended introduction to a free program.
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SPEAKER_00
So if that s all you re providing, then it s not a problem.
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SPEAKER_00
There s not a good solution.
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SPEAKER_00
So, you know, that stereotypical image is not the only solution out there.
2
SPEAKER_00
There are very good addiction psychiatrists and addiction medicine doctors who can provide an integrative and holistic assessment of other problems that people might be having, whether it s other mental health problems or other things that need addressing.
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SPEAKER_00
There are different forms of therapy.
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SPEAKER_00
There are intensive outpatient programs.
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SPEAKER_00
But these are often not accessible to people because they re either geographically limited
2
SPEAKER_00
Or especially as we ve seen since COVID, there are massive waiting lists and just not a lot of availability providers, or of course, insurance coverage in our broken system.
2
SPEAKER_00
The important thing about this is that sort of core of the 28-day rehab came about in history because there was a total vacuum, because we were totally unprepared to provide for addiction problems.
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SPEAKER_00
For example, in like the 1920s, 1930s, 1940s.
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SPEAKER_00
And we re basically in a similar situation today.
2
SPEAKER_00
It s sure as heck is better than a hundred years ago, but it s not great.
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SPEAKER_00
We still have massive shortages of physicians overall and of professionals.
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SPEAKER_00
And when you do go to a treatment program, you don t get the kind of integrative, holistic wraparound care.
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SPEAKER_00
that people really need.
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SPEAKER_00
So we have a problem both of access, period, and a problem of access to the proper sort of diversity and patient-centered flexibility.
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SPEAKER_00
that the best science shows us we really do need in addiction medicine.
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SPEAKER_00
And I mean, we could have like a whole, you know, eight hour seminar series on problems with the addiction treatment complex, but that s at least a starting point.
3
SPEAKER_01
I know that there are sort of disruptive forces within it and that there are more options that have emerged, but it seems like it s hard to break through because there is such a stronghold on one path, which again probably contributes to denial, right?
3
SPEAKER_01
Like I m putting myself into the position of if I needed
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SPEAKER_01
I don t know that I could even acknowledge, I couldn t even functionally get to the place of saying like, oh, okay, I ll just leave my work, leave my family, I have the privilege, I have insurance, right?
3
SPEAKER_01
But there s so many hurdles that feel so big, right, for so many people who are probably on the line.
3
SPEAKER_01
It s interesting in reading so many addiction memoirs and your work, Maya s work, that everyone has in their mind their own idea
3
SPEAKER_01
Right?
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SPEAKER_01
Like you are in an inpatient treatment facility sort of convinced that you need to get out of there.
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SPEAKER_01
For Maya, it was a moment where she was contemplating prostitution for drugs.
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SPEAKER_01
That to her was the line that showed her she had an addiction.
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SPEAKER_01
She couldn t grapple with that.
3
SPEAKER_01
Can you talk a bit about that?
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SPEAKER_01
Like what you think it is in people s minds that inhibits them from seeing themselves as needing some sort of intervention?
3
SPEAKER_00
Yeah, I do think it s going to be different for different people as just those examples between me and Maya.
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SPEAKER_00
But we can think about some of the different forms that that inhibition can take, like what gets in the way of somebody seeing that they have a problem.
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SPEAKER_00
You know, one thing might be that the diagnosis and the recommendations are being met with are not the good ones.
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SPEAKER_00
They re not the right ones for them.
3
SPEAKER_00
So as an example, when I went to treatment, I was ready to go.
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SPEAKER_00
I wanted to go to outpatient treatment, but you know, by and large, I was prepared to go and get treatment at the point that I kind of came out of my psychotic mania and recognized that I was an alcoholic and wanted help.
3
SPEAKER_00
I said, sign me up.
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SPEAKER_00
Like I need help.
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SPEAKER_00
Like I m ready to say that I need some sort of intervention.
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SPEAKER_00
And then I got to an inpatient treatment facility that was much more old school than
3
SPEAKER_00
the NYU inpatient facility that I started off at.
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SPEAKER_00
I mean, they were very hardcore.
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SPEAKER_00
Not everyone.
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SPEAKER_00
There are some people who are really compassionate, but there were also some people who were very old school, very confrontational, very much in the mindset like, you know, I m board certified in addiction medicine, but my real specialty is trouble and you boy are trouble.
3
SPEAKER_00
People were telling me I was a liar and doing a hair test for drugs and saying, yeah, I know I m going to find something else.
3
SPEAKER_00
What are we going to find?
3
SPEAKER_00
And I was sitting there saying, you know, I m telling you the truth.
3
SPEAKER_00
Like I actually do want treatment right now.
3
SPEAKER_00
So somebody is operating with a hoyeristic based on an outmoded model of like needing to break people down.
3
SPEAKER_00
and build them back up again.
3
SPEAKER_00
And so that was the thing that was feeding my denial for sure.
3
SPEAKER_00
It wasn t all on me.
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SPEAKER_00
It wasn t all that like it was self-generated.
3
SPEAKER_00
There can be a mismatch between what someone actually needs and what s being offered out there.
3
SPEAKER_00
And that comes up a lot because we were just talking about the way that there are options out there, but most people don t get
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SPEAKER_00
exposed to them.
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SPEAKER_00
Most people think it s just rehab and that s the only thing.
3
SPEAKER_00
And once again, rehab worked for me, you know, once I got past that sort of like confrontational hardcore stuff.
3
SPEAKER_00
And once I had a little time and just took what I needed from it and really connected with the other patients who were there.
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SPEAKER_00
which was the thing that really worked for me, that was really helpful for me.
3
SPEAKER_00
But for me today, as an addiction clinician, it s absolutely essential that I recognize that my own lived experience does not dictate what everybody else s should be.
3
SPEAKER_00
Other people will have different pathways.
3
SPEAKER_00
They ll have different pathways and different experiences, but they will need different things.
3
SPEAKER_00
And it s that kind of humility that we sort of lost in the treatment.
3
SPEAKER_01
Well, I think it just speaks to the myriad versions of people with different variations of addiction and then the myriad paths.
3
SPEAKER_01
You know, we need a more individualistic system and a little bit more grace maybe for people as they navigate through this.
3
SPEAKER_01
Can you talk a little bit, I thought this was so fascinating, about the RAND study and then also the work of the Sobels?
3
SPEAKER_01
Because this is wild to me.
3
SPEAKER_00
Oh, yeah.
3
SPEAKER_00
I ll just say it briefly.
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SPEAKER_00
I d love to hear what you love about it too.
3
SPEAKER_00
But by the 1970s, there was a lot of interest in medicalizing and professionalizing traditional recovery.
3
SPEAKER_00
And so there is a really powerful, what one former senator called the treatment industrial complex.
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SPEAKER_00
the traditional rehabs and that s basically the legacy of the system that we have today.
3
SPEAKER_00
This treatment industrial complex that was very invested in a sort of old school binary of you re an alcoholic or you re healthy normal, that there s a quote-unquote pickle line that you cross like past this point, you re not a cucumber anymore, you re a pickle.
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SPEAKER_00
That s the way people would actually talk about.
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SPEAKER_00
I ve heard that in recovery meetings and in treatment centers.
3
SPEAKER_00
So I heard it at an addiction conference that I went to last week, by the way, by one of the speakers.
3
SPEAKER_00
I mean, it s just preposterous to me because it flies in the face of the science and some of that science was being done back in the 1970s.
3
SPEAKER_00
So the very early days of the National Institutes of Alcohol Abuse and Alcoholism, which is a terrible name that they haven t renamed yet.
3
SPEAKER_00
Back then, the NIAAA didn t just do research, they also did treatment.
3
SPEAKER_00
And so they collected a lot of data about the very early waves of addiction treatment in the United States.
3
SPEAKER_00
And one of the key questions they were looking at is what happens to people when they return to moderate drinking?
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SPEAKER_00
And so it went to the RAND Corporation.
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SPEAKER_00
The RAND Corporation, people might know, is a think tank that s very closely allied with the government in Santa Monica.
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SPEAKER_00
And so they sent off all of these like punch cards
3
SPEAKER_00
old school data, and they processed it.
3
SPEAKER_00
And what the researchers found is that there was a significant portion of people who, even when they were diagnosed with very severe alcoholism, seemed to be able to return to moderate drinking without major problems.
3
SPEAKER_00
Now, of course, there are people out there who returned to moderate drinking and had terrible problems.
3
SPEAKER_00
And in my own personal recovery, that s not a gamble I m willing to take.
3
SPEAKER_00
I ve been abstinent from alcohol for a very long time now.
3
SPEAKER_00
And is there a percent chance that I could return to healthy moderation?
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SPEAKER_00
Maybe.
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SPEAKER_00
I don t know.
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SPEAKER_00
I m not interested in making that bet.
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SPEAKER_00
The point is some people will do that.
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SPEAKER_00
And it s very good to know the science of what actually happens and what the risks are.
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SPEAKER_00
And so when the RAND report
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SPEAKER_00
was in a preliminary stage, word kind of leaked out to some of the nonprofits and advocacy groups and allegedly some of the governmental actors that were involved in the whole process.
3
SPEAKER_00
And there was a really powerful effort to suppress the report.
3
SPEAKER_00
They said, this is dangerous, exactly what you were talking about earlier.
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SPEAKER_00
This is dangerous.
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SPEAKER_00
We can t give people the message that they might be able to return to moderation, because even if that s true, it s going to mislead a lot of people and cause a lot of deaths.
3
SPEAKER_00
And it became
3
SPEAKER_00
a huge public relations battle, there were sort of warring press conferences, one by the Rand Corporation, one by the opponents, and it got extremely vicious.
3
SPEAKER_00
And it sort of set the ground for the Sebel thing, which is basically just that some researchers found that if they trained people in behavioral approaches to try to moderate drinking, that it was somewhat helpful on the margins for some of those people.
3
SPEAKER_00
There s not a profound
3
SPEAKER_00
discovery, but it flew in the face of the orthodoxy.
3
SPEAKER_00
The orthodoxy said, once an alcoholic, always an alcoholic, it s irreversible.
3
SPEAKER_00
Not only is it permanent and necessarily progressive, it s irreversible, meaning there s nothing you can do to alter the course of this problem.
3
SPEAKER_00
Well, the Sobels found that that wasn t true, and they were subjected to a tremendous range of personal attacks and lawsuits and efforts to totally destroy their academic careers.
3
SPEAKER_00
And you know, lucky for them, they had enough of an academic record that they went to Canada, and they went to one of the best addiction research programs in the world, affiliated with the University of Toronto.
3
SPEAKER_00
And if they were a little bit earlier in their careers, maybe they would have been successfully assassinated.
3
SPEAKER_00
Character-wise, not literally, who knows.
3
SPEAKER_00
That s interesting because we still have those same fights today.
3
SPEAKER_00
All that happened in the 1970s.
3
SPEAKER_00
It was interesting to me to put in the book because we had the exact same battles today about the science doesn t count, or the science isn t true, or even if the science is true, we can t say what it actually is because it might mislead people.
3
SPEAKER_00
I think that s totally dehumanizing to people with substance use problems.
3
SPEAKER_00
You know, I think people want to know the truth.
3
SPEAKER_00
And by the way, the genie s out of the bottle.
3
SPEAKER_00
And there s plenty of books, much more skeptical than mine, that are out there using this data and talking about it.
3
SPEAKER_00
So we might as well approach it head on.
3
SPEAKER_00
But even I have gotten some blowback about talking about those types of studies.
3
SPEAKER_01
Yeah, but I think to your end, and maybe this is accurate, but this idea of being close to many addicts, some who venerate AA and feel like it absolutely saved their lives and, you know, myriad paths and others who feel like outsiders within their own recovery because they didn t do it in a traditional way, but there s so much pressure this
4
SPEAKER_00
like fear, this control over the whole experience and being open and speaking about your experience that it will somehow negate someone else s or give someone else a quote unquote an idea that s dangerous feels quite suppressive.
4
SPEAKER_00
And it limits, I think, the amount of people who are willing to be creative or explore what this could mean for them.
4
SPEAKER_00
I understand a tendency to be like, not for me, I don t have a problem.
4
SPEAKER_00
I m not engaging with any of this because it feels like a life sentence, I guess, that you re in a guillotine and that at any minute the blade s coming down to take off your head.
4
SPEAKER_00
It just doesn t seem like it gives anyone any room or grace.
4
SPEAKER_01
Right.
4
SPEAKER_00
And can you talk a little bit about methadone, suboxone, which is a life-saving intervention for so many, and yet it s still very stigmatized.
4
SPEAKER_00
And I know it s also hard to access, right?
4
SPEAKER_01
Yeah, I guess the thing I d like to say, because there might be people listening who are sort of wondering about the place of medications if they re struggling with control, that there are many FDA-approved, perfectly safe medications that help people with cravings and urges and problems, not just for opioids, but also for alcohol.
4
SPEAKER_01
And some of those are things like Antabuse, where you could take it with a partner.
4
SPEAKER_01
It kind of helps by making alcohol cause a bad reaction, so it s unpleasant.
4
SPEAKER_01
Others, for some people, regulate craving and desire.
4
SPEAKER_01
but not in a way that makes you into a totally desireless zombie.
4
SPEAKER_01
And we vastly underutilize those and alcohol kills tons and tons of people as well, you know, so that s another failure.
4
SPEAKER_01
But when it comes to opioids, there are a lot of things that are really helpful.
4
SPEAKER_01
I think the 12 step is really useful for a lot of people.
4
SPEAKER_01
with opioid use problems.
4
SPEAKER_01
I think that traditional therapy is really good.
4
SPEAKER_01
I think that there are many other alternative therapies such as therapeutic communities or whatever else.
4
SPEAKER_01
Whatever works fine.
4
SPEAKER_01
That s great.
4
SPEAKER_01
But scientifically speaking, the only things that have been proven to reduce death
4
SPEAKER_01
is suboxone, aka buprenorphine, and methadone, period.
4
SPEAKER_01
Regardless of what your views are about their effects on recovery or whether that counts as sober or not, blah, blah, blah, like all that stuff is a downstream question.
4
SPEAKER_01
You know, so it gets me really annoyed when people start talking about like whether something qualifies as true sobriety.
4
SPEAKER_01
Like bottom line is we re in the middle of a massive overdose epidemic.
4
SPEAKER_01
It s only getting worse year on year on year.
4
SPEAKER_01
It s topped 100,000 people this year.
4
SPEAKER_01
There s no sign that it s getting any better despite all our best efforts.
4
SPEAKER_01
Like we need expansion from the top down, but we also need just a broader recognition that these drugs save lives, period, full stop.
4
SPEAKER_01
They can be hard to access.
4
SPEAKER_01
Methadone in particular is hard to access because of a legacy of racialized controls that arose in the 1970s and a lot of stigma attached to it.
4
SPEAKER_01
That s gotten a little better during COVID.
4
SPEAKER_01
It needs to get a lot better a lot faster.
4
SPEAKER_01
I m sure Maya will talk about this as well.
4
SPEAKER_01
Maya Svalovitz, who talks a lot about harm reduction and democratizing care.
4
SPEAKER_01
But there s also, you know, there s hope for Suboxone as well.
4
SPEAKER_01
You know, I think the pandemic
4
SPEAKER_01
even though it s drastically increased the rate of death from substance use problems, has also democratized care for telehealth, and there s more and more telehealth options for suboxone, which is a useful option.
4
SPEAKER_01
Again, like some people might have like a stigma, like this is not real recovery, or it s not the answer.
4
SPEAKER_01
What I just want to say is that these medications save lives and then a lot of people get the opportunity to recover and then the opportunity to pursue other paths and find the version of recovery that works for them.
4
SPEAKER_01
My clinical practice, I take people off Suboxone, you know, not cavalierly.
4
SPEAKER_01
It s a big decision.
4
SPEAKER_01
It has to be done super slowly, but it s not a life sentence.
4
SPEAKER_01
It s just a thing that you do for a period of time to regulate your risk and to save lives.
4
SPEAKER_01
It s heartbreaking that these tools are so underutilized.
4
SPEAKER_00
Yeah.
4
SPEAKER_00
No, I know people who have tapered very slowly with psychiatrists off of Suboxone.
4
SPEAKER_00
It s a hard, long process, but it s also, again, something you can also stay on, right?
4
SPEAKER_00
And you can get it as a shot.
4
SPEAKER_00
Is that accurate?
4
SPEAKER_00
For every six months or something?
4
SPEAKER_01
Yeah, there are long-acting formulations.
4
SPEAKER_01
There s a sort of surgical implantation and then there s also a shot.
4
SPEAKER_01
And those are more and more available.
4
SPEAKER_01
You know, I heard apparently in certain rural areas of Canada and Australia, like the rate of long-term suboxone uptake is like in the 20, 30%, even 40% in some places where it s harder to do daily oral medications.
4
SPEAKER_01
And so there s real promise there.
4
SPEAKER_01
You know, there s real opportunities to make that better and to expand access there.
4
SPEAKER_00
And for people who don t understand how that drug works, it doesn t make you high.
4
SPEAKER_00
It just keeps you out of, not out of withdrawal, but you can t really take opioids, right?
4
SPEAKER_00
Like, they don t work.
4
SPEAKER_01
Exactly.
4
SPEAKER_01
Yeah.
4
SPEAKER_01
There are subtleties that we probably don t need to get into of methadone versus buprenorphine.
4
SPEAKER_01
But the bottom line is these are very long-acting medications.
4
SPEAKER_01
Methadone, for example, it takes like three to five days to build up to a steady state.
4
SPEAKER_01
And so it just exists in your body and it s at a high enough concentration, just at a basic, steady, stable level that if you were to take other opioids on top of it,
4
SPEAKER_01
It barely nudges the needle and that prevents people from the big highs and the low lows and the constant cycle of withdrawal and drug seeking and all the rest.
4
SPEAKER_01
And, you know, people can use on top of these medications to get a little bit high.
4
SPEAKER_01
It happens, especially as we get these more potent drugs like, like fentanyl and carfentanil.
4
SPEAKER_01
So it s not a perfect magic bullet, but it sure helps a lot.
4
SPEAKER_01
And the drugs themselves don t make you high.
4
SPEAKER_01
Some people, you know, I think we should be clear about what the actual downsides are.
4
SPEAKER_01
They re not without downsides.
4
SPEAKER_01
Some people feel a little bit of emotional numbing on the margins, and that s a big motivation to get off suboxone.
4
SPEAKER_01
Some people feel a reduction in sexual desire, and that s true for other psychiatric medications too.
4
SPEAKER_01
So let s not get too stuck into a binary of like drugs good, no drugs bad.
4
SPEAKER_01
But for somebody who s an active opioid addiction, it s just such a, there s no debate.
4
SPEAKER_01
whether it s worth it or not.
4
SPEAKER_01
And again, these things are not necessarily permanent.
4
SPEAKER_00
What do you think it is in our culture that s so aesthetic in a way that s so, again, this is the podcast episode about binaries, but this like idea of being clean, right?
4
SPEAKER_00
Being untainted, being sort of unmedicated, or even though
4
SPEAKER_00
you know, we re all constantly changed by our environment, by like the chemistry of our food, for example.
4
SPEAKER_00
But what do you think that that comes from?
4
SPEAKER_00
And that was the immediate backlash to methadone, right?
4
SPEAKER_00
Like this isn t, again, I think you said it, this isn t real recovery, you re not really clean.
4
SPEAKER_00
It s that somehow this idea
4
SPEAKER_00
And there s the same debate about psychiatric medicines and SSRIs, which are really helpful for some people, not helpful for other people.
4
SPEAKER_00
But there s this idea in our culture that you should be completely unmoderated.
4
SPEAKER_00
You should be a pure vehicle, vessel, container, which is kind of impossible.
4
SPEAKER_00
But what do you think that is?
4
SPEAKER_01
Well, one of the big strands where that comes from is definitely from early, early American Christian evangelism.
4
SPEAKER_01
And that s why I spent a good portion of the book writing about the Second Great Awakening and the first big temperance movement in the 19th century.
4
SPEAKER_01
I think there s a really clear through line to people once you look into that history of how it relates to today and some of those inherited ideas about purity and which are really ideas about like godliness and
4
SPEAKER_01
Being free of sin.
4
SPEAKER_00
Yeah.
4
SPEAKER_01
Yeah.
4
SPEAKER_01
And so Christian perfectionism was a name of a movement in that period of time.
4
SPEAKER_01
And I got to that not because I m some sort of religious scholar.
4
SPEAKER_01
I mean, far from it.
4
SPEAKER_01
I actually was pretty allergic to the Christian faith that I was raised in, in certain ways.
4
SPEAKER_01
But when I was researching the history of abstinence and the history of the temperance movement and the history of things like prohibition, it all led back to the first.
4
SPEAKER_01
There was a second temperance movement that preceded prohibition in 1900s, 1910s.
4
SPEAKER_01
But there was a temperance movement before that, like the 1820s, 1830s, 1840s, and that was way bigger, actually.
4
SPEAKER_01
And the reason that got so big as an anti-alcohol movement was because it was linked to this broader Christian perfectionistic movement that basically said that you proved your godliness through your own individualized action.
4
SPEAKER_01
through your own personal effort is a bit like prosperity gospel is like a way of justifying post facto like, oh, this person is rich, then it must be godly and like show that show your worth by going out and achieving.
4
SPEAKER_01
We also see today in terms of like hustle culture and a lot of
4
SPEAKER_01
you know, the weird messaging we get about money and independence.
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But I think that, you know, out of that time period and that kind of uniquely American individualistic perspective on spirituality and religion, we got some ideas about cleanliness, and about how to prove your worth.
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A lot of people have written about this in interesting ways.
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One framing that actually did not make it into the book that I really love is there s a bioethicist earlier on in the 20th century who called this the battle between psychotropic hedonism and pharmacological Calvinism, which is just a complicated way of saying that we swing between these poles of free-for-all hedonism, use whatever
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who cares, like very Wild West cowboy-esque.
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And then on the other end, pharmacological Calvinism is the idea that like, oh, through my suffering, I prove that I m godly.
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If I manage to stay completely unsullied by any substances, and that proves that I m sort of like a higher, more evolved
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individual.
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And we, yeah, we have trouble in the United States and in North American culture and Western culture in general, finding that healthy middle ground between the two where like, you know, substances are always here.
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They ll always be a part of it.
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That s what I found through the historical research.
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We ve had drug epidemics going back at least 500 years.
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Uh, we re never going to eradicate them or stamp them out.
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So we need to find a way of working with it in the same way.
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We need to find a way of working with the addiction that we were talking about before.
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Do you have any thoughts about Ibogaine and other psychedelics and ayahuasca, et cetera, and any role you think they might ultimately play in addiction?
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I know with Ibogaine, they re working to isolate hallucinogen from the drug that blocks cravings, et cetera, and sort of helps people skip withdrawal.
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But do you have any thoughts about where you think that might lead us, or are you concerned about it?
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Well, you know, I m always concerned when there s hype because there s going to be people who are misled or sort of reify the substance.
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Yeah.
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Addiction is really complex.
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You know, it always exists at the intersection of multiple causes and conditions.
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I ve seen a lot of people benefit tremendously from psychedelics and from
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you know, other more sort of novel, holistic, plant-based approaches.
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So I think there is a lot of promise there.
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We need research to validate that.
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I think that a lot of people in the psychedelic research community are a little disappointed in the more recent wave of trials on alcohol use disorder, for example.
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You know, the early phase of, say, like Michael Pollan-era work was very positive about existential distress in people with a terminal cancer diagnosis, for example.
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Very, very big results.
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huge, huge results in terms of alleviating mental suffering.
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And then the substance use disorder studies are not quite as promising, and maybe that s because those folks are a little more severe, they re more adversely selected.
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You know, the people who are facing existential distress, they haven t necessarily
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live for years in the mental health treatment system, they maybe don t have as heavy a load of trauma or adversity or otherwise.
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So I am careful about the hype.
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I don t think that they re a one size fits all solution.
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But for people who use it as part of a comprehensive, holistic, balanced, individualized, personalized program of care, by all means, you know, what s the problem?
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Yeah, and then finally, I mean, obviously your book, your work, but for those who are sort of sober curious or maybe feel like they need to engage, where do you think people should start?
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I should mention, you know, obligatory plug that I ve got my own podcast and it s called Flourishing After Addiction.
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And it s in part to answer that question because I didn t see a ton of other very clear answers to that question.
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And it s called Flourishing After Addiction because, you know, there s a lot of people who identify as in recovery, but there are other people who don t even necessarily think of themselves as in recovery.
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You know, I talk, for example, with Zach Siegel, who s a
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a journalist who focuses a lot on drugs, had a serious opioid problem, and he s gone the more medical route.
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He takes medications and he goes to his psychiatrist and he says, I don t identify with recovery because for me that feels like it s over here as part of this different community.
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Even though if he said he were in recovery, he for sure qualifies.
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That s one option.
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I think that it s really about finding your people, and it s easy to find your people if you fall in with traditional recovery and you like the 12 steps, and it s harder to find your people otherwise.
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But I would say to people that when it comes to connecting with other human beings in the real world and or over Zoom, like there are other
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alternative mutual help support groups for people who are struggling with craving and control.
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There are things like Smart Recovery, Life Ring, SOS, the Buddhist Recovery Network, which is not just one thing, but a whole range of things for people who are interested in meditation and mindfulness as relates to
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substance use problems, there s moderation management.
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The point of these things is not that any one program has the perfect answer, but I think by going out there and engaging with the diversity of offerings, not to mention professional offerings like therapists, coaches, whatever, then you find your people.
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you find the people for whom this resonates or with whom this resonates.
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And then I ve seen a lot of people eventually when it clicks, they say, okay, now it makes sense, you know, it makes sense, because I saw it in somebody else, or I heard it in somebody else s stories.
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And so I would just encourage anybody who s out there who s struggling and looking for
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engaging in sober curiosity or otherwise, just go out there and try six different things.
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Because maybe the first five you think they re assholes or you don t like them.
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Just keep going.
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Well, thank you.
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And thank you for your book.
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And thank you for your work.
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And I m excited to see, are you working on another book?
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I haven t announced it yet, but I m planning on developing a sub stack on different varieties and frameworks for recovery for precisely this question, because I don t see a lot of really broad based spectra, like across the whole variety of recovery.
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I m a very organized kind of obsessional guy.
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So I thought it would be useful to just have a serialized set of writings, just going through different ideas about recovery, different frameworks for recovery.
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And in trying to break it down, not as if I have all the answers, but just to say, here s a diversity of ways people have thought about this issue and ways that it might make sense for you.
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I think that s great.
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Someone needs to organize all of this so that there s on ramps for people.
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Yeah, I think if you re a hammer, the world tends to look like a nail.
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That s a classic Abraham Maslow quote applied to psychology and psychotherapy.
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And when I was in early recovery, I wanted someone to break it down for me.
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Instead, I got people pushing their own pet theories.
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Which is all well and good.
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I m glad that there are people out there who are champions for their own individual pet theories.
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We need those people.
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But we also need synthesizers who kind of break it down.
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That s what I think a good doctor normally does, is they break it down and say, you know, here s what I think is going on.
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Here are the options available.
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Here s the whole span of things.
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And then maybe if I have a recommendation, here s the recommendation.
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But it s our job to present the whole menu, usually.
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I agree.
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Carl s book, The Urge, is fascinating.
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I took 22 pages of notes because he explores both his own story, the stories of patients,
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the long history of substances in our country, as well as policy and practical steps toward recovery.
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And what he is ultimately pushing is just to widen the aperture here, to open
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expand the lens in terms of understanding ourselves on this spectrum, recognizing that it s really not a binary and that there are myriad creative solutions that have emerged, will emerge.
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And for anyone who s listening who feels like, oh, not quite ready to commit to exploring what might be happening, this is the sort of book that I think creates space.
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and context and ideas for how to move forward outside of a traditional framework, which is wonderful for so many people.
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I don t, I don t want this series to feel like it s sort of picking on the establishment, but it could certainly evolve and grow.
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And I think we need more solutions and more access as well.
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If you liked today s episode, please rate and review and tell a friend.
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You can find show notes and full transcripts of the episodes at EliseLoonan.com.
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While there, please sign up for my sub stack.
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I send a short note every Wednesday about topics that are aligned with this show and a deeper dive most Sundays.
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Or follow me on Instagram at EliseLoonan.
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And finally, if you haven t already, please consider picking up a copy of my New York Times bestselling book, On Our Best Behavior, The Seven Deadly Sins and the Price Women Pay to be Good, available wherever you get your books.
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It s an exploration of how women have been conditioned for goodness, men for power, and all the ways we ve been programmed to police ourselves and each other according to these cultural ideas of what it is to be a good woman.
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I d also like to give a huge thank you to my sponsors who make this show possible.
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Please support them the way they support this podcast.
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This has been a presentation of Cadence 13 Studio.
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If you enjoyed this episode, please listen, rate, review, and follow Pulling the Thread.
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Available now for free on Apple Podcasts, Spotify, Odyssey, or wherever you get your podcasts.
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I want to give a shout out to Phil Svitek, Lauren LaGrasso,
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Mary-Kate McDonough, Ali Brockman, and the entire Cadence 13 team for producing these episodes, and to Valero Dabal for my key art.
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Take care of yourselves.
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I ll see you next time.