This review by Mick Sussman was published in The New York Times.
Sunday Book Review: A Disease, Not a Crime
It must be the purest agony to be the parent of a child succumbing to drug addiction. David Sheff’s previous book was an account of his son Nic’s descent from a thoughtful boy to a sullen pothead to a self-destructive methamphetamine fiend, and of his own tormented and bewildered reaction.
If that book, “Beautiful Boy,” was a cry of despair, “Clean” is intended as an objective, if still impassioned, examination of the research on prevention and treatment — a guide for those affected by addiction but also a manifesto aimed at clinical professionals and policy makers. Sheff’s premise is that “addiction isn’t a criminal problem, but a health problem,” and that the rigor of medicine is the antidote to the irrational responses, familial and social, that addiction tends to set off.
Sheff, a journalist, writes that America’s “stigmatization of drug users” has backfired, hindering progress in curbing addiction. The war on drugs, he says bluntly, “has failed.” After 40 years and an “unconscionable” expense that he estimates at a trillion dollars, there are 20 million addicts in America (including alcoholics), and “more drugs, more kinds of drugs, and more toxic drugs used at younger ages.”
Sheff says that drug addiction is a disease as defined by Stedman’s Medical Dictionary, since it causes “anatomic alterations” to the brain that result in “cognitive deficits” and other symptoms. But isn’t drug use an act of free will, distinguishing addiction from other diseases? Sheff responds that behavioral choices contribute to many illnesses: think of unhealthy diets and diabetes.
Like other diseases, addiction has a substantial genetic component. Mental illness and poverty are major risk factors. These susceptibilities help explain why 80 percent of adolescents in the United States try drugs, but only 10 percent become addicted. Sheff emphasizes the vulnerability of adolescents. Neuroscience corroborates our intuition that their impulsivity develops faster than their inhibitions, and drugs may stunt their emotional growth, making them yet more prone to addiction.
Although the medical approach to drug abuse has yielded techniques with proven effectiveness (Sheff’s touchstone is “evidence-based treatment”), he is scrupulous about not overselling it. “Addiction medicine isn’t an exact science,” he concedes, “and it’s still a relatively new one.” Treatment programs have success rates that are only comparatively less dismal than doing nothing. Just a small minority — even the claim of 30 percent may be inflated — of addicts who have been treated remain sober for a year. “The persistent possibility of relapse,” he says, is a “hallmark of addiction,” which he calls a chronic disease requiring lifelong vigilance. He laments the variable quality of treatment programs. Even in some expensive clinics, medical professionals are scarce, and the worst programs border on “voodoo.”
Sheff may lose some readers as he sprints through the research for every aspect (neuroscience, social science, psychology, law) of every stage (preventing early use, identifying abuse, detox, treating addiction, maintaining sobriety) of every drug problem. Though leavened by profiles of addicts and their healers, “Clean” feels overstuffed and miscellaneous, in the same way that a 300-page overview of everything we know about cancer would.
Nevertheless, Sheff is a skilled journalist on an urgent mission. He prevailed over the anger and hopelessness he felt at his son’s affliction by calling upon great reserves of love and discipline to investigate what might help — first as a father and then, in this book, as a reporter and an advocate. His forbearance and clearheadedness could serve as an example for America as it confronts its drug problem. He has performed a vital service by compiling sensible advice on a subject for which sensible advice is in short supply.