Substance abuse and addiction have reached epidemic proportions in the United States. Every day, on average, about 8,120 individuals age 12 and over try drugs for the first time and 12,800 try alcohol. About 60 million people binge drink. Mortality rates from abuse of prescription pills are skyrocketing. All-in-all, in addition to destroying families, devastating inner cities, and causing crime and car accidents, substance abuse is responsible for more deaths than any other "non-natural" cause.
In Clean: Overcoming Addiction and Ending America's Greatest Tragedy, David Sheff, the author of Beautiful Boy, a moving account of the addiction and treatment of his son, Nic, draws on research in psychology, neuroscience and medicine to present a new approach to dealing with what may well be our greatest social problem. Sheff insists that addiction is an incurable but treatable disease, not a moral failing. Since choice "has nothing to do with the disease," he emphasizes, it is counter-productive to exhort young people to "Just say no" or dismiss addicts as dissolute or undisciplined. Treatment must be based on evidence, not urban legends, guilt or wishful thinking.
Providing a wealth of information and practical advice, Clean is the best book on drug abuse and addiction to appear in years. Sheff's claims about choice, however, raise far more questions than they answer.
Clean busts a mountain of myths. People living below the poverty line, he reveals, are 100 percent more likely to abuse or be addicted than more affluent individuals. Sheff cites studies that show that the DARE program, which is used in 75 percent of the nation's school districts, may actually raise rates of drug use. He demonstrates that addicts will not respond best if they're allowed "to hit bottom." He makes a compelling case that "no one really knows how often AA works and for whom," and that we do know that AA retention is low and attrition is high. Although he cites no studies, Shef claims that "the science based approach rejects cold-turkey detox."
Sheff also makes specific recommendations about treatment options and how to make informed selections. He sorts out types of accreditation and licensing for facilities; favors programs where psychologists, clinical social workers and family therapists are "full-time and don't just stop by weekly" and psychological and physical examinations and medications (if necessary) are administered on site; and he advises nailing down ahead of time the assistance staff will provide with a transition to a new program when the patient is ready or he or she has been expelled.
Grounded in evidence of genetic predispositions and the effect of drugs on the brain, Sheff's main theme -- that addiction is a disease, not a character flaw -- does counter a pervasive and pernicious tendency to "blame the victim" (or the parents of the victim). But it leaves us struggling to comprehend the role of "free will" in resisting the disease.
In our judgment, Sheff is neither consistent nor clear in distinguishing between drug abusers and addicts or in finding a way to understand or explain the choices users make. Hard put to explain "why some people do stop using on their own," he speculates that members of this small group "aren't as addicted in the first place." His analogy, that "blaming an addict for relapse is like blaming a cancer patient when radiation and chemotherapy don't work," doesn't seem entirely appropriate.
Throughout his book, it is worth noting, Sheff acknowledges that choices are available to abusers and addicts. "Before a person can change his behavior," he writes, "[he] has to want to change it." Motivational interviewing "can help addicts understand the conflict between their life goals and their drug use." Given "cues" during Cognitive Behavioral Therapy, Sheff asserts, addicts can be taught to select alternative behaviors to defuse triggers -- like going for a run -- when they reach a "choice point." When Luke Gsell took Dramamine and drank beer while in rehab to celebrate his 15th birthday, came down from it, recognized he was an addict and vowed "I'm done with this," Sheff declares that "if he needed confirmation that his decision was a smart one, he received it the next day," when his roommate OD'd after taking 36 pills. And in the appendix to Clean, Sheff concludes, "If kids are to make informed choices about drugs, they need to have facts about them. They need to know what they're risking in order to get high."
Free will is an elusive and enigmatic concept. Although philosophers have gone free will hunting for centuries, they have never really understood why people choose what they choose. Nor is free will yet amenable to measurement by scientists. We believe that choice, as it is commonly understood, and as Sheff himself uses it, is relevant to the scourge of abuse and addiction, and to the tactics, strategies, and policies his extraordinarily valuable book lays out to help us to overcome them.
Glenn C. Altschuler is vice president for University Relations and the Thomas and Dorothy Litwin professor of American Studies at Cornell University.
Patrick M. Burns is associate director of Young Alumni Programs at Cornell University.