David Sheff’s Addiction Manifesto
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Authors in the addiction and recovery space don't come a lot bigger than David Sheff. The journalist entered this field involuntarily when he endured a parent's nightmare, as his son, Nic, became addicted to crystal meth and other drugs.
"My Addicted Son," a 2005 article by Sheff Sr. for the New York Times Magazine, resonated so much with readers that it gave rise to a memoir, Beautiful Boy. Published in 2008, that account of one family's struggle with an addicted member was a critical and commercial smash, topping the New York Times bestseller list and earning Sheff a nod in Time magazine's 2009 list of the world's most influential people, among other accolades.
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He says he considered writing his next book about something completely different, like architecture. But a sense of unfinished and urgent business drew him back. His new book, Clean: Overcoming Addiction and Ending America's Greatest Tragedy, tackles the subject in a very different way from Beautiful Boy. It’s Sheff’s comprehensive, meticulously researched analysis of the national problem and his call for potential solutions—with social, scientific and political dimensions. “His forbearance and clearheadedness could serve as an example for America as it confronts its drug problem,” wrote Mick Sussman in the New York Times review.
David Sheff was interviewed as part of a special event in his honor hosted by The Fix in Newport Beach, California.
As the author of Beautiful Boy and Clean, you’re inevitably seen as a standard-bearer for the US addiction-recovery movement. Is that a role you embrace willingly?
It's uncomfortable for me, so I don't like it. I'm someone pretty quiet at home. I'm a writer who works in a small room with a computer and I come out once in a while for a cup of tea, and that's pretty much it. So to go out and be in this situation is overwhelming. [The recent book tour] was intense. I can’t tell you how many people I met—you can tell, they just have this look in their eyes—they come up and tell you that their kids didn’t make it. Over and over again. What do you say? I just give them a hug and tell them how sorry I am. That gets hard. It happened so often and I was starting to find myself getting depressed.
On the other hand, it’s the greatest thing in the world to go out and talk about addiction and recovery. It feels really gratifying to be part of a conversation that needs to happen. Addiction comes with all this stigma and shame and guilt, so people don't talk about it. So the idea of coming to a place where they can be with people who get it—because we're there too, or we've been there—feels very powerful.
One major theme of Clean is that addiction must be seen as a disease. The relationship between addiction and choice is a tricky one for lots of people though, isn't it? People might accept that active addicts use because they're compelled. On the other hand, some people say you can “choose” recovery. How would you explain this apparent contradiction?
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This is one of the most important things that all of us in this world have to help communicate. I was one of those people: I heard talk about the “disease” and thought it was almost pathetic, an excuse for unconscionable behavior. Because it looks like a choice to use, to keep using even when your life is falling apart, or you're breaking into your family's home, as my son did. I started to research this and spent time with scientists, and saw pictures of the difference between addicts' brains and non-addicts' brains, and the explanation. I started to get it over time.
"Our silence equals death with addiction. If nobody knows how many people are affected, that people they love are affected and people they work with, why should they care?"
Once I started realizing that my son was not making choices, I went from being angry and judgmental to being able to look at him with compassion: He's sick; he needs help. It also allowed me to figure out what I needed to do: He's sick; he needs to be treated. I understand the resistance, because it doesn't look like other diseases. Cancer doesn't make you break into people's houses. People who have cancer want to get help. Addicts most often probably don't. But that's the nature of the beast.
They've done surveys and even doctors, even psychiatrists and psychologists wrestle with this. A lot don't get it; they just don't buy it. A lot of people who've gone to see a doctor, the doctor will scold them: "Just stop!" or, "Just go to a few AA meetings." These are people who are shooting heroin, and probably have other problems. It's not enough.
Is addiction a yes-or-no proposition? Are you either addicted or not? Or is addiction more accurately viewed as a spectrum, with a lot of grey areas in the middle?
I think it's a really hard question and a really good question. I have come to believe that there is a spectrum. What's the difference between somebody who goes into recovery—they'll go into a program, or to AA meetings and then they'll be fine, they won't relapse—and someone like my son, who is in treatment 10 times and ends up on the streets, shooting drugs and overdosing? What's the difference? That looks like there's a scale, that some people have a more severe case of addiction.
The researchers that I've spoken to sort of affirm that. There's been a lot of talk about the new definition of addiction in the community of psychiatrists—the DSM-5. It talks about a spectrum: It talks about "mild" addiction, all the way up to "severe." I think it's really useful. It explains more about why it's a disease; if some people can choose to get well, why can't others? Well, sometimes somebody has a really mild form of cancer and it goes away, or a very brief treatment will help. And sometimes that's not the way it works.
Here's one that Fix readers often fight about: Does "recovery" always mean total abstinence, or can it take other forms?
Nic was addicted to every drug. He went through tons of treatment programs. He got out, and would be sober for a while. Then he would think, like a lot of addicts do, "Yes, I'm addicted. I can't shoot heroin, I can't do crack, but, I can smoke pot and if I get stressed out it sort of evens me out." And he would smoke a joint. Then he would smoke another joint. And as he describes it, within a few days, he'd be out scoring some more meth. So he can't. Most of the researchers describe the way the brain works like a switch. And drugs, whatever kind, flip the switch, so craving begins.
But we don't know a lot. Let's say somebody ends up in treatment, and they don't use and they stay sober for a few years; I know people that [now] smoke pot or have a drink occasionally. Does that mean that they weren't addicted in the first place, or did they have a much milder form? It's a hard one. The ultimate answer is that everyone's different—but I think it's pretty risky to assume that it's ok.
Let's talk about AA. Again, our readers love arguing about the effectiveness and validity of 12-step programs. In Clean, you cite some figures, but conclude, "Nobody really knows how often AA works and for whom." Will we ever know?
One of the doctors I interviewed, this guy at UCLA, Steve Shoptaw, said "This is the place where science meets people." It's not an exact science. I think that AA, the 12 Steps, is profound—one of the most miraculous inventions, if that's what you call it, ever. It's saved millions of lives. It saved my best friend, who's been in recovery for 35 years.
I started to look at this again because of all the people I heard from—hundreds—who said that they, or the person in their family, relapsed over and over again and would not go back into treatment. Kids were just, "I've been there; I've done that. AA does not work for me." These teenagers are being told through the program to admit they're powerless and turn their lives over to a higher power. Part of being a teenager is, you're not going to turn your life over to anybody; teenagers feel all-powerful.
Does AA work? I've spent time talking to all the scientists who've researched this, and the conclusion I got is that yeah, AA works—for some people. For some people, it doesn't work. For some people, it's part of a program that includes other treatments too.
The only complaint I ended up having is about the insistence of some counselors in some programs that AA is a requirement and that it's the only way to get sober. That alienates people. They won't return to treatment, because they don't want more of the same thing. Counselors yelled at [Nic], like it was his fault because he wasn't doing it their way. Here's this kid who's sick, yet he's being yelled at—and if you don't practice the Steps, you're out. He was kicked out. And I was begging them to keep him, and they said, "No, you've gotta do it our way, and if you don't, here's a black garbage bag, you put your stuff in it and take a walk."
On the whole anonymity-in-AA debate, you write that strict interpretations of the 11th Tradition can have negative consequences for the recovery community, by keeping it in the closet. You add that addicts shouldn't be "outed." Do you applaud those AA members who choose to go public?
I think it's essential. As you said, I can't make that choice for any individual. But I lived in San Francisco during the '80s when AIDS hit. It wiped through our community and killed two of my dearest friends. There was stigma; people hid. And there was a community that said, "We won't accept this any more." There was the whole "Silence equals death" campaign. Our silence equals death with addiction. If nobody knows how many people are affected, that people they love are affected and people they work with, why should they care?
I did an interview for a magazine of one of the hippest young movie stars in the country. Beautiful Boy had come out and he said, "I love your book. How's your son?" We talked and he said, "If it wasn't for the program, I wouldn't be alive today." We talked about how he learned that you can have a great life, a better life than you ever imagined, when you're sober. He talked about the community of AA and the meetings he goes to. Then we continued and finished the interview.
"I endorse needle exchange completely. All of those things. Safe-inject sites are brilliant."
The interview was published and the phone rang. He'd gotten my number from his publicist, and he was freaking out. He said, "You betrayed my trust about me being an addict in recovery and it was all off the record. I cannot believe you did that." I would never print anything that was off the record; he insisted that it was. So I made a copy of the tape and sent it to him. He called up and apologized, and I said, "Why? You are a role model to kids. Wouldn't it be cool if you were to come out and say, 'I'm in recovery, and it's great?'" He was like, "No, it's a violation of the principle."
It's an individual choice. But I've been hearing people over and over again talking about this, and making the decision: I'm tired of hiding in the shadows. And I've never heard of anybody having a bad experience—it's the opposite. They're embraced and they're supported. It helps people in recovery because it affirms their recovery. It's awesome.
One program that has profoundly influenced you is Al-Anon. Could you tell me a bit about that?
When Nic got addicted, people said to me all the time, “Go to Al-Anon.” I was like, "There is no way I am going to go to Al-Anon." I had this image of people sitting in a circle whining in this pathetic kind of self-help thing.
But eventually—and it was a measure of how desperate I was—I went. As soon as I did, it was the first time I'd been in a room where I felt safe. People understood what I was going through. It was the support, but also lessons. About this idea that addiction is a disease. About how bad it can get. About how other families felt the same bafflement. A lot of the things you hear over and over become clichés and lose the weight of what they deeply are. This idea that addiction is a family disease—I didn't get it. I did get [that] this is a disease that devastates a family—we were devastated—but I didn't understand the part about the system that exists in a family. Over time it was life-saving.
In your book you note that harm reduction programs like needle exchange and safe-inject sites are associated with positive outcomes. Do you fully endorse them?
I do endorse needle exchange completely. All of those things. Safe-inject sites are brilliant. There’s one in Vancouver: Insite. When this doctor wanted to start this program there was uproar, you know, “It’s going to be a center where you’re condoning drug use, you’re making it easier.”
People protested [but] they were able to set up a pilot project. They thought it was going to bring up crime in the neighborhood, all kinds of calamities. The opposite was what happened. Crime went down. More addicts went into treatment and stayed in treatment. People were able to be in a place where they had a clean needle, and were with people that were going to take care of them. If there was an overdose, there was somebody there to save their life. They were trained people, therapists who would gently—not forcibly, people wouldn’t have come—guide people into treatment. That whole neighborhood is now safer.
In the US, when somebody was suggesting a clean injection site the then-drug czar [John P. Walters] said, “This is state-sponsored suicide.” It’s not going to happen here for a while. Needle exchange programs are here and they work. They’ve been shown to save lives. They don’t encourage drug use. Other experiments are going on around the world that are profound. It’s insane that we don’t consider them. This goes back to the same problem; we’re stuck in this world that says these are bad people, they have to be stopped and punished.
You agree with most in this field that the US war on drugs has been a failure. You agree with most Americans that marijuana should be legalized. Yet you write that you don’t advocate legalizing other currently illegal drugs. Why should the arguments that apply to marijuana not also apply to those?
I feel like we’re just not there yet. There’s a practical fact: Pushing for legalization of other drugs right now would kill any progress that’s being made on marijuana. And marijuana should be legalized for a million reasons—social reasons, health reasons.
There are experiments now in different parts of the world with legalization or decriminalization of other drugs, and the returns aren’t in—but it looks really promising. It looks like it doesn’t increase drug use, and fewer people die. So I am hopeful that we will evolve to a place where we will look at those things. But the returns aren’t fully in. I can’t imagine a time when we’re going to legalize crystal meth; maybe there will be some way to make it work, so people can get safe. There’s arguments even for crystal meth, or heroin: You’re going to get cleaner drugs, you’re not going to get people dying because they’re taking drugs that have been tainted.
And drug dealers don’t ID...
Yeah—but we’ve got to do a lot of research and education before that will happen.
In Clean you're quite damning about the US addiction treatment industry. You use words like "pseudoscience," even "voodoo," and write that "addiction medicine is 40 years behind where it should be." What's behind this disaster?
Everything goes back to this: If addiction is a disease, there's a system that we know to rely on, the medical model. You go to the doctor when you're sick. But if addiction is something else, if it's about morals, choices, then it's a completely different universe. This goes back forever: Addicts look like bad people; they’re the criminals. Most crimes in America are related to drugs and alcohol. There’s a whole treatment system that built up over the years based on this model that people need to be chastised. Nic was in programs where he would break a rule—not going to enough meetings or not cleaning up the dishes well enough. He’d have to get a toothbrush and go to the floor of the bathroom and clean the grout. If you’re sick, it doesn’t make sense.
"There’s no monitoring: In some states you need a license to open a coffee shop or laundry, but anyone can open a treatment center."
A lot of the programs that I’ve been to are started by the loveliest people; they so badly want to help. But their only training is that they’ve been in recovery for a long time. They hit bottom maybe and were desperate to get well. That’s all they think will work—their whole model is based on someone has to hit bottom. It’s just haphazard. I heard all kinds of things: Somebody told me to send Nic to boot camp. That’ll straighten him out—get him marching in the desert! It’s a system in disarray. There’s no monitoring: In some states you need a license to open a coffee shop or laundry, but anyone can open a treatment center.
Earlier today we were also talking about some of the exploitation and unethical practices involved in the treatment industry. How prevalent do you think that is?
I would say most in the industry are good people who want to help, but there are people who are just cashing in. Nic was in bad shape—the police were there and I convinced the officer to let him get into treatment. He was on meth and shooting heroin and pretty psychotic, and I didn’t know what to do. I called a program and they were way, way expensive and I couldn’t afford it. They gave me the name of another program and said “This is a good program”...I only later learned that they owned this other program they referred me to.
Nic ended up in sober living houses after treatment. Nobody told us but there were kickbacks: “If you go through my program, what do you do next? Well, there’s this great place down the road...” These people are making 10k a month. A lot of people aren’t being helped and are leaving treatment. Too often they relapse and die.
You emphasize the importance of prevention and early intervention. To what extent has the very structure of the US health care system disincentivized these desirable approaches?
Don’t get me started! It’s something I could rant about for a long time. Health insurance companies traditionally have not covered addiction treatment. Maybe they’ll pay for somebody to get off drugs, to be in the hospital for seven days to detox, but that’s it. Then they end up paying for liver disease, or accidents they get into.
My sister-in-law’s a nurse and she told me about these “frequent flyers.” They come into the emergency room; she told me that 70-ish percent of people are in there because they’re addicts. They get patched up, if they have an infection, a broken bone, and they’re sent back out. There’s no attention to the fact that the real reason they’re there is because they’re addicted. They come back over and over again. She looked up the charts of one patient, and his costs in this emergency room over a year and a half were over a million dollars—on one patient. If we got him the first time...they say every dollar spent on treatment saves us $18 in other costs. The system has been set up backward and it’s costing a fortune. Plus it’s killing people.
One of the hopeful things is that under the Affordable Care Act, Obamacare, for the first time, in theory, insurance is going to pay for addiction treatment.
Somebody with cancer, you’re treated for a month. They evaluate, do you need more time? Maybe you need to stay another month. After two months, you’re doing better, you go home, keep seeing your doctor. Then it hits again. You go back into the hospital and insurance is there; it has to be.
"Insurance has to pay whatever it costs to help people who are ill with this disease."
With addiction, that doesn’t happen. Now, in theory, it will. It will have the potential to transform the whole treatment system. Because when insurance companies pay for treatment, they want results. They want programs to be using evidence-based treatments, and they’ll monitor them. The ones that don’t do it will either do it, or they’ll go out of business.
The last chapter of Clean is called “Ending Addiction.” You write about the medical, social and political advances that could contribute to that. We might all hope, but what do you think will happen? How far will we get?
I think the idea of ending addiction completely is a quixotic dream. But who knows? I’ve spent time with scientists who are showing that it may well be possible to create vaccines that will effectively prevent certain drug addictions, cocaine for instance—there’s some real evidence that that’s possible.
But that’s not going to happen for a while. In the meantime, my hope is that we start to treat this differently. We have to support treatment; we have to support prevention; insurance has to pay whatever it costs to help people who are ill with this disease. [When] the treatment system is regulated so that we know that programs are good, the numbers will go down. It’s within reach to imagine a time when fewer people become addicted, and when more addicts are treated. It’s about science and policy. Also the other piece of it, that goes back to something you asked earlier: I think that now is the time—something is shifting and I feel it—when people are just tired of hiding this problem.
We’re not going to take it any more. We are not going to suffer in silence, and we are going to demand of our legislators that they reject what we’ve been doing in the past. Stop spending money on programs that aren’t working. Spend more money on programs that work; get them into our schools, our communities, educate parents. And have treatment programs that are accessible to anybody who needs them. All those things coming together are going to cause a shift. Are we going to end addiction? Not tomorrow. Maybe someday. But in the meantime, we’re going to start saving lives.
Will Godfrey is the Editor-in-Chief of The Fix.