"Clean" Book Review - Once an Addict's Father, Now an Advocate - NYTimes.com Addiction swallows lives whole, and not only with overdose, illness and concentric cycles of rehab and relapse. A less onerous but still tenacious kind of post-traumatic stress disorder may develop as well, with recovered addicts and their families compulsively reliving the past in private - or, like David Sheff and his son Nic, in public. In the last five years the two have written a small library of memoirs centered on Nic's long battle with substance use, comprising two by Nic (now 31, and sober) and the 2008 best seller by his father, "Beautiful Boy." Now comes "Clean," the fourth in the series, less memoir than guide for those just entering the terrain Mr. Sheff knows so well. If the book represents a certain redundancy of subject, its likely audience - those who must watch as friends and family spiral away - cannot hear too many sympathetic reiterations of the same truths. In "Clean," Mr. Sheff changes perspective, writing as advocate and journalist rather than distraught father. Still, his story line recreates that of "Beautiful Boy," tracing the trajectory of addiction from cradle to rehab and beyond with the same question in mind: How does a promising cleareyed kid from a good family wind up in an inconceivable sea of trouble? His answer, bludgeoned home with the repetitive eloquence of the missionary, is entirely straightforward: The child is ill. Addiction must be considered a disease, as devoid of moral overtones as diabetes or coronary artery disease, just as amenable as they are to scientific analysis, and just as treatable with data-supported interventions, not hope, prayer or hocus-pocus. This perspective is easy enough to articulate but extraordinarily difficult to sustain - hence Mr. Sheff's determined reiterations. The symptoms of this particular relapsing illness, after all, include deceit, denial and the systematic betrayal of near and dear. Cardiac patients stop to rest halfway up a flight of stairs not because they want to, but because they have to. Similarly, addicts lie and steal, over and over again, not because they want to but because they must. Wrapping the mind around this formulation requires an enormous act of will, and it is Mr. Sheff's foremost achievement that his arguments are likely to influence even the angriest and most judgmental reader. The book's scope is encyclopedic, from the genetics of addiction (genes are now thought to account for about 50 percent of addiction risk) to the semantics (when does use become abuse and then addiction?) and out to the periphery, where psychiatrists debate whether "codependence" is an actual psychologic condition or just a normal response to a set of outrageous circumstances. Mr. Sheff reports from various stops along the road to clean and sober, including a staged intervention, an adolescent group meeting and a few iterations of Alcoholics Anonymous. He winds up in lobbyist mode, calling for an end to the war on drugs, the legalization of marijuana and the decriminalization of other drugs, citing evidence from other countries that such measures can help move addicts into treatment. Still, readers who are just hoping for a clear-cut recommendation on the best available treatment may be disappointed. Unfortunately for them, addiction is a new enough disease that most major scientific strides have been made on the molecular and cellular levels, with relatively little percolating down to patient care. Mr. Sheff deplores most current addiction treatments: "a haphazard collection of cobbled-together, often useless and sometimes harmful recovery programs based not on medical science but on tradition, wild guesses, wishful thinking and pseudoscience, some of which borders on voodoo." But despite his repeated ringing calls for scientifically validated alternatives, he is often caught short when it comes to specifics. Treating addiction, he concedes, is not yet like treating other diseases. Given the current state of the science, "sometimes there's no clear course forward even for those being advised by highly skilled doctors." Some basic questions remain unclear. Among them are these: ¶ Should addicts, once detoxified, enter residential rehab programs, or can they safely stay home and go to outpatient programs? Study results have been mixed, Mr. Sheff reports. ¶ Are adolescent addicts helped by group sessions with addicted peers, or just intimidated and, occasionally, taught bad new habits? The literature is complicated, suggesting both outcomes are possible. ¶ When can recovering addicts leave the bubble of the "sober living house" and head back out into the world? "There's no single answer that applies to every patient," he writes. ¶ Is the Alcoholics Anonymous model for relapse prevention so popular because it is so successful? (In fact, statistics here are all over the map. "No one really knows how often A.A. works and for whom," Mr. Sheff concludes.) Many behavioral therapies aim to train addicts to interrupt the unconscious reactions that drag them back to their substance of choice. But which therapy will work for whom, Mr. Sheff freely acknowledges, is often a matter of trial and error. In the end, the uncertainties still far outnumber the proven facts of this disease, one reason hype and voodoo, with their promises of certainty, still hold sway. "Beautiful Boy" was a page turner, a dark fable that spoke to worried parents everywhere. "Clean" is a reference work and a manifesto, an annotated map of the same frightening territory where dragons still lurk at the edges. The two complement each other well enough to be sold as a boxed set.