Book Review: Clean: Overcoming Addiction and Ending America’s Greatest Tragedy, by David Sheff

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You may recognize this author’s name, as he wrote Beautiful Boy, a gripping account of his son’s addiction to methamphetamine and the effect the addiction had on the whole family. This second book on addiction is more scholarly than personal, but still thought-provoking.

Clean is well-researched. It’s written with great attention to information and opinions given by experts in the field of addiction, and to scientific research in the field. The author successfully assimilated the information and distilled it into understandable paragraphs. The book is divided into seven sections, titled “America on Drugs,” “Why We Use,” “When Drug Use Escalates,” “Getting Clean,” “Staying Clean,” “Treating a Chronic Illness,” and “Ending Addiction.”

In the first section, “America on Drugs,” Mr. Sheff explains why some humans, particularly adolescents, are more susceptible to addiction. He explains why adolescents begin to experiment with drugs, and describes why drug use is more perilous in young adults. The human brain is still developing until age twenty-five or so, and the structure and function of these immature brains may be more impaired by drugs than more mature brains seen in adults over age twenty-five. The author points out that ninety percent of people in the U.S. who develop addiction start using drugs before the age of eighteen. In other words, the younger someone is at first drug experimentation, the higher the risk of addiction.

The author points out that we tend to see drug addiction as bad behavior rather than the disease that science has clearly proven it to be. (The U.S. puts more of its citizens in jail than any other country in the world as a proportion of the total citizens. Cuba, Rwanda, and Russia all have much lower rates of incarceration. The majority of inmates in the U.S. have addiction that remains untreated while they are incarcerated, all because of the criminalization of addiction. Thus the “war on drugs” is really a war on people who use drugs.)

The author not only outlines risk factors for initiating drug use, but also the risk factors for moving from drug use to drug addiction. These factors include the pleasures of drug use, stress, trauma, poverty, family issues, learning disabilities, behavioral disorders and mental illness. Combinations of these risk factors cause a situation ripe for the development of addiction

Then the author has a long chapter containing ways that parents can offset risk factors for addiction in their children, along with ideas for schools and communities, too. All of this is important information, but the positioning of this chapter was a little jarring to me. It felt like a long chapter about prevention was wedged into a book otherwise devoted to treating addiction. I agree it’s an important topic, perhaps deserving a separate section or even a separate book.

Another section of the book describes warning signs of addiction, and provides information about how professionals assess for addiction. There’s a chapter about interventions and how they can be done – as well as some dangers involved with staging interventions.

I liked the chapter about detox. The book explains the different ways of detoxing, and says detox is only the beginning of treatment, an important idea for families and addicts to understand.
The author goes into some specific details about the types of therapies addict receive in the course of treatment for addiction.

The next section of the book is all about getting clean: the difficulties addicts and their families have in finding appropriate treatment. The book describes what usually happens in a drug addiction treatment facility, and gives some ideas about things to look for in a good treatment center.

Twelve step recovery occupies a lengthy chapter in this book. I thought the author was even-handed and presented what we know about these programs, including that they don’t work for everyone

Part of the book describes evidence-based treatments, and that’s helpful, but the author doesn’t mention that many treatment programs don’t use – or under-use – evidence-based treatments. He also describes warning signs which may indicate a program should be avoided. He talks about the cost of treatment, and some of the difficulties of insurance payment for treatment.

There’s plenty of scientific information in the book, and it’s mixed with anecdotes of addicts and family experiences. The information was accurate; I didn’t detect any blatantly bad science.

I enjoyed the chapter titled provocatively titled, “Treating Drug Problems with Drugs.” Aside from a few misstatements and minor misinformation, it’s great. Granted, this chapter is nine pages long, in a three-hundred and thirty-one page book, but that’s better coverage than most popular books on addiction treatment give medication-assisted treatment of opioid addiction (which is, as you know I’m fond of saying, one of the most evidence-based treatments in all of medicine, let alone addiction medicine). This chapter talks mostly about methadone but there are several pages on buprenorphine, too. Sadly the brand name “Suboxone” is used repeatedly in this chapter instead of the more appropriate “buprenorphine” but hey, I’m not gonna quibble too much. I’m just happy this information was included.

The author does point out some of the weaknesses of our prevailing addiction treatment system, but he does so in a gentler manner than in the book, Inside Rehab, by Anne Fletcher. I reviewed Inside Rehab earlier this year on my blog, and I preferred it to Clean. In Fletcher’s book, she’s emphatic to the point of being spew-y; that made her book interesting. Sheff’s book is accurate but more docile and polite. Inside Rehab is more of a “Hey wake up!” in tone.

Both books are good additions to the plethora of books about addiction and recovery, and I recommend both to any readers interested in the subject.

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11 responses to this post.

  1. I am so thankful that you posted this! I saw this book on Goodreads (love that program/app, though I must confess I haven’t used it as much as I intended – I did review YOUR book on it, though! 😉 ) a few months back, and I have had it on my list to check out. I’m glad he gave at least 9 pages to evidence-based treatments, but I’m afraid those of us who are disseminating information to the public – in ANY way – have a moral obligation to spend a LOT MORE time and pages on the most effective treatment(s) for opioid addiction considering the addiction & overdose epidemic that is plaguing the nation.

    Thanks for the review; This is one, for me, that is especially useful, as this book was already on my list to check out!

    Regards,
    Zac Talbott
    NAMA-R TN
    http://www.tnmethadone.org

    Reply

  2. Will surely be picking this up, thanks, Dr. Burson!

    Reply

  3. I have actually used sections of “Beautiful Boy,” in working with adolescents, giving them a look at a young person’s addiction from the perspective of a parent. It took effect with a few, not all (as you know, not every intervention fits every client), but it was nice to have young people engaged with the parent in the story, not the teen. We did some role-play with the young folks talking to their “future children,” or younger siblings about drug use. Literature from different perspectives not only educates but provides authentic springboards for working with those who are involved with drugs at all levels.

    Reply

  4. I’ll have to check it out! I’m glad he used a more neutral/scientific approach than his first novel which was obviously exists in a totally different writing genre. I seem to recall getting a bit upset at comment in ‘Beautiful Boy,’ where Mr. Sheff called a buprenorphine prescribing physician treating his son for a short period of time a legal drug pusher or something close to that. I think Mr. Sheff’s son was concurrently using benzodiazepines and likely not using Suboxone in a productive way, which can obviously tilt a parents opinion. I agree, even 9 pages on MAT with little to no misinformation is a taker!

    Reply

    • I don’t think “Beautiful Boy” was a novel. I’m pretty sure it was a non-fiction account of his son’s journey in addiction and the family’s struggle as well.
      I’ll look at his book again for that buprenorphine comment…

      Reply

      • You’re right, I do recall liking “Beautiful Boy” only having my ‘feathers ruffled’ by the one comment regarding buprenorphine.

  5. Posted by Samantha Smith on January 4, 2014 at 6:57 am

    Very nice post, now I know that the younger age of a person takes drugs, the higher the risk of becoming an addict/abuser. But does anyone know how to cure this? Hoping for your replies, thanks.

    Reply

    • The cure for alcohol and drug addiction is the same as the cure for diabetes and high blood pressure. All are chronic diseases which need ongoing managment in order to stay well.

      Reply

  6. Posted by Carlos on May 27, 2014 at 8:32 pm

    Is it funny, I just realized I have a copy of this book in my computer as an ebook in my mobi file. I began to read it some time ago. I have a ton of a library in the science of psychology and substance use treatment. Including harm reduction stuff. I lost quite a bit of interested when I notice that they got a bit too 12Stepished. Not much science in the 12Step. It was not designed as a treatment protocol, but as a fellowship or society.
    I think it fails miserably when you force people to attend meetings. Like any other religion it converts people and tell them what to think, they do not teach people how to think.

    I have one called a Cure of Alcoholism (2008), which is a book about the use of Naltrexon with alcoholics. If interested I maybe able to sent you a copy. It is an area that is so much ignored including the residential facilities who are always complaining and discharging patients out because they relapse.

    This is the only treatment that discharge patients when they get worst. Can you imagine discharging a patient out of the hospital when their hallucinations and delusions get worst. Or a cancer patient. We have too many reasons for failure, and it is always some some something characteristic about the patient. It is never that we treated the patient incompetently. or softer we just did not have the technical know how.

    I in agreement with Nora Volkow when she points out that historically when we have not understood the medical condition well, we always blamed the outcome on the patient.

    .

    Reply

  7. Posted by Zak Waldrop on May 30, 2014 at 4:25 am

    Is the book being sold till today? And where is it being sold thank u.

    Reply

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