Every day, millions of Americans gather in church basements and community meeting rooms to take turns announcing, "Hi, I'm X and I'm a Y addict." The practice seems simple, and in a sense it is. Since Bill W. founded Alcoholics Anonymous back in the 1930s, the participants in various 12-step programs have reached a reasonably clear consensus on what "the program" is and how to work it. Nevertheless, the rank and file of the recovery movement stand at the roiling center of profound controversies about human nature itself, questions of genetics and free will, talk therapy and psychopharmacology, secularism and religion, responsibility and helplessness.
The people that journalist Benoit Denizet-Lewis profiles in his new book, "America Anonymous: Eight Addicts in Search of a Life," lavishly illustrate the paradoxes and contradictions in our current notions of addiction. They're alcoholics, meth fiends, crack heads, compulsive gamblers and overeaters and shoplifters. They beat the odds, then relapse at the moment things seem to be going their way. They congratulate themselves on kicking one drug while kidding themselves that they're not getting hooked on something else. They talk of having both a "disease" and "issues." Throughout, their individual histories testify to how essentially American the recovery movement is, in spite of the footholds it has established internationally. The 12-step ceremonies of public confession and contrition, the emphasis on humility before the community, the promise of an enlightened, remade self awaiting anyone willing to work hard enough, the very idea that who you are is not an immutable fact, but rather a story whose theme is change -- all of these rituals and dreams are part of the fabric of American culture.
Yet so is the quick fix, the magic bullet, a cure in a pill. Olivier Ameisen, a distinguished cardiologist who has worked at New York Hospital and Cornell University Medical Center, promises as much in "The End of My Addiction," also published this month. Not to be outdone in the 12-step tradition of personal narrative, Ameisen, too, has a compelling story, the autobiographical saga of a successful physician who was nearly destroyed by his uncontrollable binge drinking. Then, one day, after he had exhausted seemingly every single therapeutic approach (including AA), an old girlfriend sent him a news item about an obscure medical study of baclofen, an antispastic drug customarily prescribed to sufferers of multiple sclerosis that also diminished cravings for cocaine. Ameisen decided to experiment, using himself as a guinea pig. With sufficiently high doses of baclofen, he maintains, he has become "effortlessly indifferent" to alcohol, not only able to abstain from drinking entirely, but even capable of taking a single drink at a party and stopping at that.
Ameisen's book has caused a sensation in France (where he was born and now lives), according to a report from the BBC, prompting patients to inundate doctors with requests for the drug. Some experts have cautioned against the notion of a "miracle cure" purporting to eradicate what most regard as a highly complex, intractable problem. Ameisen insists that the medical resistance to baclofen really results from mere force of habit combined with the fact that no one can make much money off of it. The drug is relatively cheap and out of patent, so pharmaceutical companies have little motivation to fund clinical trials unless they can figure out how to concoct a new, patentable (and therefore profitable) version.
Is addiction mostly caused by messed-up brain chemistry, as Ameisen thinks -- there's much talk of dopamine receptors and gamma-aminobutyric acid transmission in "The End of My Addiction" -- or is it the result of emotional trauma or even, as people once thought, simple weakness of will? Ameisen may unreservedly endorse his pharmaceutical remedy and the people profiled in "America Anonymous" may, by contrast, embrace what's essentially a psychotherapeutic solution, but the two camps are not as far apart as they at first appear. "I'm a firm believer that with drug addiction, issues alone, or a bad childhood, don't make you a drug addict," says Jody, an addiction counselor whose life has been an epic pendulum swing from success to catastrophe and back again. "I wholeheartedly believe that my body processes drugs differently than your body does."
Ameisen, in turn, wonders whether environment -- in the form of his mother's history as a Holocaust survivor -- put him "at increased risk of post-traumatic stress disorder, severe anxiety and depression"; other children from similar households have grown up to be troubled by "the atmosphere in which they were raised." He sees his alcoholism as an attempt to medicate the bouts of extreme anxiety he has suffered throughout his life, gnawing fears that he will be unveiled as a fraud. Baclofen, he believes, works in large part because it is an anti-panic drug as well as a relaxant.
As is customary with most addiction specialists, Ameisen's doctors pushed him toward 12-step programs and kept telling him, "If you stop drinking, you won't be so anxious anymore." Ameisen himself was convinced that the anxiety was his "fundamental" problem and that he could stop drinking if it were "resolved." Sympathetic physicians prescribed Valium and other tranquilizers, and he seems to have been better able to resist the urge to drink while taking them, but any drug use at all is usually forbidden in true 12-step regimens. It's part of the pervasive fogginess of Ameisen's account that, while he swears up and down that he gave AA his best shot by faithfully attending daily meetings and leaning heavily on sponsors, it's not entirely clear how much of this time he spent truly drug-free. He became so irate when a state agency in charge of regulating physicians' licenses insisted that he go off Valium while in alcoholism treatment that he wound up leaving the U.S. entirely, to escape the situation.
It's hard to know what to make of "The End of My Addiction." Ameisen seems sincere enough, and almost painfully candid about his own shortcomings. At the same time, he has a tendency to veer from self-abasement to grandiosity (claiming to feel unworthy of his achievements, honors and famous friends while at the same time making a point of listing each of them), which looks a lot like classic unregenerate addict behavior. For all his disclosures, he apparently still lacks self-awareness. His desire to help other addicts, while no doubt genuine, is hopelessly entangled with the impulse to make a spectacle of himself; jazzed by his initial encounters with AA, he was eager to speak publicly to fellow doctors of his substance problems and recovery. His physician gently suggested that he get five years of sobriety under his belt first, and Ameisen relapsed within a week. It wouldn't be entirely out of character for him to jump the gun in championing baclofen.
Nevertheless, Ameisen lands some palpable hits against conventional addiction wisdom. "You can search high and low," he writes, describing his fifth stint in rehab, "but no rehab center will ever state a specific success rate. Nor will they reveal the sad fact that the overwhelming majority of alcoholism rehab patients relapse within four years." Figures on the abstinence of graduates are self-reported -- "based on nothing more than patient's responses to follow-up telephone call or questionnaire," despite addicts' notorious propensity for lying.
Even the truest believers in the recovery movement will admit that multiple relapses are pretty much par for the course, and those who never attain any significant sobriety outnumber those who do. The life stories that Denizet-Lewis recounts in "America Anonymous" are, for the most part, grinding cycles of backsliding and the excruciating task of starting over again from scratch, testimonials to the fortitude of the souls portrayed but also to the fragility of "the program." When Ameisen observes that "there is no proven protocol for addiction treatment," he has a point.
At the heart of the 12-step model is a seeming contradiction. It insists that addiction is a "disease" -- a chronic one, like diabetes or hypertension, controllable if not curable. This removes some of the stigma from what used to be regarded as a moral failure. But while diabetes and hypertension are controlled by medical means -- drugs and diet -- the recommended treatment for addiction is, in essence, psychotherapeutic: group therapy. Furthermore, the first of the 12 steps calls for an admission of powerlessness; "willpower," the mainstay of earlier, more stoic generations, as members are wont to say, just isn't enough. Yet the key to staying sober is a determination to "work the program" -- which often looks a lot like willpower.
These conflicts can be resolved in a paradoxical, Zen-like way, especially when accompanied by an ample dollop of "higher power" spirituality, but they aren't rational in a way consistent with science, and medicine is a science. For years, the medical argument on behalf of 12-step programs is that, however mysteriously they work, they are supposed to work better than anything else, including all the currently prescribed drugs (Antabuse, naltrexone and topiramate are three). But if AA and its permutations aren't, as Ameisen maintains, all that effective, then why are many specialists so resistant to the possibility of new drugs that might work?
This question becomes even more pointed as the 12-step model expands into new territory, offering itself as a corrective to compulsive behavior that doesn't even involve drugs. Denizet-Lewis himself admits to being a sex addict, probably the most disputed province in the 12-step kingdom. Sex addiction is not listed in the DSM-IV, the American Psychiatric Association's official diagnostic manual of mental disorders, and as Denizet-Lewis experienced it -- entire days squandered looking at Internet porn and chasing down anonymous sex partners in chat rooms -- it resembles other forms of self-defeating self-indulgence in, say, video games or the "Twilight" saga. Perhaps it is in some particulars, but Denizet-Lewis seems to have gone further overboard than the rest of us in "medicating" his "loneliness, disconnection, shame, anger and a core belief ... that I am inherently unlovable." He believes that sex can be addictive because of the many times he felt that nothing else in his life mattered at all.
Proponents of the addiction model claim that behavioral "addictions" -- gambling and shopping or shoplifting as well as sex, for example -- are rooted in neurochemistry and the afflicted brain's dysfunctional response to stimulation and satiation, which is much the same whether the source of the stimulation is booze or porn.
Sex addiction is particularly fraught because some critics see it as a blame-dodging attempt to pass off moral deviance as an illness. In yet another camp are those who regard it as a veiled attempt to impose overly restrictive standards of sexual normality. After all, a behavioral addiction is usually defined as the irresistible impulse to keep doing something even though you desperately want to stop and despite the threat of harmful consequences to your professional and personal life. By that standard, simply being a practicing homosexual in pre-1970s America could qualify as a sexual addiction. The consequences (arrest, disgrace, shame) and the desire to stop (internalized homophobia) we now see as the toll unjustly imposed on gay men and lesbians by a sexually oppressive society; at the time, few doubted that such people were "sick." Little wonder, then, that some conservative religious groups have latched on to the sexual addiction model, allowing them to label any interest at all in pornography or even masturbation as pathological.
If Ameisen is right, and baclofen or yet undiscovered drugs really can provide total relief not only from cravings but also from the mood disorders frequently linked to them, then would someone like Denizet-Lewis start taking pills to help him resist the desire to hook up with casual sex partners in chat rooms? That may sound preposterous, but yet another medical opinion on compulsive sexual behavior views it as a type of obsessive-compulsive disorder, an illness that can also be controlled with antidepressants. Prozac and its ilk, medications intended to regulate mood and temperament, have already ignited debates about how much of our identity comes down to mere chemicals, and most people think of their sexuality as an integral part of their identities. When decisions that for millennia have been regarded as matters of morality and free will also become the target of pharmaceutical manipulation, chances are many of us will feel our humanity has been further eroded.
Yet who would knowingly withhold relief from people like Ameisen and the addicts profiled in "America Anonymous," and the millions upon millions of others who have suffered so terribly? It would be unthinkable, yet the very things that make their stories so moving -- their courage, their camaraderie, their perseverance, qualities we think of as characteristic of humanity at its best -- might never have emerged without the challenge offered by those sufferings. For all the circumspection with which he writes about them, it's clear that Denizet-Lewis views his subjects as heroes of a kind; in truth, the key to the genius of the recovery movement lies in its ability to transform everyday survival into a heroic endeavor, investing it with tremendous meaning. If we find a pill that can banish the demons and dragons, we'd be crazy not to use it, but we should prepare ourselves for some unsettling side effects. Along with the dragons, more than a few heroes will fade away as well.