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I’m very inclined to agree with you. Addiction is not a uniform phenomenon. But the difficulty of defining recovery is merely one more way that the medicalization of addiction shows its limits.

The heart and soul of medicine is diagnosis. Diagnosis means fitting the patient’s signs and symptoms to a recognized pattern. From that fitting follows what treatment should be chosen. (I recognize none of this is as simple as my description sounds. But, in the end, medicine is a science only because it recognizes and uses certain universals. Otherwise, it has no “right” way to do anything.)

Addiction as a “disease” suffers more from this universalization process than probably any other. Everybody supposedly knows certain things about addiction: its morbidity, its progressivity, its incurability, its total-abstinence-or-total failure nature, its inevitable character destruction and the consequent need for moral reformation. And everybody supposedly knows that success is rare, relapse common, and only addicts who after “treatment” continue indefinitely in AA or some other group motivation program have any hope of remaining clean/sober.

What is lost in this is that addiction, like other behavioral disorders, is a very personal predicament involving severe inner conflict. It must be addressed on that same personal level. Unless the addict can clearly see the self-sustaining destructive behavioral loop that operates in him and that commandeers all his mental and physical resources to sustain itself, everything remains murky, and he’s likely to pursue dead-end inquiries (“I was always an outsider,” “My mom didn’t love me” etc.) or futile generalities. You must know your enemy before you can defeat him.

That approach entails recognizing many things other than lifelong abstinence as “recovery.” For some addicts/alcoholics, particularly so-called dual-diagnosis ones, harm reduction may be the most they and their therapists can hope for. For others, managed moderate drinking may be not only possible but the best — i.e., most sustainable — way for them to recover. Similarly, marijuana has for some been a successful substitute for alcohol; marijuana may have issues of its own, but there’s little question it’s a far less destructive thing than booze. For some alcoholics, disulfiram is a relatively quick, simple way to get and stay sober. And even people who prefer a total abstinence goal need quite a bit of support and guidance building a long-term strategy. Very little of this is actually medical, other than the prescribing of medications. Most of it is psychological-philosophical work. (The best psychological help doesn’t pretend to be medical.)

This personalized help is available only in a very few places. The cost is correspondingly high. The alternative is the thousands of rehab mills that are a doorway to recovery for some, but whose overall record is believed to be quite dismal. If addiction is a disease, it’s a chronic one and has to be managed as such. Thirty days in group therapy doesn’t do that. On the other hand, such models may, economically, be all we can support. And if that’s the case, we’d be better off closing down most of the existing rehab facilities (which we don’t have the legal ability to do).