Heroin overdoses happen every day. Hundreds of people are addicted to this newer, more powerful strain of drug that can kill in an instant. Small articles have been popping up in the press for months about police reporting a rise in heroin busts and emergency rooms reporting overdoses and deaths from lethal amounts ingested, mostly by injection.
Last year articles were popping up about the “new heroin” and its dangers. Higher levels of purity, or cut with fentanyl; this is not the heroin of the 1970’s made famous by the movie The French Connection. This heroin is brown, with origins in Afghanistan by way of a route that rings the world and comes up from Mexico to the US. The cartel has changed, the drug has changed. What has not changed is how we approach addiction treatment.
In his State of the State speech, Vermont Governor Peter Shumlin devoted his attention to a “rising tide of drug addiction” and cited statistics that at best, were alarming; “nearly double the deaths from heroin and opioids (..) than in the preceding year” and “nearly 260% increase in people receiving heroin treatment since 2000, with a 40% increase last year.”
Addiction and drug overdoses by famous movie stars isn’t something new, either. Recently the New York Times listed the names of talented performers who have died from drug overdoses, and Wikipedia lists the deaths of “notable people who have died from drug-related causes.” Among the names that stand out who have died in the past decade: Mitch Hedberg, Whitney Houston, Lisa Robin Kelly, Heath Ledger, Michael Jackson, Robert Pastorelli, Amy Winehouse, Cory Monteith, and now, Phillip Seymour Hoffman.
The reaction that has rippled through various communities – Hollywood, the media, fans, those in recovery, advocates of treatment and treatment specialists – has been palpable. Hoffman was an “actor’s actor” who was respected and loved; a prolific thespian, director and writer with numerous accolades to his name, including an Oscar. Phillip Seymour Hoffman was a unassuming neighborhood celebrity, taking his kids to school, running errands at local stores, minding his own business. Churning out films, projects, winning awards – and unlike most of Hollywood’s notables, Hoffman seemed to avoid from the glitz, the lights and the flash, preferring instead to work a craft and to do so with incredible talent.
It is hard to say whether the shock was from the fact that he was found with a needle still in his arm, or over 50 bags of heroin in the apartment where he was staying, or that yet another gifted artist was cut down at the height of his career; whether his partner had tried some tough love and thrown him out the week before, or that he was an admitted addict and had been sober many years; or that he had just come out of “rehab” only a short time prior.
If Malcolm Gladwell is correct in asserting that “change happens not gradually, but at one dramatic moment” then the “tipping point” of this event may well be what will cause a change in how we view, and treat addiction, once and for all.
In the past decade we have had more breakthroughs in our understanding of the disease of addiction than in the prior four or even five decades. Technology has assisted in our ability to understand what happens to the brain under the influence of substances, how addiction takes place, and how the very structure of the brain is changed as a result. Whether from alcohol, cocaine, barbiturates or opioids – the brain’s susceptibility to become addicted is now well understood. In the words of Dr. Nora Volkow, Director of the National Institute of Drug Abuse, “addiction is a disease of the brain.”
What is confounding is how the models of treatment have not kept up with the models of addiction. A model of addiction can be viewed as a “foundation from which to organize addiction into a set of fundamental principles that prioritize problems,” which enables us to search for and implement solutions within that model.
In 1810, Dr. Benjamin Rush was one of the very first medical practitioners to define addiction as a disease. In 1965, the American Psychiatric Association began using the term as a comprehensive part of its definition of addiction. Unlike the Temperance Model (vis Prohibition or “Just Say No”) or the Moral Model (addicts are weak, sinful, and irresponsible) the disease model incorporates multiple facets of the problem.
According to the 2011 definition of addiction by the American Society of Addiction Medicine “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.”(ASAM, 2011.)
Treatment of addiction can be categorized as a Hodge-podge of approaches, each one competing for precious insurance reimbursement dollars, and vying for market share of an addicts choice. With the exception of only four or five treatment centers in the US, there is no standardized approach to treating addiction in this country. Much like an A-la-Cart menu, treatment centers offer a plethora of “solutions” which include boot camp or spa-like environments, remote or sunny locations, high end cuisine or bare bones nutrition, tough love or no love, talk-therapy or group therapy, 12 Step or Rational Recovery, medication assistance or chelation therapy, cognitive behavioral therapy or motivational interviewing, concierge treatment or recovery coaching – the list is daunting.
For those of us in the field reading that Phillip Seymour Hoffman spent “10 days in rehab” red flags go up. Ten days is not rehab; ten days is “detox”, and the difference is serious. Detox, short for detoxification, is the process by which a patient is withdrawn from substances, usually under strict medical supervision. Heroin withdrawal can be painful, but not deadly. Alcohol withdrawal on the other hand, can cause heart attack, stroke, or death. Ten days is the approximate time that it takes for the body to begin to flush out drugs or alcohol, and begin the healing process. Ten days does not include the formidable treatment needed to overcome the addiction itself.
Long term treatment is the only manner in which an appreciable chance of overcoming addiction can be realized. With relapse rates hovering around the 60-70% mark for short term treatment, the research literature is clear that the longer an addict is in treatment, the better chance they have for long term sobriety. This doesn’t mean months at a rehabilitation facility. What it does mean is an appreciable stay in-patient (usually 30 days), long term out-patient (six months or more), with comprehensive supports that sustain a sober lifestyle after discharge.
The drug and alcohol rehab centers that are well known for their outstanding work in this field don’t take insurance. Costs can run as high as $1,000 a day or more, with few financial adjustments available , and even fewer scholarships. This is a first-come, first-serve business, requiring cash or credit card in hand. Facilities that do accept insurance only take certain kinds or companies, and often don’t take Medicaid. Insurance companies limit the time of stay or number of outpatient sessions. Precious rehab staff resources are devoted to haggling with insurance companies to add sessions in order that a patient can complete a program. Meantime, the patient is subject to varying degrees of approaches, clinical expertise, and success. All this presumes that one can get the addict into treatment. Desperate families reach out to interventionists to help them, with good success. Recovery coaches pick up where the rehabs leave off, ensuring that the individual facing the return home has a solid support system to rely on. And all this takes money – lots of it.
We’ve heard talking heads discuss how this nation is in the middle of an opiate crisis, how addiction has to be treated as a public health issue (because that’s what it is), and how we need to devote more funding to the issue. For addiction counselors who have been advocating for decades, this is a no-brainer. Like AIDS, Cancer, Heart Disease, the movement to get addiction out of the closet and into the public health realm has been an upward battle fraught with the complexities of shame, public scrutiny and anonymity. An entire movement has arisen over this issue and a ground breaking video entitled the Anonymous People has confronted it head on.
But it seems that these admonitions only scratch the surface. Perhaps the deeper problem lies in the patchwork approach to addiction, lack of national treatment standards, lack of continuity of care standards, and the absence of comprehensive education followed by meaningful wages for substance abuse counselors. And finally, affordable treatment.
So are we finally at a tipping point? Have we reached contagiousness, little causes having big effects and change happening at one dramatic moment?
How many more deaths will it take before change does take place? How many sons, daughters, husbands, wives, fathers, mothers, sisters and brothers – how many loved ones need to die before we change our attitude and approach to the treatment of addiction? How many more addicts need to be found with the needle still stuck in their arm before we do something? How many known and unknown people need to die, needlessly?
Until we end the debates and start engaging in action toward comprehensive solutions, we are all guilty of contributing to an addicts death – including Phillip Seymour Hoffman.
(c) 2014 Kimberley L. Berlin, LSW, CSAC