Could Proper Standards of Care Have Saved Robin Williams?

Cross-posted with Recovery.org.

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Why does addiction care still, too often, lag behind the care you’d receive for other illnesses? I asked three addiction doctors how we can reimagine treatment as an ongoing collaboration.

When I first heard that Robin Williams died, of course I thought, Another overdose. But when I read “suicide due to asphyxia,” I remembered a 2013 statement from his publicist, which the media is now repeating into an echo chamber: Williams last year checked into rehab to “fine-tune” his sobriety.

What does fine-tuning your sobriety mean?

That the vagueness of this statement was accepted without question in the major media illustrates not only the media’s lack of knowledge about addiction but also the vast gray area in which addiction treatment operates. As a person recovering from addiction, I have the only life-threatening illness I know of in which I’m expected essentially to diagnose myself and oversee my own treatment and recovery.

Would we expect someone with cancer to diagnose herself? Hell, no. Does anyone with cancer check into the hospital to “fine-tune” her treatment? Well, in fact, maybe—if, for example, she were experiencing new symptoms that indicated a complication in her standard system of care. The physician might then use a physical exam and tests to retool the treatment accordingly.

And this is how some physicians are beginning to imagine addiction treatment: an ongoing collaboration between patient and doctor to carefully oversee lifelong recovery.

“I imagine people in recovery regularly seeing an addiction medicine physician,” Kevin McCauleyM.D., medical director of New Roads Treatment Center in Sandy, Utah, tells me. With his background as a Marine pilot and flight surgeon, and with eight years in recovery from painkiller addiction, McCauley talks about taking newly sober people through a system of recovery, in the way soldiers returning from war with injuries are led through recovery practices.

“The team assesses the condition, assigns names to the injuries, and takes the individual stepwise through exercises and therapies to get them where they can, for example, grasp a cup, and then walk again,” he says. “We would regularly see an addiction medicine physician. As I pass through my recovery through the rest of my life, I need to be in that collaborative relationship with a professional.”

But such a collaboration requires standards of care, which are sorely inconsistent—or even nonexistent—in addiction treatment.

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What is the Standard of Care for Addiction Treatment?

“I don’t think there is a standard of care—I think that’s evolving,” says Michael V. GenoveseM.D.J.D., the incoming medical director of Sierra Tucson in Tucson, Arizona. “It’s just becoming apparent to people that addiction is a disease. So that’s the first step, and now there will be a medical model that surrounds it.”

I don’t think there is a standard of care—I think that’s evolving…It’s just becoming apparent to people that addiction is a disease. So that’s the first step, and now there will be a medical model that surrounds it.—MICHAEL V. GENOVESE, M.D., incoming director of Sierra Tucson treatment center

Many people, especially some in 12-step abstinence-based recovery—which emphasizes humility—think that celebrities shouldn’t be given any more attention than any other recovering person, and there’s some truth to this. But when Philip Seymour Hoffman died, I wept. He was just a couple years younger than me, and what further choked me and so many others was the abbreviation of his artistic contribution.

McCauley blames the lack of a standard of care for such deaths. “It’s a terrible idea to leave detox and go home,” he says of Hoffman’s situation. Hoffman had relapsed after 23 years of abstinent recovery; he had apparently gone into rehab, been given Suboxone and gone home.

“If the standard of care had been [to give him] naltrexone for at least a year, and in that time get [his] rather considerable and proven recovery skills back up to snuff, that man would have lived,” McCauley says. Both Genovese and Harry HaroutunianM.D., medical director of the Betty Ford Center in Rancho Mirage, California, agree. Betty Ford is now a part of the Minnesota-based network of Hazelden, through which Williams sought to “fine-tune” his recovery.

Opinions differ on the kind of practitioner that might best oversee the process of recovery. “An addiction medicine physician also needs to be thought of as an addiction recovery physician,” says Haroutunian, who is himself a recovering alcoholic. “Certainly addiction physicians who are themselves in recovery and have good recovery may be best suited to help observe and guide someone who’s on that path from the dangers—everything from identifying other addictions such as workaholism, to relationship problems such as codependency, to excessive exercise or eating habits and nutritional deficiencies.”

“I understand [Haroutunian’s] point,” says Genovese, a board-certified addiction psychiatrist who is not in recovery, “but I think some of the best oncologists may never have had cancer. The best cardiologists don’t necessarily have cardiovascular disease.” He doesn’t think that the practitioner overseeing care needs to be a psychiatrist: “It could be an internist, an addictionologist, any practitioner with additional training in addiction.”

Many are saying that it was depression that killed Williams. People said the same thing about the author David Foster Wallace, who hanged himself at 48 after a lifetime of struggling with both addiction and mental illness. But you only have to look at the clips of Williams’ performances on YouTube to know that he had been a hard-core alcoholic and addict and that he negotiated sobriety on a daily basis. (Likewise, you only have to read Wallace’s writings—Infinite Jest, for example, or his essay, “This Is Water”—to find his struggle with addiction and his understanding of recovery.)

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Williams’ cocaine clip has 2.5 million views, and his bit about alcohol and weed has almost 6 million. Some of my favorite bits—inexplicably, because I never copped on the street—are of Williams “doing” drug dealers. In a Thanksgiving appearance on Craig Ferguson’s show he does a “turkey-dealer” selling tryptophan; he and Ferguson (another recovering alcoholic) riff about knocking back heroin and Jack Daniels to get through the holidays and take turns making each other laugh their asses off.

Williams had been sober 20-odd years before he started drinking again in 2006. Nobody seems to know whether he carried on and that’s what necessitated the “fine-tuning” trip to Hazelden, or whether he’d climbed back on the wagon. But whatever happened, addiction was a major part of the mix, and like most of us in recovery who wake up and want to either bang our favorite drug or suck on our exhaust pipes, he wasn’t getting enough help.

Eventually, that help might look like the kind of support patients get when they have cancer, diabetes, cardiovascular disease, even near-sightedness—any chronic health problem that requires regular follow-up visits with medical specialists who operate according to scientifically backed protocols, measurable outcomes and standards of care. According to McCauley, “That’s what recovery oversight ought to look like.”

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