Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Could Proper Standards of Care Have Saved Robin Williams?

Cross-posted with Recovery.org.

Robin Williams fish

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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7 Comments

  1. From the latest info, it doesn’t seem that Robin Williams had gone back to drinking, but clearly was suffering from depression and anxiety. It disappoints me that so many have leapt to the conclusion that he was drinking again, believing the “once an addict, always an addict” mantra. I find it such a demoralizing view of life and our capacities for growth, strength and change.

  2. Kathryn, thanks for writing. I’ve read that Williams’s wife said he had been diagnosed with Parkinson’s, a progressive neurological disorder. My piece doesn’t say he went back to drinking. But:

    1. what if he had?—I’ll tell you this: drinking and drugging saved me. Using was a solution for a while—for a long time—and it certainly prevented me from offing myself. I and many others wonder whether, if he had begun drinking again, he might still be here.

    2. if he had established the kind of supportive, long-term collaborative relationship with a compassionate practitioner of the kind I spoke with, they may have been able to spot the signs of depression and help him get it treated.

    Of course, hindsight is always 20/20.

    Thoughts?

  3. I understand what you’re saying, and appreciate your points. I suppose I’m reacting to the avalanche of commentary on what Robin Williams – or his loved ones – should have or could have done.

    And they may have done all they were capable of, and he still took his life. That’s harder to accept. And I hate to think of his grieving family and friends, who are certainly feeling not just the loss but their own guilt about what they did or didn’t do.

    Thanks for your note, and your blog. I’ve read it for over a year now, and really appreciate your thoughts and your ability to put them into words.

    Kathryn

  4. I think that Robin Williams’s death speaks more to the failings of the mental health and psychiatric care offered to Americans other than just addiction medicine.
    I’ve been seeing the same psychiatrist for 8 years, she just dismissed me as a patient after we had a minor argument about payment (I owed her one session worth and that’s all she talked about during our entire session)
    Now I’m on several addictive drugs (Klonopin, Xanax, Adderall, I try to keep my doses low to make sure I don’t get addicted.
    She gave me one month worth of meds and told me how to obtain several drugs from Mexico to end my life.
    I enjoy my life immensely, but only when my anxiety is under control.
    If I can’t find a replacement for her I fear Mexico is my only choice.
    With all the psychiatrists taking vacations in August, I can’t find anyone.
    The mentally ill need better treatment than this!

  5. Tom, thank you for writing. This is an incredible and sad story—I have heard of shrinks cutting patients off with so little notice, but never of a professional who recommended assisted suicide. I hope you’ll keep seeking treatment that works. Before you choose Mexico, please read Robert Whitaker’s ANATOMY OF AN EPIDEMIC, which is the most reliable and thoroughly researched examination of the mental health profession’s treatment of chronic mental health problems with drugs. And please keep looking for help. http://www.madinamerica.com

    p.s. In the best of all worlds, addiction care ought to be considered part of mental health care. Which is the point I was trying to make in this piece.

  6. I believe that Robins inability to remain sober and that struggle caused him to become more and more defeated and depressed.

  7. addiction is but a vicious cycle. A huge number of users consume addictive substances out of depression but, in the long run, the addiction (or the inability to break the addiction) itself becomes the source of depression.

    I totally agree with you Guinevere. Addiction care SHOULD be a part of mental health care.

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