Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: long-term recovery

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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The Treatment that Might Have Saved Phil Hoffman.

Cross-posted with AfterParty Chat.

Philip-Seymour-Hoffman

Late last week it was suggested that a cultural stigma against maintenance medications such as methadone and Suboxone helped kill Philip Seymour Hoffman.

This doesn’t make much sense to me given the fact that, shortly after he died, it was reported that buprenorphine was found in Hoffman’s Bethune Street apartment. Buprenorphine is a long-acting opioid the FDA approved in 2002 for opioid detox and maintenance. It’s used mostly for maintenance: it’s the New Methadone, but it’s much easier to get, because while methadone is approved for addiction-treatment only in a clinic setting, buprenorphine can be dispensed in a doctor’s office. Refills can be called in or faxed to pharmacies.

So how did Hoffman get his bupe? Either he was being prescribed buprenorphine for his opioid habit, i.e. he was “on maintenance”—as so many opioid addicts are: buprenorphine maintenance is a booming business in this country. Or else, as many heroin users do, he obtained his buprenorphine on the street.

Poor heroin users often cop street “bupe” to tide them over between fixes. But Hoffman was far from poor. So it’s speculation, of course, but I think it’s more likely he got his buprenorphine from a doctor. That’s what doctors do these days with opioid addicts: When we get honest about our addictions inside the exam room (and because Hoffman had spent 23 years sober and abstinent via 12-step fellowships, it may be fair to say he had practice in being rigorously honest) the doctors’ fear kicks in and they boot us into Suboxone clinics, where we’re prescribed upwards of 16mg of this very strongly-binding, fat-soluble drug that stays in our bodies for days before it’s excreted. In painkilling power it’s weaker than morphine or oxycodone, but in binding power—in its ability to stick to the body’s opiate receptors—it’s the second-strongest out there.

The strongest is fentanyl, the drug that’s been cut into heroin and has killed nearly two dozen in my region alone.

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Some publications are wont to report that opioid addicts—like Hoffman, like me—wreck our brains’ opioid receptors forever through drug-use. (This proves they don’t understand how the body’s painkilling system works: a great portion of the body’s opioid receptors actually reside in the gut. Which is why we get that lovely warm feeling throughout our bellies when we use painkillers or shoot heroin.) But there’s at least as much scientific and anecdotal support for the idea of neuroplasticity in recovery—the fact (it’s not just an idea anymore, it’s a fact) that the central nervous system is far more adaptable than we ever before believed and is evolved to use this resilience to recover from major traumas and illnesses, including addiction—especially if we help it by taking care of our bodies in basic ways, with exercise, good nutrition, and relaxation.

So the “old-school” idea is not 12-step programs, as these pieces suggest. “Old-school” is what I was taught as a kid: that once you lose brain cells, you never get them back, that our nervous systems cannot heal.

Still, these publications are putting the idea out there—and it is not a fact, it is just an idea—that if “most opioid addicts” don’t take maintenance medications forever to “correct” the “permanent damage” we’ve done through drug-use, we’re doomed to relapse.

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Philip Seymour Hoffman just four or five years before he got sober, in his 1985 high-school senior-year portrait.

Philip Seymour Hoffman just four or five years before he got sober, in his 1985 high-school senior-year portrait.

The clearest example that this isn’t the solution exists in our states’ physician health programs (PHPs)—systems of recovery designed to help addicted and alcoholic physicians keep their licenses to practice. These programs vary from state to state but generally provide five years of continuous care and oversight. Success rates for PHPs are extraordinarily high—upwards of 80 percent of physicians finish five years of treatment and are able to keep practicing.

These programs ought to be considered models for our citizenry. But they remain off the radar because they’re rigorous, expensive and intensive—five years, as opposed to a 28-day rehab, or even a ten-day or three-day detox.

Also, studies of PHPs show that linking recovery to one’s work is one of the strongest incentives you can give an addict to take responsibility for healing. Addiction thrives in situations of un- and under-employment not because the poor are somehow more susceptible to addiction, but because the people affected don’t have enough, or any, productive work.

It’s sometimes said that PHPs are effective for “highly motivated” addicts. Which leads me to my last point. I find it astonishingly patronizing that some are suggesting that public prejudice against maintenance killed Hoffman. Hoffman was an extraordinarily intelligent, articulate, “highly motivated” man and consummate professional whose work, he said, required him to be extremely introspective and emotionally present. I find it hard to believe he would be so easily swayed by public opinion about his choices.

I can more easily see him protecting his ability to work.

To act with the depth of feeling and nuance that he managed required full use of his entire internal emotional range. And opioid medications—including buprenorphine—necessarily dull one’s range of feeling.

I think it’s more reasonable to suggest that Hoffman tried bupe and found that, while taking it, he couldn’t access his feelings to the degree to which he’d become accustomed.

To be sure, he likely felt a great deal of shame during his relapse. One of the more damaging aspects of some 12-step groups, in my opinion, is their focus on “sober-time”: to “come back” from a relapse after a sober period of 23 years—half one’s life—would have been not only extremely embarrassing for anyone but also physically difficult, given that the heroin available these days is wicked strong.

But no way could Hoffman have wrecked his neurology permanently by using heroin for less than a year. I think it’s likely he did what so many who use heroin do: he chipped heroin, then switched to bupe, thinking it might remove his cravings. In fact, buprenorphine reliably does this for many opioid addicts who take it.

But craving is a feeling, and you can’t numb feelings selectively. My bet is that, feeling not-high but not-normal—after all, he’d been sober for 23 years: he knew what His Normal felt like; he knew what it took for him to do his job with the precision and quality with which he was used to doing it—he said what so many of us say when we’re caught between a rock and a hard place.

Fuck it.

What he needed was not more drugs. What he needed was a better form of treatment, perhaps the best evidence-based addiction treatment system we have going: the time-consuming, attentive one we give to doctors, the people we trust to protect other people’s lives.

But because Hoffman was “just” an artist, he followed the cheap, easy, brief trajectory that ordinary people in this country follow.

Pills. Then heroin. Then Suboxone. Then heroin again. Then death.

Hoffman in perhaps the last photo ever taken of him, a tintype made by Victoria Will two weeks before his death.

Hoffman in perhaps the last photo ever taken of him, a tintype made by Victoria Will two weeks before his death.

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