The evolution of addiction treatment began during the Vietnam War, with thousands of troops returning to the U.S. after being exposed to the abundance of cheap drugs in South East Asia. Today funding has been shaved off the treatment pillar leaving addiction treatment desperate for a fix.
My friend Leo was a raging alcoholic. A fisherman from Port Alberni, Leo loved the sea, but his family wanted him on the other side of the Island working in their gravel pit. He would put in week after week driving a grader in the hills behind Duncan, then one night he’d suddenly snap, drink a bottle of Jim Beam, get into his truck and try to make it home, like a salmon with wheels. The last time he tried this stunt the cops found his truck in the ditch outside Butterfly World. He had a blood alcohol reading of .39. You and I would be dead. He was still trying to shift gears. The doctor told him his liver might go at any moment, but what scared him more than death was that one more drunk-driving charge would mean jail time. Yet he just couldn’t stop. So a month later, before he could repeat his offense, his family staged an intervention. They took him to Vancouver General Hospital for a check-up. Once he was inside, two orderlies grabbed him. Later he said, “It was weird. The orderlies had the faces of my brothers, and the nurse had the face of my mom, and I tried to get ’em.” They put him in a cement cell in the psychiatric assessment unit, with a plastic ice cream pail of drinking water and another for a bedpan. He kicked the door with both feet, over and over, until repeated landings on the cement floor threatened to break his hip. “Then I got smart. I pulled the mattress over to the door so I was falling on it.” He kicked that door all night until his feet were slippery with blood. When he got home we spent countless hours at his kitchen table talking about detox and rehab. “Twelve steps really helps,” he said. “If you can just open up and talk about this shit, it really helps.” I was not convinced, because Leo was slurring his words as he spoke. In fact, every morning he rose at dawn, drank his twenty-sixer of bourbon, passed out around noon, and woke up again in time for supper and AA, whose 12-step shtick hadn’t altered his flight plan in the least. After a few months of these kitchen table chats, Leo’s liver failed and he died of a heart attack. At his funeral people said he had a death wish, but I couldn’t forget the way he kicked his cell door all night. Leo wanted to live. He just didn’t know how. In the dozen years since Leo’s death, science has changed our understanding of addiction. B.C.’s rehab business has mushroomed into an industry, with private clinics popping up all over the province and raking in the cash. But patients still die weeks after walking out the door, because the new system is flawed in new ways. The program that failed Leo was a standard 28-day residency, which came out of the Vietnam War. Cannily intuiting that the returning troops would need some serious TLC after indulging in the cheap and plentiful drugs of Southeast Asia, hundreds of American entrepreneurs founded private rehab clinics that offered solace on a vet’s insurance budget. The 28-day period was chosen simply because it’s the length of the shortest month, the maximum stay the army was required to cover. These new facilities claimed wonderful results, which over the next few decades were slowly revealed to be completely bogus, based not upon scientific evidence but on whatever the clinic owners thought their clients wanted to hear. Before Congress cottoned to the scam, billions were squandered, and the one-month residency program had become entrenched all over North America, including B.C. After the shakedown, the B.C. government set out to develop a new “evidence-based” policy, which is outlined in the Ministry of Health’s 2004 manifesto, Every Door is the Right Door. Appendix III of the document sums up the history of addiction treatment: the original “shame-based” model, which blamed the victim’s moral weakness, evolved by the 1960s into the “disease model” used in the original 28-day program, which treated addiction as a medical condition. By the mid-’90s, the disease model had been retooled into “cognitive behavioural therapy”; addicts undergo behaviour therapy to help them break the connection between troublesome situations and their habitual responses to them. At the same time, cognitive therapy is provided to help them identify the thinking patterns that provoke their addictive behaviour in the first place. The government’s approach is commonly known as the four pillars: harm reduction, enforcement, treatment and education. It sounds very stable, but those pillars keep changing height. Ten years ago, little or no money was spent on such harm reduction measures as safe injection sites, needle exchanges and methadone clinics because the medical community considered these strategies ineffective. [pagebreak] Today funding has been shaved off the treatment pillar and added to those of harm reduction and enforcement. Hence the ballyhoo over the opening of the dual diagnosis centre in St. Paul’s Hospital in Vancouver, which handles such unsavoury combos as bipolar disorder and crystal meth addiction. Crystal meth comprises only a tiny slice of the addiction pie, but in terms of television news coverage, it can’t be beat because it involves colourful street characters, the children of voting parents, and labs that create fireworks when they explode. Thanks to such coverage, most people assume ground zero for B.C.’s addicted population is the Downtown Eastside, whose denizens drug themselves to kill the pain that comes from being too broke to cover the basic necessities of consumer life. But Fort McMurray counsellors say the addictions they treat are typically rooted in the stratospheric wages of the resource sector. Drug addiction spans the province, affecting affluent communities and impoverished ones; having money to throw at the disease is no cure for it. Take my friend Stan, for example, who lived across the hall from me in a giant Victoria mansion that has been divided into what realtors call character suites. Stan was a 30-something divorcee with an Eraserhead hairdo and the eyes of Rasputin, who helped found a health-food restaurant in town that was a big hit with the wheat grass crowd. The other owners bought him out with a handsome settlement, so he didn’t have to work. He spent his days napping, watching DVDs and playing the drums. Some nights he would scratch my door like a cat, and when I answered he’d walk right in, talking a mile a minute about something he’d just found on the Internet, and scraping tiny tracks of cocaine together on my kitchen counter. As a child of the ’70s, I occasionally enjoy the numb surgical chill of the white lady, but I always get the sense that cocaine wants to drive the bus, so I’ve done it less than a dozen times. The last few times were with Stan. Then one morning two years ago he knocked on my door and sheepishly handed me a giant bottle of tequila. His family had staged an intervention. He was quitting everything, forever. He went to Edgewood, a government-supported rehab facility in Nanaimo, and I looked after his apartment. At the end of summer he came home plump and shiny-faced, babbling like a song from The Lion King about seizing the day and owning the pain, and how the Navajo used only verbs because to them life was a “process.” On his first night back he borrowed a roll of toilet paper, claiming he hadn’t had time to get to the store yet. Fair enough. On the third night I came home to find my front door unlocked. Stan said he had lost his key, so he’d climbed in my back window. I checked my stuff, feeling like a rat, because I liked the guy. On the fifth night we made vague plans to watch Rabbit Proof Fence on his giant TV. I ended up going to a movie downtown instead, and when I got home Stan had left a replacement roll of toilet paper on my doorstep. I was glad to see it. Perhaps I had misjudged the situation. But across the hallway, Stan was already dead. Next morning I watched two paramedics wheel him outside in a big black tote. What a waste. That guy had a unique mind, and God knows how many thousands his family spent cleaning him up. After a while I got to thinking: This was the second time a friend had died just after going through rehab. With an issue as grave as mortality I consider once a coincidence and twice enemy action. I called the Edgewood treatment centre to ask a few questions. The receptionist told me the founder, Neal Berger, had left years ago, and now ran a private facility named Cedars at Cobble Hill, just north of Victoria. When I got hold of him, he said he wasn't surprised to hear about Stan's post-Edgewood demise, adding that three months of residence without follow-up can be fatal. At Cedars he offers individual treatment plans whose length of stay depends on the client's progress, and their ability to stick with an effective continuing-care strategy. After talking to a number of pros like Berger, I began to wonder if the root of the relapse problem is the government’s attempt to change rehab from a medical issue into a social one. Liberal apparatchiks have recently redefined treatment from abstinence-based models to ones of harm reduction, despite insistence from the medical community that harm reduction has an 80- to 90-per-cent relapse rate, and therefore costs much more in the long run. Plus, as Keynes gloomily observed, in the long run, everyone is dead. The failure of the government’s model is one source of the spate of private rehab clinics that have sprung up all over B.C. (see “Route to rehab,” below). Another is backlash from the collapse of the original 28-day model in America, where residency programs have been tossed out with the bath water. Stateside insurance now covers only a portion of any kind of treatment, and costs have doubled in the past five years, so these days it’s actually cheaper for Americans to pay the whole shot at a B.C. clinic than it is to cover the uninsured portion south of the 49th. As a result, facilities like The Orchard, founded four years ago by Bowen Islander Lorinda Strang, serve a clientele that is up to one-third American. At the Sunshine Coast Health Centre in Powell River, the percentage of clients that hail from the States can rise as high as fifty. Mark Sadler, director of the Top Of The World ranch outside Cranbrook, which offers 28 days of rehab, horseback riding and hiking for $20,000, says the ranch’s price tag shocks both Canadians and Americans, but for opposite reasons. U.S.-based, high-end facilities similar to Top Of the World cost up to $70,000 a month. Meanwhile, British Columbians who can’t afford ranch-style rehabilitation must make do with non-profit clinics like the 35-bed Pacifica Treatment Centre, located in downtown Vancouver and 75 per cent funded by the provincial government via the Vancouver Coastal Health Authority. The other 25 per cent comes from paying clients. Treatment is free for those on income assistance, costs $40 a day for the employed, and $130 a day for clients from other parts of Canada and from the U.S. – although it seems odd that a publicly funded facility with a waiting list accepts non-Canadian clients at all. Pacifica employs a bio-psychosocial spiritual model, which sounds pretty sexy, but unwrapped turns out to be the old four-pillar approach – harm reduction, and so on – and it’s up to the client to maintain his or her own after-care regime. Relying on addicts to police themselves seems absurd. My neighbour Stan, for example, while he was filling his system with crack, turned down a glass of tap water because it had chlorine in it. And there's a lot of bullshit flying regarding the effectiveness of such clinics, which sometimes claim up to 80-per-cent success rates, while program directors like Berger and Ray Baker, who designs treatment plans with a company called Health Quest, say even thirty per cent would be high. [pagebreak] Baker feels the most successful addiction strategy is the one used to straighten out airline pilots and licensed physicians. It’s an abstinence-based model whose adherents must sign an agreement that makes their jobs contingent upon compliance with follow-up treatment. According to Baker, some of the B.C. government’s residency-style programs are so flawed that if a pilot or a doctor was sent to one he or she could sue the referring agency for negligence. But how do private facilities like Cedars factor an open-ended problem like relapse into their business models? Baker tells me bluntly that they can’t. The only hope is to develop a system where intervention comes early and follow-up is the major portion of treatment. Baker no longer deals with MSP-funded services because he can’t spend enough time with patients to make a difference. Plus, there’s now a month or more wait between detox and rehab. That’s a disaster. During addiction, a person undergoes neuro-adaptation. Their brain chemistry changes until their tolerance to the poison of choice becomes stratospheric. After detox, their regular dose can kill them. That's what expunged Stan. Baker has been an expert in addiction medicine since 1986, and has never had to wait this long to get people through treatment. He calls the government policy “criminal,” adding that politicians “lack the science base to create good policy. Alcoholism is not social drinking that’s gotten out of hand. It’s a disease of the mesolimbic system of the brain.” Alcoholism has a pathogenesis as hackneyed as a Hollywood blockbuster. Its first and third acts, from addiction to death, run on average 19 years for males and a little less for females, whose stomach linings lack an alcohol metabolizing enzyme, allowing more of the poison to reach the liver. Also, a woman’s fat-to-water ratio is higher, which adds up to higher blood alcohol from the same amount consumed. Yet three times more men are afflicted, an imbalance rooted in genetics. Extensive adoptive twin studies show that if a man’s father was alcoholic he is four times more likely to go down that same road. A man whose dad had cirrhosis is at extraordinary risk, even if they’ve never met. To Baker, these are not the hallmarks of a social problem but of an ailment as organic as diabetes, and the government’s reliance on harm reduction is on a par with funding more comfortable beds for people who need a new kidney. One can understand the government’s dilemma. Anything that reduces health-care costs on paper must seem very attractive to anyone seeking re-election. (Provincial government officials did not provide figures on the average cost of treating an addict in a 28-day rehab centre.) Unfortunately, the evolution that has supposedly led from shame-based treatment through disease models to cognitive behaviour therapy is actually a loop, because its success depends upon clients showing the kind of personal responsibility so evidently lacking in junkies. Such reliance on the moral fibre of the individual sounds good, but is in a sense a return to the old shame-based model. That’s not how the government literature puts it, but anyone still reading Every Door is the Right Door will notice by page 116 that there is no official definition of “disease model” or “abstinence” in the glossary, whereas cognitive behaviour therapy and harm reduction are explained at length. It’s a philosophy that puts the BC Liberals at odds with medical research, but it puts them in step with Oprah Winfrey, whose book-of-the-month selection, A Million Little Pieces, authored by James Frey, argues that addiction is not a disease but “a weakness.” As a discredited Frey later proved, a more common malady these days is twisting facts till they serve your own ends. Of course, no one reads jargon-filled documents like Every Door is the Right Door. It’s impossible to get though all that doublespeak. So I phoned Victoria Withdrawal Management Services, the Garden City’s government-run detox clinic, to find out what was happening on the front lines. The facility was protected by an automated switchboard that can only be described as baroque. God help any drug-addled soul trying to get into treatment. Finally I reached a harried drone who three times in five minutes put me on hold with only Enya for company. He said the centre had a four-week waiting list because the government would only fund eight beds for all of the south island. Then he put me on hold again, although this time I could still hear him behind Enya, his voice cracking as he implored a loved one at the other end of line two to take his frozen roast beef dinner out of the fridge. Then: “Can I call you back? Things are crazy here.” Crazy. That’s the word I’ve been looking for. How else to characterize the three-ring circus that rehab has become, with its cut-rate public policy based on media hype and bad science, a private sector inflamed by U.S. dollars, and ordinary British Columbians falling to their deaths between the two. Between six and 10 per cent of us now wrestle with addiction, and 10 per cent is the figure at which a disease becomes epidemic. Good thing the government has decided it’s not a disease.