The Rehab Economy
Helen -- so not her real name that, a few days after we talk, she asks me not even to use the first consonant of her real name -- figured from the start that she was smarter than the average junkie. She did well in college, excelled in sports, held a top sales position at what she calls a "highly recognizable company" in Los Angeles. But after the failure of one more "dumb-ass relationship," Helen decided to experiment with heroin. She did it the way she does everything else: She read up on the drug's effects, researched thoroughly the most cost-effective and safest methods of getting high. Following the detailed instructions on a Web site at the "Letric Law Library," Helen, at 35, learned how to prepare a solution, fill a syringe and inject the drug into her vein. "That was July 6, 2000," she remembers. "I never thought I'd be an addict this long."
Since then, Helen hasn't spent more than five weeks clean. She has tried to get straight three or four times, twice with the help of the newly FDA-approved drug buprenorphine, which kills both withdrawal symptoms and cravings for heroin. Somehow, the cure doesn't stick. "I guess I'm just not ready yet," Helen admits at the end of yet another frustrated week in which she has managed to stay drug-free for just one day. "I just hope I can quit before I turn 40."
Helen is suffering from what drug-treatment providers call a "recovery-environment problem." None of her friends knows about her "shitty little habit" (although she worries they might read this and recognize her); she is single and does her work independently. What she needs most of all is not simply to quit, but to examine in a therapeutic context her reasons for using. In other words, Helen is a perfect candidate for inpatient detox -- even if she's not particularly motivated. "There's a lot of research that says those people who are coerced into treatment have the same outcomes as people who go in willingly," says Albert Senella, chief operating officer of Tarzana Treatment Centers, whose seven facilities in the area make it the largest private treatment provider in the state. "People who come in here because they've been told by the court that they have a choice between treatment and jail" -- in other words, the beneficiaries of Proposition 36, which since 2001 has mandated treatment over incarceration for drug offenders -- "do just as well as people who come in off the street."
While some treatment programs "haze" their prospective clients, requiring them to prove that they're committed to giving up drugs for good, Tarzana takes anyone who can pay for its seven-day program, during which the drug user is administered daily a steadily tapering dose of methadone -- enough to mitigate the symptoms of withdrawal, but not so much that he or she can't still benefit from educational programs and therapy. The attitude is progressive and practical: "We think a lot about how to increase retention," says the facility's clinical director, Dr. Ken Bacharach, a psychologist, "which involves working with people in a positive motivational sense, not a confrontational and punitive sense. We don't say, 'How committed are you to quitting?' We say, 'Come in, wanting to drop out is normal, it's okay, let's get it out in the open, look at the choices you have.' We treat people like adults."
Tarzana's long-term rate of success is hard to measure: People often disappear after treatment, and usually need to quit several times before the program takes. But "Eighty percent of the people who start the detox program complete it." And even if they need to quit three or four times before they're really done, recovering addicts who follow up a treatment regimen with nine to 12 months in residential or outpatient programs typically stay clean for good.
Helen is lucky: She has money, insurance, vacation time -- nothing to stand in the way of her finding a slot in any one of Southern California's drug-treatment facilities. Not everyone has that luxury: If you're poor, out of work or even just a working stiff without sound medical coverage, finding a bed in a treatment facility gets harder every week. In the next year, according to the current state budget proposal, California will reduce funds for drug treatment by $11.5 million; Los Angeles alone will lose $4 million. "And this was an underfunded department in the first place," says Senella. "I wouldn't argue that it's the first thing to get cut. But it's oftentimes not among the first items on the state's list of priorities." The bulk of Tarzana's inpatient clients have enough money or insurance to pay the $425- to $525-a-day fee for seven days of detox. But California has traditionally funded a number of slots at Tarzana for indigent drug users wanting to avail themselves of the treatment center's wide variety of services, from 24-hour nursing care to recreational therapists, who help defeat the boredom so many recovering addicts complain about. That may change unless the budget crisis is resolved soon. Humane as places like Tarzana may be, they are also businesses, and drug treatment is simply too costly to provide for free.
Drug offenders diverted to rehab under the provisions of Prop. 36 will have less trouble than ordinary civilians landing a state-funded bed at Tarzana, because public money has been earmarked for that purpose. It's probably money well spent: The Drug Policy Alliance recently estimated that sending drug offenders to treatment instead of jail saved the state $279 million last year in incarceration costs. But it also means that fewer discretionary dollars are left over for individuals to take advantage of Tarzana's resources without insurance or a court order. Senella defends the initiative's success, but admits, "There's something a little screwy about having to get arrested to get into a treatment program."
If you're hell-bent on inpatient rehab and want a tonier facility than Tarzana, there's always Harmony Place up in Malibu -- $39,950 for a 28-day program. If you don't have that kind of money, there's Cri-Help in Burbank, where no one is refused admission for inability to pay. There are also a number of outpatient and residential programs: For a full list of facilities in Los Angeles County, go towww.lapublichealth.org/adpa/ reports/guide0702.pdf. And for the truly indigent, Homeless Healthcare will find clients a bed in some facility, somewhere -- usually at American Healthcare or Redgate in Long Beach -- within a week. But prospective patients must show up on time and be willing to detox without the help of methadone -- which for many addicts may effectively mean getting no treatment at all.
"There are a lot of barriers to getting [poor] people into treatment," says Terry Hair, the executive director of Clean Needles Now, the embattled needle-exchange program currently operating out of an SUV on the city's streets, which often serves as a drug user's first link to the medical establishment. "Say we set somebody up through Homeless Healthcare; they have to go every day at 8 a.m., and if there's a bed open somewhere, then they send you over, and if there's not, they say, 'Come back tomorrow.' Then, if you come back the next day and somebody else gets there first, you lose that spot -- they're not going to hold a bed for you.
"We're talking about people with chaotic lives anyway," says Hair. "It's hard to make them jump through these hoops."
Having money, however, doesn't necessarily make everything easy. Helen, who is one of Hair's clients at the needle exchange, did not find it such a privilege to be middle class when it came to kicking. She refused to check herself into treatment, both for fear of sacrificing her anonymity and an unwillingness to admit she could not go it alone. "I know I can do it myself," she insisted. "I've done it before." Realizing how that sounds, Helen offered another explanation: "You know that saying from the Bible about how it's easier for a camel to go through the eye of a needle than for a rich man to get into heaven? I'd say that about sobriety. If it were taking a toll on my finances, I might be more motivated to quit."
But heroin was taking a toll on her body and happiness. After a third aborted attempt to quit in as many weeks, she finally made her way to Narcotics Anonymous, where she'd been told that 90 meetings in 90 days would spur her will to quit. When after 45 days she was still using, she effectively got herself arrested -- a guy in the program told her he was going to "sit on her" until she quit. He confiscated her cell phone, moved her in with friends, and kept her his willing captive while she took refuge from the hot flashes of withdrawal by sprawling on the kitchen floor. It worked. A month after our last despairing conversation in which she confided yet another failure, Helen called me to say she had 15 days clean. I told her she sounded good. "I know," she observed triumphantly. "Did you notice I'm laughing?"
Judith Lewis writes for the LA Weekly.