By Alex Grabtree
The alcohol and drug service system has absolutely failed most homeless people in the United States. Dr. Lonny Shevelson, an emergency room doctor in San Francisco set out on a tour of the treatment and rehabilitation programs in an effort to gauge the impact that these programs are having. San Francisco passed a treatment on demand initiative, and Dr. Shavelson wanted to see first hand how this had improved life on the city by the Bay.
In his 2001 book on his tour called Hooked: Five Addicts Challenge our Misguided Drug Rehab System, which was intended to follow people in the system to find out which program was most successful. His conclusion was that all the systems fail miserably in serving people with addictions. This book should be required reading at every local alcohol and drug addiction services board, which continue to base treatment on the person curing themselves and the agency helps the person remain drug free.
Shavelson followed five homeless people struggling with addictions to drugs or alcohol or both in a city that has recognized the need to provide treatment. Most cities have a waiting list and an inability to place addicted people into residential treatment without insurance. In Cleveland, there are only a couple of beds reserved for homeless people or very low income people. There is always open enrollment in the day treatment program which asks individuals to stay sober while returning to drug and alcohol saturated environments. Providers routinely report 15 or more attempts at rehabilitation are typical for people with addictions to endure.
In California two initiatives passed, which to the general public decriminalized drugs and provided treatment on demand to the citizens of San Francisco. It was expected that these two efforts would start the process of cleaning up the streets. The reality was that a new bureaucracy was constructed, but the appropriate level of funds never materialized.
Shavelson met Darlene, Mike, Darrell, Crystal and Glenda during his journeys. While this is a non-fiction exploration of a societal problem, the reader gets caught up in the lives of the drug addicts. All are amazing people with a talent for survival despite the punishment that their bodies endure. Darlene is severely mentally ill and an addict. Her self medication allows her to function moving from tents to bushes and underpasses to stay warm and dry. She stays with an abusive partner and rides around on a bicycle.
Mike is separated from his family and is in and out of treatment. He wants desperately to have a good relationship with his wife and child. He puts up the most valiant effort to live by the rules of the residential treatment facilities, but still is lured by his addiction.
Darrell is the one who makes it off the streets. He pushes forward and patiently waits for housing, which in the end he finds. He is overjoyed, but succeeded despite the system. He had the ability to adapt and give up his individuality to survive the system.
Glenda was part native American and spent most of her life on the streets drinking. She finally was taken into custody by the Death Prevention Team and put in Detox. This program was working until they forced her to graduate into independent living which last only a couple of days.
Shavelson met Crystal in the Drug Court after a severe tongue lashing by the courts. After a great deal of backsliding, she did make it to graduation from Drug Court.
It would be wrong to reveal the ending of this book because it does read like a novel, but the simple profile of five people ends with one dying of their addiction, and one ends up in prison for an extended sentence. The most difficult part of writing this book was seeing people destroy their lives as a journalist and not interfering.
The interesting thing that many of the patients share is their disturbed, child abuse and specifically child sexual abuse. The untreated mental health needs of addicts was staggering. National experts report 7 in 10 people with substance abuse problems were caused or exacerbated by child abuse or neglect. Children of parents who abuse drugs are three times more likely to become addicts.
Hooked looks at the San Francisco drug courts as well as the harm reduction outreach teams. Drug Courts provide a carrot and stick approach in order to move people into treatment. The men and women in drug courts are punished if they do not complete a treatment program and they do not maintain sobriety. Without effective referrals to treatment it is hard to measure the success of the Drug Court.
Throughout the book, we read of the overbearing rules at both out patient and residential treatment facilities. The author questions whether the rules are ways to screen out difficult to serve individuals. The result is often early death.
Shavelson talks about the insanity of turning people away after they relapse. If cancer patients were turned away when they relapse, we would see cancer patients walking the street being eaten alive by their own bodies. Yet, we allow the health condition known as addiction to go untreated until the person is “ready” for treatment. Shavelson ends the book by detailing his suggestions for how to improve the current system. He says:
• When an addict in rehab gets worse and heads back to drugs, the program must increase treatment, not withdraw it.
• Each and every rehab program must be required to have a formal structured association with a drug detox center where it can send relapsed clients.
• Abuses and humiliation in the name of therapy must cease. Cities must establish an ombudsman to monitor the rehab programs, and addicts must be allowed to access the ombudsman without repercussions.
• All rehab counselors must be trained to recognize and treat the multitude of addicts who also have psychological disorders, and refer them to appropriately intensive additional care when needed.
• Cities must establish a comprehensive case management system to guide addicts through the maze of programs and services. The case managers should not work for any particular rehab program, but rather represent and advocate for the addicts in the overall system.
• Government agencies that provide funds to the programs must assure that addicts are receiving comprehensive and effective treatment.
• Federal funds and efforts must be shifted from drug interdiction aboard to drug rehab at home.
Shavelson believes that rehab can work, but needs careful monitoring and oversight. This is a great Christmas gift for the trees of the Alcohol and Drug Board members, and our community would do well to take to heart the advice in Hooked.
Copyright NEOCH Homeless Grapevine in December 2002 in Cleveland, Ohio