Vol. 286 No. 20,
November 28, 2001
Books
Hooked: Five Addicts Challenge Our Misguided Drug Rehab System
by Lonny Shavelson, 310 pp, with illus, $24.95, ISBN 1-56584-684-2, New York, NY, New Press, 2001.
Reviewed by
Barry
Liskow, MD
Vol. 286 No. 20,
November 28, 2001
Books
Hooked: Five Addicts Challenge Our
Misguided Drug Rehab System
by Lonny Shavelson, 310 pp, with illus, $24.95, ISBN 1-56584-684-2, New York,
NY, New Press, 2001.
Reviewed by
Barry
Liskow, MD
Is
treatment of severe drug addiction effective in reducing drug use and repairing
the psychological and social damage done by addiction? This is the question
tackled by Lonny Shavelson, MD, an emergency department physician,
photojournalist, and author of previous books on subjects as diverse as assisted
suicide and the effects of chemical contamination on a community.
In
1997, Shavelson received permission from the city of San Francisco to observe
and interview patients attending an intake drug clinic. For the next two years,
he followed five individuals who were seeking or were forced into treatment,
observing their struggles with drugs and the treatment system. Shavelson
skillfully weaves their separate stories with information from (mainly)
government sources, interviews, and his own evolving insights. He concludes that
the system, although staffed by generally well-intentioned people, does not
serve the people who need it most, is often more concerned with maintaining
entrenched views on how to treat patients than with the effectiveness of
treatment provided, and lacks a commitment to coordinated and continuous care.
Shavelson's
compassion for the three women and two men he observes and befriends is clear on
every page and in his photographs, included throughout the book. He is aware of
the frequent bravado, scams, lack of concern for others, and criminality of this
group of addicts and does not try to judge whether these characteristics are
causes or consequences of their addiction. His focus is that each is suffering
from and struggling with his or her drug addiction and is in need of effective
treatment. He documents their attempts to find such treatment and the outcomes
of the treatment received.
Mike,
a heroin addict for more than a decade, is required to demonstrate in various
ways that he is motivated for treatment for a month before being allowed to
enter therapy. After entering a residential care therapeutic community and doing
well for three months, he is expelled with no aftercare as a consequence of a
brief relapse.
Darlene,
homeless, addicted to intravenous methamphetamine, and chronically
hallucinating, seeks care in both mental health and drug clinics, neither of
which is willing or able to deal concurrently with her psychiatric and
substance-dependence problems.
Glenda,
a homeless chronic alcoholic with severe liver disease, is forced into treatment
by a worker from the San Francisco health department. Placed in a 3-month
residential program, her physical and mental health improves, which several
sequential photos highlight. She is discharged without coordinated follow-up
care and is soon back on the streets, where she dies shortly thereafter.
Darrell
is an alcoholic who has been through multiple therapy programs and stays in
successful recovery for the 2 years, mainly by using his own internal resources
and developing his own recovery program.
Crystal
is a street-wise methamphetamine addict Shavelson meets when she is brought
before a drug court. The court insists she remain drug-free and in
rehabilitation and responds to her relapses by insisting on more intensive
treatment rather than jail. Drug courts, which are relatively new, divert
nonviolent drug offenders in trouble with the law to rehabilitation rather than
jail. Shavelson sees drug courts as a useful method for delivering coordinated
care, which is lacking outside the judicial system.
In
describing the experiences of each of these individuals, the author offers
thoughtful, at times passionate, ideas as to what is necessary to correct the
current system of treatment. He believes that relapse is inevitable and should
be a signal for increased care, not abandonment, that motivation or even
agreement is not necessary for addicts to benefit from treatment, that treatment
must be flexible and meet the needs of patients rather than the treatment
system, that personnel in mental health and drug clinics should be cross-trained
in both disciplines, that patients should have case managers who coordinate all
their care, and that money should not be wasted on unproven or limited
therapies.
A
weakness of the book is that Shavelson does not discuss the value of a number of
available treatments, such as Alcoholics Anonymous, Narcotics Anonymous,
methadone maintenance, or other pharmacotherapies. The omission of methadone
maintenance is especially notable given the positive reports of its
effectiveness for patients similar to Mike.
In
summary, Shavelson has provided a valuable service to his community, profession,
and the five troubled friends he made in writing this book. He has given those
entrapped in a web of addiction, poverty, homelessness, mental illness, and
uncoordinated care a face and a voice. Both the faces and voices insist that
they not be abandoned to the current well-meaning but all too often ineffective
system for helping them recover from the their disease of addiction and its
consequences.
