Reviewed by Steve Heilig, MPH*

For a field which is ostensibly based so much upon honesty, overcoming shame and secrets, “taking inventory”, and the like, the discipline of drug treatment itself has many sacred cows and taboos, ideological and otherwise. Critical works by “outsiders” to the field tend to fall short due at least partly to the authors’ own preconceived perspectives: At the extremes, writers such as Stanton Peele - usually safely insulated in academia - doubt if addiction really exists, where others such as Anne Wilson Schaef extend the addiction model so broadly as to render the concept virtually meaningless. Truly “objective” critiques are rare - understandably so, as most knowledgeable authors have some direct contact with addiction, in self or loved ones, and are informed - or misinformed - not only by research and experience, but by pain and passion.

Last November, California voters overwhelming approved Proposition 36, a new policy whereby people arrested with illegal drugs will be sent to addiction treatment instead of prison. Other states may soon follow suit. A humane, economical, and overdue change no doubt, but one crucial overriding question remains: Just how effective is “drug treatment”? What factors hinder optimal treatment? And what might be done to improve it?

Berkeley’s Dr. Lonny Shavelson, with “Hooked,” attempts an objective look at these question. Or at least he starts out objectively, as a physician with deep interest and enough scientific background to wade through ideology in search of facts. He’s not an “expert” in addiction medicine, although as an urban emergency room practitioner he has likely seen some impact of addiction on every shift worked. What he encounters during the over two years spent preparing this book, however, challenge his every preconception and turn him into an advocate as well as journalist - which is all to the reader’s benefit in this case.

“Hooked” is deeply searching meander through the labyrinth of drug rehabilitation programs in San Francisco, a city with more resources and more progressive approaches than most, but still not enough of either. Shavelson both utilizes and exceeds his professional roles in following five of addicts as they seek, fail, and reattempt to overcome their addictions to various drugs. Their stories provide compelling evidence of how difficult that can be, and how some counterproductive ideologies and policies hinder even the best-intended efforts to help.

“I started researching this book wanting to believe that drug rehab can succeed,” Shavelson begins. “Yet with so many addicts heading from the streets to rehab, then back to the streets and drugs again, my declaration of hopefulness seemed foolish at best.” The struggles of heroin addict Mike, alcoholic Glenda, “speed freak” Darlene, and others - all homeless or close to it - lend him fuel for cautious optimism at best. But these are all “precisely the type of difficult (addict) that rehab programs must succeed with if they are to make a dent in the crime, violence, and craziness that comprise the drug problem.”

The personal stories Shavelson explores are quite moving. One repeated message is that drug addiction rarely arises on its own - a tragic history of pain usually precedes it. Consider Mike, a macho plumber and father who has lived with secret nightmares of his childhood sexual abuse for decades. Shavelson is “incredulous” upon learning how prevalent such links are, and quotes research showing that rates of drug use “are up to 25 to 50 times higher for boys who have been sexually abused than those who have not”, and as for women, “some 60 percent who enter drug rehab have experienced incest and molestation as children.”

Yet many or most drug rehab efforts deal only with addiction, a hefty charge, to be sure - and ignore or discount the myriad other psychological issues often involved. Shavelson finds that “dual diagnoses” - of both addiction and mental health problems such as clinical depression, whether from past sexual abuse or any other reason - are given much lip service but much less appropriately-tailored treatment.

What’s worse is that many addicts must fight to get into treatment at all. Long waiting lists result from underfunding, but some barriers are intentional, intended to screen out the unmotivated or the troublesome, who even if they are accepted may leave as soon as they are subjected to the routine humiliations some rehab programs practice. Shavelson delves into the controversies about such traditions and sides with those who argue such barriers are counterproductive. Many addicts, his profiles show, tend to be weakened and humbled enough already; rehab efforts must take advantage of any glimmer of desire to quit, for “the fierce power of an addict’s obsession with drugs is matched, when the timing is right, by an equally vigorous drive to be free of them.”

More than once in his book, Shavelson compares the dominant treatment approaches to addiction with those of other chronic diseases, and finds what he sees as fundamental flaws in the former. Subsequent to publication of “Hooked”, I heard him remark, in a succinct summary of one of the main shortcomings he perceives, that “We expect (insist) that clients can maintain sobriety while in programs, when what they came to us for was help because they can’t maintain sobriety. This fundamentally strange idea, that they have to be cured to be treated, still strikes me as bizarre.”

And before they addicts are truly ready, there are ways to help them - here the controversial specter of harm reduction appears - which are neglected where they conflict with strict “abstinence only” ideologies. Shavelson’s subjects are booted from treatment at the seemingly slightest failure to comply with the hallowed rules and regulations of some treatment programs. In the meantime, until they are ready to fully play by those rules, they remain at highest risk of overdose, exposure, other diseases, and legal trouble.

As for linking of services, Shavelson diagnoses a dysfunctional rehab system which hardly deserves the name. Programs serving the same “client” often seem to labor under a complete lack of coordination. Shavelson accompanies his addicted subjects from program to program, watching them get bounced around and lost to no good end. Summarizing Darlene’s plight, he recounts that “she has been tossed about in a cyclonic quest for rehab; referred to and then immediately kicked out of three drug treatment programs; flung through a futile search for a case manager in the mental health system; referred by the city’s mental health counselors to the substance abuse counselors; referred back to mental health in circles that have spun me dizzy just watching.”

Shavelson doesn’t just watch, though. He obviously becomes emotionally attached to some of his subjects, and eventually becomes as much advocate as journalist, crawling through mud to locate Darlene and get her to an appointment, arguing with reluctant treatment personnel on her behalf, almost himself getting busted at one point; when Mike’s girlfriend has his baby while Mike is imprisoned due to a relapse, he pleads with Shavelson, who has become perhaps his last best friend and supporter: “Can you go over there, and hold the baby for me?”

Some may fault Shavelson for this apparent lack of impartiality, and thus perhaps question his conclusions and recommendations for remedying the problems he has witnessed so closely. But his examinations of the relevant research are sound, and the stories he relates here are moving and all the more meaningful for his lack of “professional” distance. In fact, that very breach is part of what makes “Hooked” a landmark work, which reads like read like compelling fiction at times, but is an essential look at an all-too-real problem. Shavelson challenges cliches many times in this book. but here’s one more, honestly offered: “Hooked” should be required reading for anyone in the addiction treatment field. You may not like it, it may not taste good if your own strong convictions are challenged herein, but this medicine may be very good for you.

*Director of Public Health and Education, San Francisco Medical Society.
1409 Sutter Street
San Francisco, CA 94109
e-mail: heilig@sfms.org