The Rehab Economy

Illustrations by Daniel Peacock

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 like 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’s 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.