Overdevelopment, Overpopulation, Overshoot
Container City: Shipping containers, indispensable tool of the globalized consumer economy, reflect the skyline in Singapore, one of the world’s busiest ports.
With the news last week of country star Mindy McCready’s suicide by gun, the death toll among Dr. Drew’s “Celebrity Rehab” patients now stands at five, giving the show an unusually high mortality rate of nearly 13 percent. But what’s even more disturbing is that most of those deaths — possibly even McCready’s — might have been prevented if the program had utilized treatment practices proven to be most effective.
Although Dr. Drew appears to truly believe in what he does, addiction experts say that the treatment philosophy and policies demonstrated in his show and public statements often do not reflect the best evidence-based practices. His rejection of maintenance treatments, use of punitive detox practices and humiliating therapy, and insistence that people cannot truly recover without complete abstinence through 12-step programs reflect the conventional wisdom of the 1980s, not the data of the 21st century. Indeed, “Celebrity Rehab’s” treatment — leaving aside the massive confidentiality violation of being televised — diverges dramatically from the National Institute on Drug Abuse’s (NIDA) Principles of Drug Treatment, a guide that lays out standards for the best addiction care.
Take the harsh way McCready was treated during her detox on season three of Pinksy’s show, which premiered in 2010. As the cameras rolled, the country star began shaking and making involuntary movements. Her roommate, Mackenzie Phillips, simply laughed at her, apparently buying into the stereotype that addicts who seem ill must be faking it. But as Phillips belatedly realized that the seizure was all too real, the cameras continued to roll. She raced around, screaming and searching for a nurse; nearly a minute goes by with no one stopping the production to help. Instead, the camera person actually zoomed in as McCready shuddered and shook.
Prior to treatment, McCready admitted to drinking and taking benzodiazepines (anti-anxiety drugs like Valium and Xanax) — both of which can cause withdrawal seizures if patients aren’t adequately medicated during detox. Indeed, withdrawal from benzodiazepines and alcohol — unlike methadone or heroin withdrawal — can be fatal because these seizures can progress into a condition called status epilepticus.
Charles O’Brien, M.D., Ph.D., is the director of the University of Pennsylvania’s Center for Studies in Addiction. He has developed drugs to treat dependence to alcohol, opioid and cocaine, done pioneering research into the clinical aspects of addiction and the neurobiology of relapse, been a longtime adviser to the government on drug policy, and is widely seen as one of the top treatment experts in the world. He says that the death rate from such seizures can be as high as 10 percent. “If you properly medicate, you can usually prevent seizures,” O’Brien tells me. (To be fair, McCready had also suffered a previous head injury, which could also have caused the seizures.)
Seizures and other behavioral consequences of Pinsky’s tough-love, no-medication, abstinence-only approach make for high drama, which is why some detractors have argued that “Celebrity Rehab” may put entertainment ahead of the most effective treatment — and even safety. For his part, Pinsky argues that drama is the only way to attract viewers. He told the New York Times in response to criticism of such practices by other addiction specialists that “the problem with my peers is they don’t understand television … you have to work within the confines of what executives will allow you to put on TV.”
Dr. Drew’s treatment “philosophy” diverges dramatically from government standards for the best addiction care.
Sadly, that’s not the only way in which the show fails to provide evidence-based treatment. Consider what happened to former Alice in Chains bassist Mike Starr, who, under the current standard of care, probably should not have been detoxed at all, let alone as rapidly as was done on the show. In 2011, he died of an overdose of unspecified prescription opioids.
In the first episode of season three in 2010, Dr. Drew notes that withdrawal symptoms vary but that Starr is “in for a painful and even dangerous journey.” Starr was withdrawing from methadone, which he had been taking for 10 years to treat heroin addiction, a not insubstantial period of time.
Most experts say that methadone detox, done slowly, even after decades of use, needn’t be either extremely painful or dangerous, merely unpleasant and at times seriously uncomfortable. But Starr was withdrawn quickly, producing pain — and drama. He vomits voluminously at one point, leaving the puke to fester overnight when no one comes to clean it up. Sanitation issues are not the main problem, however.
O’Brien says that allowing people to suffer by abruptly stopping methadone is unethical. “It’s a moral thing, and it doesn’t have anything to do with recovery,” he says. “Why should we be sadistic and want people to suffer just because they’ve become addicted? There’s not a shred of evidence that it’s good. This has absolutely no benefit.”
On day two of Starr’s detox, Pinsky describes his withdrawal as “so bad that he’s becoming confused, paranoid and rageful.” However, the doctor apparently does not slow the detox process to ease these symptoms. Indeed, as Starr kicks things, curses at the staff, makes obscene gestures and demands the cameras be turned off, the production continues, ignoring what appears to be a removal of consent to tape.
By day four, Starr has broken a lamp and refuses to get out of bed. Dr. Drew considers sending him to a lockdown psychiatric center, describing the musician as “overtly psychotic, a complication of his methadone withdrawal.”
However, psychosis is not considered a symptom of methadone withdrawal, according to O’Brien. “If someone becomes psychotic during withdrawal, it might be underlying schizophrenia,” he says, explaining that many people with addictions also suffer other psychiatric conditions. “We have seen people who are doing well on methadone go to pieces when they are taken off abruptly,” he says. “That’s why you take them off slowly. The best way is long-term detox over months as an outpatient.” That is, not 21 days’ inpatient like Dr. Drew’s program — and probably not at all if the patient does poorly without the drug.
“Celebrity Rehab” also reinforces negative stereotypes and myths about addiction — primarily the idea that abstinence through the 12 steps is the only hope for recovery. That idea may have been deadly for Starr and some of the other patients, like bodybuilder and actor Joey Kovar, who overdosed on opioids last year, and actor Jeff Conaway, who died of pneumonia that was probably sparked by an opioid overdose in 2011.
For one, Pinsky’s repeated insistence that abstinence through 12-step programs is the only way to recover is a fundamental deviation from evidence-based best practices. In a voice-over on the show, Pinsky says, “12-step meetings are the cornerstone of recovery. Therefore, attendance is mandatory.” He also states, “Without 12-step, in my experience, there is no possibility of recovery.”
In a statement, a spokesperson for the National Institute on Drug Abuse (NIDA) disagreed, saying, “Different treatment approaches are needed for different people, since not everyone afflicted with addiction responds to the same intervention.”
Indeed, it’s not clear why a methadone patient like Starr should have been encouraged to stop that medication at all. Studies have shown conclusively that methadone reduces opioid use, cuts death rates and lowers crime: it is at least as effective as abstinence-based treatment on these measures, and in some cases, more so.
While some methadone patients can achieve lasting abstinence, the risk of relapse and resulting death by overdose is extremely high. As a result, expert advice is generally to support attempts at abstinence but not to disparage maintenance or oppose a return to it if the patient isn’t doing well.
In fact, a 2007 consensus statement convened by a panel of experts by the Betty Ford Center — not exactly a hotbed of support for non-abstinence treatments — recognized that people on stable maintenance should be seen as being in recovery, just like those in 12-step programs. The experts wrote, “formerly opioid-dependent individuals who take … methadone as prescribed and are abstinent from alcohol and all other nonprescribed drugs would meet this consensus definition of sobriety.”
This is apparently news to Dr. Drew, who tells patients that “methadone takes your soul away,” which can’t mean that he thinks methadone is consistent with sobriety. When questioned about this statement, he told VH-1, “If you get enough for it to work, you’re just on the couch. You can’t do anything.”
“That’s completely false,” O’Brien says. “We’ve had people on methadone going back to school, practicing law. There’s hard evidence that methadone saves lives and probably a lot of souls, too.”
Pinsky discourages not only methadone but also maintenance with buprenorphine (Suboxone, Subutex), which is also consistent with sobriety if used as prescribed, according to the Betty Ford consensus. Indeed, Hazelden itself — the originator of the 28-day abstinence-based model on which Dr. Drew’s program is based — has recently begun offering buprenorphine maintenance. It had found that too many people were dying of overdose following treatment, so it changed its practices based on the data. Three of the five deaths following “Celebrity Rehab” have involved opioid relapses that might have been prevented by maintenance.
But Dr. Drew insists — again contrary to NIDA guidelines — that buprenorphine “is supposed to be a medication for outpatient detox,” not a maintenance drug. NIDA says, “Buprenorphine has been approved to treat opiate addiction, reducing withdrawal symptoms and preventing relapse without producing euphoria or sedation.”
Still, on an episode of ”Sober House 2,” a counselor can be seen taking buprenorphine away from Starr, calling it “the root of all evil.” While Starr had been using crack and other substances as well as his maintenance drugs, experts say that he could have been detoxed from them while on methadone or buprenorphine.
“Where I get really annoyed is when people say that they ‘don’t believe in’ medication or that it’s ‘against my philosophy,’” O’Brien says. “That’s not scientific. Maintenance has saved thousands of lives. People who have this prejudice are engaging in unethical behavior.”
“I wish I could claim more responsibility for [Mindy McCready's suicide],” Dr. Drew said.
And sadly, the deviations from recommended treatment on “Celebrity Rehab” don’t stop there. In episode two of season three, McCready and fellow patient Dennis Rodman were taken for brain scans, purportedly to show them how much their addictions have damaged their brains and the harm that will result if they relapse.
“We do a lot of research with brain scans but we don’t claim this has any role in treatment at the present time,” O’Brien says. There’s no way currently of knowing what the scans really mean for recovery. However, on “Celebrity Rehab,” patients are told that their brains are damaged. The intention is apparently to use fear of the negative consequences to strengthen their resistance to relapse. But this exposure to their own brain damage could make them hopeless about their ability to avoid relapse instead.
If someone were providing care on national TV for years that was as far away from what experts recommend for any other condition, it wouldn’t take a journalist to bring the misleading claims to the experts for debunking, especially after someone dies. But addiction still isn’t really seen as a disease where research evidence should determine the best treatment. Instead, it’s a matter of “philosophy” and faith. You can say, “Methadone steals your soul,” and still get a national TV show and be quoted every time a celebrity relapses—and no one even reports until after a death that all of the major bodies on addiction medicine disagree.
While the choices that McCready, Starr and others made after leaving treatment are clearly their own and cannot simply be blamed on any treatment provider, insistence that a return to any form of maintenance treatment is a failure and that there are no alternatives to the 12-step program of abstinence certainly does not offer hope to patients. If they begin to find the pain unbearable and do not find the steps useful, they may believe they have nowhere else to turn but back to drugs.
And giving people punitive treatment — the way Dr. Drew does in detox — may be part of why they drop out or fear seeking additional help. McCready, for example, was apparently seriously reluctant to get psychiatric help for depression following the recent death of her son’s father, even when Dr. Drew urged her to hospitalize herself. And apparently she left that treatment early, against medical advice. In several decades of research, not one study has supported the confrontational approach over a more empathetic style.
Dr. Drew responded to McCready’s death and the criticism of the show in a call-in appearance on ”The View” last week. He said, “In a weird way I wish I could claim more responsibility for this. The reality is, though, I haven’t seen Mindy, say, in years. I’ve talked to her occasionally, and we’ve been friendly, but I’ve not been her doctor in years. I wish some of [the 'Celebrity Rehab' clients] would stay with us. Some of them do, and some of them are sober, but some go on their own way and cut their own path. And I wish I could be more responsible for them.”
He could start by practicing more responsible addiction medicine.
Maia Szalavitz is the author of the forthcoming book "Tough Love America: How the 'Troubled Teen' Industry Cons Parents and Hurts Kids" (Riverhead, 2005). She has also written for the New York Times, Elle, Redbook and other publications.More Maia Szalavitz.
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