Four beds are crammed into a tiny room, their mattresses encased in bodily fluid–proof rubber and covered in thin, ratty sheets. Dusty dorm furniture in disrepair is shoved in a corner.
The common area reeks of sweat and stale smoke. An antique television with a wire-hanger antenna plays grainy tapes from a comically outdated video library. Extra folding chairs are arrayed against the wall outside the doctor’s office, to accommodate patients during the winter months, when this place is filled to capacity.
A few feet away, crudely tattooed dope fiends in early withdrawal sit around a rickety round wood table, playing endless rounds of Spades while cooking up futile schemes for scamming extra doses of Subutex, a medication that eases narcotic withdrawal.
Outside, a grim patio is surrounded by a slim slab of concrete to defend against people trying to smuggle drugs on to the premises. Patients huddle in the cold, dancing from foot to foot while sucking down cigarettes.
Welcome to Welfare Detox. These are your amenities.
Addiction treatment in America is a two-tiered system, like most of our society. For those of us wealthy enough to pay cash, going to rehab can be kind of fun—like a luxe seaside vacation or wilderness retreat. But the poor and uninsured get what the government is willing to give them. In these times of brutal cuts to public funding for addiction treatment, that amounts to less than ever.
Eight years ago I dragged my broke, uninsured and heavily addicted ass to a welfare detox. During my time there I took notes, some of which are excerpted here. In the intervening years, the collapsing economy has cratered state and city budgets, forcing deep cuts in addiction prevention and treatment. As a result, conditions in these institutions haven’t improved. In many states they’re worse than ever.
I slumped into my cot here the night before, a shaky, sweating mess. At daybreak a nurse’s rapping foot bangs on the leg of my bed, waking me from my daze. I squeeze my eyes tightly shut and open them twice before the sad room finally comes into focus. It’s my first morning in detox. A tall nurse is standing over me. “You can’t sleep all day—it’s not allowed,” she growls. “If you don’t get up, you’ll miss breakfast and then you won’t be able to eat until this afternoon. When was the last time you ate? Go eat something!”
Publicly funded inpatient rehabs can get downright horror-movie-esque, replete with dried blood and excrement on the walls, collapsing urine-smelling furniture, roach and rodent infestations, and orderlies who trade cigarettes for blowjobs from addicted prostitutes just in from the streets.
Destitute addicts access treatment in one of several ways. Many know where hospital detox units are from past experience and walk in off the street asking for help. Others, in the desperation of hitting bottom, go to the emergency room—there’s generally one within walking distance of any major city’s hot dope corners—and say they’re going to kill themselves. Threatening suicide is a sure-fire way to get a bed, as the hospital has to admit you when you do.
Increasingly, drug users are sent to treatment by the justice system. An addict gets picked up by vice for turning tricks, say, or cuffed and stuffed for smashing a car window to snatch a GPS unit. The pretrial services division of the justice system interviews you at the police district via video conference. In determining bail, you’re asked if you need—and are willing to go to—rehab. Rehab generally being preferable to jail, a holding pen is increasingly the front door to recovery, aka the “community behavioral health system.”
The room’s cinder block walls are painted a dingy white. Squeezed into a tiny room, the beds are more like cots whose slender metal legs are attached to thin, rusty frames holding a layer of thick wire mesh, the mattress—and me. The wire mesh sags like a hammock. There’s a nightstand between my bed and the next bed over. There’s a dresser near the door and a small closet. The nightstand and dresser are both nailed to the floor; the room’s only lamp is nailed to the nightstand. Beside my bed is a duffel bag overflowing with stale clothes. Next to it is a garbage bag, similarly stuffed, the luggage of one of my roommates.
Once you’re in the system, you get evaluated by means of a questionnaire called the Addiction Severity Index, the granddaddy of clinical assessment tools . The results help determine which treatment you need; in turn, the evaluator tells the state, which has stringent guidelines regarding who gets what types of care, how much public funding it should release in order to treat you. However, what you need and what the state is willing to pay (from its strained repository of state block grants and Medicaid federal dollars) may not agree. In that case, the addict gets stiffed on the number of inpatient days and is shuffled to a cheaper outpatient rehab or methadone clinic.
More and more local governments rely on managed-care oversight to control the ballooning costs of publicly funded treatment. These entities receive the clinical evaluator’s recommendation—for example, four days in detox and a 28-day rehab for an addict with a ten-bag-a-day heroin habit for five years. Managed care weighs this recommendation against its internal records to determine if it’s “cost-effective”—and if you’re worth the money.
When was the last time you went to rehab? Did you complete the program? Did you follow up with outpatient treatment? If you’ve been to detox a million times and always walk off after a few days AMA (against medical advice) to go buy dope, managed care may decide you’re not worth spending scarce dollars that could otherwise be used by a first-timer with real motivation and better prospects of staying clean. This is the daily detox dramaturgy: social workers haggle furiously on the phone with managed care for more treatment days for clients, many of whom are sent walking with a referral to a cheaper outpatient program.