Lorne Hildebrand runs Edgewood addiction treatment facility, in Nanaimo, B.C., a posh example of B.C.'s booming treament industry.
In a province famous for its drug culture – where marijuana is our top cash crop and where strung-out addicts are part of the modern Vancouver tableau – it should come as no surprise that there are more addiction treatment providers in B.C. than anywhere else in Canada. What is surprising: how little is known about these facilities and whether their treatments actually work .
It could be a spa. Or a corporate retreat that emphasizes mindful reflection once the PowerPoints are done for the day.
The reception area at Edgewood is a tasteful blend of leather couches, copper-tinted flagstone flooring and customer-service-sensitive personnel behind the counter. Out front, people stroll along a gently winding covered walkway, paper coffee cups in hand, or pause in the small garden behind for a moment of tranquility, in spite of the faint roar of a highway nearby.
Inside, the gift shop is a cornucopia of artistic T-shirts and jewelry, stuffed animals and giant muffins. And the buzz of activity in the lobby next to it seems like a familiar morning preliminary from other realms, perhaps to another exciting day of “Achieving Better Sales in Office Supplies” or “Maximizing Infrastructure Projects for Your Region.”
Only the luxury pool appears to be missing.
Then the picture starts to come into more focus. The doors along the hallways open to rooms with plain single beds, two to a room, not luxury suites with 600-thread-count sheets on pillow-top king beds. The staff are not young kids schlepping suitcases and room-service trays but people in their 40s and 50s with the authoritative look of school principals. The sombre black plaque at the entrance to the building tolls the bell for “those alumni who have lost their lives to chemical dependency,” listing some 100 names, starting with “Bill G., Age 50” and ending at “Jeremy P., Age 31.”
And then there’s Andrew Singh (name and some details changed), who talks about his nine weeks here with evangelical fervour.
“Now I’m so in touch with my higher power. I know somebody’s looking after me,” says Singh, a Bollywood-handsome 31-year-old whose well-off Prince George family is paying for a stay that is indefinite at this point. “There’s so many things this place has taught me. I used to think about tomorrow. Now I only think about today. I think about not having that hit today. It’s about accepting the things that happened in the past. If I dwell on it, I’m not going to have a chance to grow.”
Addiction Treatment: The Shadow Growth Industry
While it looks like one of the many resorts that dot Vancouver Island, Edgewood – a lodge-like building in a suburban/industrial cul-de-sac near Nanaimo’s Departure Bay ferry terminal – is, in fact, an addiction treatment centre. Andrew Singh is here on his second round of treatment in the past five years because of his problems with alcohol, cocaine and, occasionally, ecstasy. At the urging of both his wife and parents, he has taken indefinite leave from a shoe-store management job and spent two months going to group therapy, talking about what triggers him to use alcohol and drugs, learning that it’s a disease that he’ll always have and abiding by a routine of meetings and chores that’s meant to provide the structure for a new life forevermore.
With 80 beds in its main facility, Edgewood provides services to as many as 500 clients a year, making it one of the province’s biggest treatment facilities. But it is just one small part of B.C.’s huge addiction treatment industry, a little-known growth industry that exists in the shadow of its publicity-hogging nasty big brother, the illegal-drug business. The industry defies easy analysis in much the same way as the illegal operations. Their results are, by and large, unverified. Standards and certification are variable. There is no unified approach to treatment. Indeed, there isn’t always agreement on exactly what treatment is.
THE B.C. MYTHOLOGY IS THAT IT'S HARD to get addiction treatment in this province. The reality is that there are more treatment providers here than anywhere else in Canada. The Canadian Centre on Substance Abuse (CCSA), which lists all known addiction-related agencies, shows 288 treatment facilities in B.C. That’s three times as many as in neighbouring Alberta, and a dozen more than Ontario, where the population is triple B.C.’s. In fact, B.C. is home to more than a quarter of the 1,016 treatment providers in the whole country. Some of that can be explained by the resort effect: it’s more attractive to set up a drug-rehab centre for drying-out executives in Beautiful B.C., next to mountain ranges or the ocean, than amid the oil rigs of Alberta or potash mines of Saskatchewan. But that doesn’t account for all of it. As CCSA policy analyst Rebecca Jesseman notes, Quebec used to rival B.C. in the numbers of private facilities, but that has changed since the Quebec government introduced a certification system. In B.C., which has no provincial certification system, the numbers continue to increase.
That lack of regulation has led to a bewildering array of approaches and training. Some facilities operate with little more qualification than a sincere desire to do well and the fervent testimonials of their clients, a carry-over from the 19th-century roots of addiction treatment as moral missionary work. At the other end, programs run or funded by hospitals operate according to rigorous health-care standards set by Accreditation Canada, the body that oversees hospitals and extended-care facilities in the country. In between there are varying degrees of credentials attached to either the facilities or individual staffers, including the Canadian Society of Addiction Medicine and the American Society of Addiction Medicine. Edgewood, heavily populated by university-trained and ASAM-certified psychiatrists and counsellors, is one of 17 B.C. facilities certified by the U.S.-based Commission on Accreditation of Rehabilitation Facilities.
Training and standards are only two of the grey areas; money and effectiveness are the others. No one knows exactly how much governments in this country spend on addiction treatment. A 2002 CCSA cost report estimates the cost of various levels of addiction treatment paid for by the health-care system across the country at just over $2.1 billion. B.C.’s health ministry, when asked for a number, offered up $1.26 billion – but that’s for addictions and mental health together, blended inextricably in this province. If only half the government spending in mental health and addictions is for addictions, that’s $600 million right there covering detox beds, day treatment, clinics, and some or all of the $100-a-day fees that a lower-cost facility typically charges for its minimum six-week residential cycle.
And government spending is only a part of the money that flows to treatment. There are also all the private clients, who pay anywhere from that $100 a day to much more at the upper end. Typically, employee-benefit programs choose the level of treatment they think is appropriate and pay all the costs. Companies with a lot invested in a valued manager, skilled technician or highly paid professional appear to be willing to spend to hang on to those people. Edgewood, a non-profit that charges $325 a day for a residential treatment program that lasts seven to eight weeks (and then somewhat less for the lengthy after-care phase), gets a significant portion of its business from employee-assistance programs. For people who have the personal resources to pay the fees or who have an extremely generous employee program, there are places such as the ultra-posh Sunshine Coast Health Center, which does have that luxury pool for its 16-bed facility. Fees there range from $14,000 for the “accelerated 30-day program” to $26,560 for the extended 90-day program.
And what does one get for all that money? Persistent critics of 12-step programs – the famous creed of Alcoholics Anonymous that is used, in some form, at almost all treatment centres – say the real rate of success looked at over the long term is about five per cent, no higher than the rate of spontaneous remission. Other long-term studies show success rates as high as 80 or 90 per cent, among treatment groups such as doctors. But definitive, long-term rates for other groups are hard to find.
Most treatment facilities link to stories on their websites from anonymous successful clients. Few provide statistics publicly. At Edgewood, director Lorne Hildebrand, a 53-year-old former business consultant, refers repeatedly to a recent survey done of 181 people who completed the program in 2007, where 92 per cent said they were still sober and two-thirds said they hadn’t even had a relapse. But a notation on the Edgewood website cautions that “internal surveys are subject to bias. Outcome studies conducted at larger facilities by independent firms indicate a typical abstinence rate of 50 per cent after one year.”
In Canada the CCSA and other researchers have identified the lack of information as a central problem in evaluating what works and what doesn’t. Benedikt Fischer, the interim director of SFU’s Centre for Applied Research in Mental Health and Addiction, says he is mystified by how the provincial government makes decisions about treatment funding. Fischer is part of Canada’s burgeoning addiction research industry (UBC, the University of Victoria and SFU have each developed addiction research centres in recent years), which is trying to bring some small measure of scientific method to treatment. But that’s happening in the research institutes, not the health ministries or authorities.
The Last Door Recovery Society, managed
by Dave Pavlus, is led not by doctors but by
people who have been through recovery.
“IN B.C. WE'RE NOT TERRIBLY GOOD at measuring the impact of any of the programs,” says Fischer, currently overseeing a study on whether short-term interventions are effective for university students overly dependent on cannabis. “I have no idea how [health ministry bureaucrats] make policy decisions when they have no information.”
It’s not just the ministry that is making decisions in the dark. Even addiction doctors and employee-assistance counsellors, who make referrals to programs, can only make educated guesses about which programs are the best, based on personal visits to treatment facilities, checks into staff training and what results they are getting from the people they send to various centres. They have to keep updating that, they say, since facilities can swing up or down over time. Barb Veder, the national clinical director for Shepell FGI, one of Canada’s largest employee-assistance-program providers, says the company has one manager dedicated to keeping tabs on treatment services: “What we commit to is keeping our pulse up, maintaining a relationship and rapport with different providers so we can make successful referrals.”
But none of them has comprehensive, long-term data. No facility has the financial capacity on its own to track every one of the hundreds of clients who pass through each year and verify how they are doing five, 10, 20 and 30 years later, not just 12 months later. It’s proven equally difficult for independent researchers and even government agencies to do the long-term tracking that addiction requires.
The main form of evidence is anecdotal and highly selective: facility staff members who primarily remember their success stories or people in treatment themselves. And except for those who drop out early, people who go to treatment facilities almost invariably speak in glowing, quasi-religious tones about how wonderful their program is.
The Last Door Recovery Society
Another gruelling, belly-laugh-producing morning. The 25 men gathered for the daily 9:30 meeting in the back room of the Last Door Recovery Society, located in a well-maintained Victorian house near downtown New Westminster, have also stripped emotionally naked.
The group has done a partial round robin of confessions about how dumb they used to be, about the high they got from being able to go back to work in Mississauga or take a vacation in New York or fly to Europe without using drugs or alcohol, about reconnecting with their kids or fathers. Throughout, group leader Dave Pavlus prods them, his speech liberally sprinkled with the F-word and “eh” and stories that frequently involve the phrase “laughing our asses off” or “learning to be a stand-up guy.”
One well-dressed, young Indo-Canadian man talks about the self-deception you get into when you’re using: “I’m behind this dumpster in the Downtown Eastside and it’s pouring rain and there’s another guy behind another dumpster. And I thought I was better than the other guy because my dumpster had a lid and his didn’t. I thought I’m not doing that fucking bad.” Heads nod, people laugh in recognition.
Others tell stories about the positives of their new lives. One man, a big broad-shouldered guy with a grizzled beard and a baseball hat, says his 18-year-old son actually wants to spend time with him now. “I feel like a father today,” he shares in a shaky voice. “And I’m getting calls from his mom – we split up, like, 16 years ago – saying how proud she is of me.” Even more surprising, he says, is that when some driver cut him off recently when he was driving down Kingsway, he didn’t go ballistic.
Repeatedly, the guys in the group say they’ve found meaning and gratitude in their lives and, over and over, how the program, this group, saved their lives. But there’s also a note of uneasiness today as the men refer cautiously to Harold. Harold, a nurse, had been at Last Door for almost 60 days and was doing well. Then he’d gotten a disability cheque just the night before and had taken off on a binge. Some of the men had seen him, blasted, at the SkyTrain station nearby. It was an unwelcome reminder of how easy it is to fall. Usually, people who bolt from the program do it in the first week, not after 60 days. There’s no tolerance for relapses when men are in the residential program at Last Door. No one had to tell Harold officially he was kicked out; he was packing his stuff that morning.
[pagebreak]PAVLUS, TAKING A BREAK in the front office after the high-energy session, admits the sessions are tough. But that’s his whole approach. Tackling an addiction in your life is tough. It can’t be done by checking into a posh place with no drugs, staying clean for 28 days and thinking you’re cured. The 50-year-old former coal miner and road builder went through 28-day treatment programs four times himself and saw what was wrong with them: “After I went to the Nechako Centre in Prince George, I got drunk on the way home. But I did quit cocaine that time.”
Pavlus came to Last Door in 1983 as a volunteer at the tail end of his fourth and, it would turn out, final round of treatment. He took over the business in 1984 and has been running it ever since, although it was quickly converted to a non-profit. The centre began with two homes on Carnarvon Street before moving to the Eighth Street address in 1989. It has now expanded to include two walk-up apartments and three other sites in New Westminster. About 300 people go through the facilities’ 85 beds each year, ranging from Alcan employees and oil rig workers to dentists and lawyers to people coming out of Downtown Eastside alleys. Pavlus describes his fees as flexible. Some companies pay as much as $500 a day to place an employee there, others $250. Someone who’s paying the bills privately and who is strapped might be asked only to pay what he can afford. “I do a means test to charge different rates,” says Pavlus. He also has 16 beds that are funded by Fraser Health.
Unlike Edgewood, which is heavy on medically trained staff, Last Door is almost completely dominated by people who are ex-addicts themselves, and it follows the therapeutic-community model. Their philosophy: clients don’t learn from experts. Instead, they learn from others like themselves who are further along. The focus is on slowly developing more orderly patterns in their lives – along with new interests, activities and friends. They test out their ability to live new lives during their residency, doing test runs for a few days at a time as they progress with the support of the group. And although Pavlus and his staff have completed courses that qualify them for the International Certified Drug and Alcohol Counsellor accreditation system, Pavlus says Last Door is really run according to his approach: “I train most of my staff.” He unhesitatingly acknowledges that about 25 per cent of people who go through his program relapse. But he adds that half of the relapsers get themselves to a recovery-support program to get back on track.
The Birth of the 12-step Program
Addiction treatment has always been, as author William White noted in his 1998 book Slaying the Dragon, “the synergy of religion, science, social movement and business.” Doctors started trying out treatments for alcoholism in the mid-1700s, ranging from skin blistering to cocaine. As the temperance movement grew, mutual-aid societies sprang up to help people deal with their drinking; Alcoholics Anonymous and the legendary 12-step program emerged from that in 1935. The idea of a 28-day residential program arrived with the alcoholism treatment pioneered by three Minnesota hospitals in the early ’50s. Like tuberculosis, addiction in the so-called Minnesota Model was treated as a disease that had reached an acute stage; when it reached that stage, you were sent off to a kind of sanatorium and then presumed to be well after that. Combinations of 12-step and residential treatment have been with us ever since, along with new strategies: cognitive behavioural therapy, therapeutic communities and more.
The addictions world has also undergone a sea change since the days when alcohol was the focus of addictions treatment. “Ten years ago, it was 50 per cent alcohol problems here. Now everybody’s using a bunch of everything,” says Edgewood’s Hildebrand. “We have more single-user marijuana users than single-user alcohol users.” Legal painkillers, often used for people recovering from accidents or surgery, are also claiming a significant number of new addicts. And there are different kinds of people showing up. “Now I’m working with people who never had a problem with drugs in their entire lives, in their 40s to 60s,” says Pavlus. “Half of them get into addiction with legal pharmaceuticals, OxyContin, Percocet, morphine. Anything you ever heard of on the street, there’s a legal version now. And it’s combinations these days.”
As the addiction patterns have changed, so have people’s ideas about what addiction is. It’s gone from being seen as a moral failing to something much more complex. Many addiction specialists now view it as a chronic relapsing disease similar to diabetes or hypertension. Recent research has also painted vivid pictures for the public about the way drugs alter brain functioning, bolstering the view of drugs as a malevolent force that overtakes people.
But not everyone holds to that view. At the Portland Hotel Society, the Downtown Eastside housing association that runs Insite, the province’s much-debated supervised-injection site, and Onsite, the detox and treatment site now attached to it, staff emphasize working on all the other parts of people’s lives that make them turn to drugs. “Making the drugs absent from a person’s life doesn’t fix all the other problems,” says Portland director Liz Evans. Portland’s holistic approach includes providing art classes, camping trips, medical care and non-judgmental friendship and support to the group they work with: Vancouver’s troubled mix of homeless, mentally ill and addicted. If the person’s drug use declines, that’s good – but if people keep using, they’re not denied access to Portland’s services. Critics say this “harm-reduction” approach allows and even encourages people to stay addicted. Defenders say it keeps users alive and on a path to healthier lives, without the sense of failure that the abstinence-relapse cycle produces.
Lyle King has gone through five rounds of
treatment in a 15-year battle with addiction.
THE ONSITE MODEL STANDS IN sharp contrast to the philosophy of places such as Edgewood or Last Door, which hold that success means total abstinence, not just from illegal drugs or alcohol but also from, for example, the heroin substitute methadone. At Last Door, even cigarette smoking is discouraged – one more addiction that needs to be beaten, in their books. That has led to tussles with B.C.’s health ministry, which insists that people on methadone should have access to government-funded residential treatment beds – an insistence that has led people such as Hildebrand and Pavlus to characterize the government as tilted toward harm reduction.
Those on-the-ground differences are repeated at the upper levels of the addiction hierarchy. David Marsh, the soft-spoken researcher who was Vancouver Coastal Health’s lead addiction specialist until June (he left to become an associate dean at the Northern Ontario School of Medicine in Sudbury), has been a consistent advocate of harm reduction and is dubious about those who claim anyone can find the path to abstinence. Ray Baker is the pyrotechnical talker who runs a private consulting business in Vancouver, HealthQuest, focused on employer-paid addiction programs; he’s part of the group of B.C. addiction doctors that in 2008 wrote an open letter opposing the City of Vancouver’s harm reduction strategies, arguing that it undermines the health of addicted people in favour of public order. He insists that abstinence is possible for even the most damaged person in the Downtown Eastside.
However, those differences, which often dominate the public discussion of drug treatment, disguise agreement among providers and experts such as Baker and Marsh on many other issues.
In keeping with the treatment of addiction as a chronic disease, both Marsh and Baker see early intervention as key to heading off acute problems. They also think outpatient treatment can be as effective as residential programs in some cases and that what happens in treatment isn’t nearly as important as what happens after. Overcoming addiction isn’t just about quitting drugs; it’s about fixing all the other things in your life that made the drugs so attractive in the first place. “If I can’t use my drug of choice to comfort myself, what am I going to do to be happy? That’s what long-term treatment is about,” says Baker. Finding new activities and friends is a crucial part of what it takes to be successful.
And there has to be ongoing monitoring, with consequences, says Baker. In the programs he consults for, employees with addiction problems are frequently monitored for up to 10 years by employer-paid caseworkers after they’ve been through treatment, monitoring that includes both counselling sessions and urine-testing.
Early intervention and post-treatment support
Employee-assistance programs have adopted those ideas of early intervention and post-treatment support. At Shepell FGI, which is the employee-assistance provider for 200,000 B.C. employees (and last year worked on addiction issues with 300 B.C. employees), there are now several stages in the addiction-treatment strategy. Anyone who calls Shepell to get help for any kind of problem has a counsellor include drug- and alcohol-use questions on the first visit to find out whether a depression, marriage or parenting problem is tangled up with a substance-abuse problem. If that’s the case, those people – along with streams of employees who have come to counsellors because they got hit with a drunk-driving charge, because they passed out in the company bathroom or because their boss has noticed their erratic behaviour – get the soft approach first. How much do you actually use? Have you thought about the long-term consequences? What do you think triggers you to use? How about trying to go for a week without a drink/toke/hit and see how well you do? Sometimes those questions are enough to get people to make immediate changes.
If that doesn’t work, there’s a more intensive approach, including residential treatment if necessary. But that’s only the beginning.
“We know that supporting someone to treatment is only one-third of what needs to be done,” says Shepell’s Barb Veder. “It’s after that that’s the most important, the relapse prevention.” Caseworkers keep checking back with employees and finding resources for support, if needed.
That’s also increasingly the kind of language and strategy two of B.C.’s senior cabinet ministers are using. Health Minister Kevin Falcon and Housing Minister Rich Coleman, whose ministry provides addiction services as part of its increasingly numerous supportive-housing programs, are the two big spenders on addiction treatment in the province. In the past, says Falcon, “we have taken the acute-care approach. We wait until people become very sick and very addicted and then we try to look after them.”
Coleman and Falcon, who represent neighbouring ridings in the Fraser Valley and who confer frequently on their joint file, are tackling the information deficit that researchers have identified. They now have their staffs at work analyzing what is actually working, based on long-term tracking through medical records. Those results aren’t public yet, and it’s not clear how far back in time they can track at this point, but their efforts, when finalized, will mark a giant step forward for addiction treatment in the province. Falcon says they’ve been discovering, for one, that early intervention is a powerful tool: “The work that my ministry has done shows the results from that are quite earth-shattering.”
B.C. health minister Kevin Falcon.
FALCON IS PREPARING TO RELEASE B.C.'S second-ever 10-year plan on mental health and addiction this fall, which will incorporate changes based on what staff are discovering about effective treatment. Coleman is planning to quietly change funding for some of the addiction treatment his ministry now pays for. That is likely to shake up a part of the treatment world. As Coleman says bluntly, “I’m being told that some of the treatment facilities we fund are pretty ineffective. People are using again within seven days.” Still, he admits that it’s a tough go figuring it all out: “The trouble is trying to track the records. Those numbers are not easy to compute.”
Everyone agrees that what has to change is what’s happened to people such as Lyle King for the last two decades: a cycle of addiction and relapse resting on a foundation of a messed-up personal life. King is only 39. Unlike many people who’ve been through what he has, he still looks and acts 39 with his round, unlined face and reflective way of speaking. An Ojibway from Ontario, he had his first beer when he was a toddler on his hard-drinking reserve in Penetanguishene. At 15 he ran away from home to look for his mother in Vancouver. Shortly after, he was supporting himself by selling drugs and working day-labour jobs. By his 20s, he’d married and moved to Kamloops, where he worked in construction but always sold drugs for extra money and, of course, did drugs as part of the scene.
In the past 15 years, he’s gone through five rounds of intense residential treatment that took up almost three years of his life. Sitting in a back room at the Onsite facility on East Hastings, King tries to remember all the times and places, a roller-coaster of being sober and then using that’s motion-sickness-inducing. “The first time was in Kamloops. I went to the Phoenix Centre for detox, then the Kiwanis for treatment. I think I mighta lasted a couple of months there,” says King. His next try at treatment was five years ago, when he ended up in the hospital for 10 months after developing a hepatitis C infection and losing a lung, along with not taking care of his diabetes or, in fact, himself. In the hospital, he got on the meth program and then went to the Awakenings Recovery House in Surrey, where he stayed for nine months. Then, at some point, he ended up at the Salvation Army’s Miracle Valley near Mission for six months. Oh, and he went to some kind of treatment after drug court. He was homeless for a while. He was at Onsite for two weeks sometime last year, the detox on the second floor, but never made it to the third floor, the next phase. He went out and used for a while, then cleaned himself up on his own for a few weeks. On Feb. 2, he came back to Onsite, the third floor this time.
Attempting a New Start
Today, as he talks about his life, it sounds like an oasis of calm. In the morning, he starts with acupuncture and a meditation group. Then a 12-step meeting somewhere in the city, lunch and a long walk somewhere for a couple of hours. Another meditation session after dinner, then another 12-step meeting. Tuesdays he goes to an aboriginal drumming group near Commercial and Broadway.
For the first time since he left his wife and children eight years ago, he’s reconnected with his kids on Facebook, using one of the computers installed in the third-floor common area. His plan is to go on to Round Lake in July, an aboriginal treatment facility in Armstrong, for six weeks. Then this fall, he’s hoping to get into a housing-support program managed by the Portland Hotel Society as part of their supported independent living program. If he qualifies for the rental support, he’ll live in an apartment in the West End and have regular visits from a support worker, someone who will check to see if things are going off the rails or going well.
It’s a more intense kind of post-treatment regimen than someone from Edgewood or Last Door would follow. But it’s often what’s needed for people with a more profound history of hard times such as King. Another important difference: he might slip into using, but that won’t mean he gets kicked out of his housing. Instead, Portland support staff Tanya or Shane will work with him to help him get back to a place where he feels good about himself, to work on helping him transfer his drug-free routines and mindset from the protected setting of a treatment facility to the outside world. That’s the trick, say many addiction specialists. A lot of people do so well in treatment, it’s like they’re addicted to it. But they can’t seem to bring the routines they establish in treatment back to their ordinary lives.
“I’m so determined on getting it right this time,” says King with a quiet sureness. “At Miracle I graduated, but I didn’t have no after-plan. I usually go get a job and my own place, ’cause I’m a workaholic, and then I quit phoning my support people. I’m doing a lot of things different this time.”