Rehab For Poor People

By Jeff Deeney 03/05/12

Dirty and depressing, public treatment centers are a far cry from Celebrity Rehab, but they've helped thousands of down-and-out addicts turn their lives around.

Med time at a Philadelphia clinic. Many states are slashing their treatment programs.
photo via

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 An antique television with a wire-hanger antenna plays grainy tapes from a comically outdated video library.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 various states of withdrawal sit around a rickety round wood table, playing 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 has basically become a two-tiered system. For wealthy people, rehab can be kind of fun—like a luxe seaside vacation or a wilderness retreat. But poor and uninsured Americans have to settle for what the government is willing to give them. And in lean economic times that doesn't amount to much.

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 fact, in many states they’re worse than ever.

I slumped into my cot here the night before, a shaky, sweating mess. At daybreak a rapping foot bangs on 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,” says a tall nurse. “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 can get treatment in one of several ways. Many know where hospital detox units are from past experience. Others just walk in off the street and ask for help. Most, in the desperation of hitting bottom, go to the emergency room—there’s generally one within walking distance of any city’s hot dope corners—and say they’re going to kill themselves. Threatening suicide is a sure-fire way to get a bed.

Increasingly, drug users are sent to treatment by the justice system. An addict gets picked up by vice for turning tricks, say, or nabbed 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 has become the front door to recovery for many indigent addicts, aka the “community behavioral health system.”

The cinder block walls of my room here are painted a dingy white. The beds are more like cots. Their slender metal legs are attached to thin, rusty frames that uphold a sagging layer of thick wire mesh, the mattress—and me. There’s a nightstand between my bed and the next bed over. A dresser is shoved between the door and a small closet. Both the dresser and the nightstand are tightly nailed to the floor; the room’s only lamp is fused to the nightstand. Beside my bed is a duffel bag overflowing with stale clothes. Next to it lies a garbage bag, similarly stuffed, abandoned by 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 what kind of treatment you need; 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 have started to 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 experts weighs these recommendation against their own internal records to determine if a stay in rehab is “cost-effective”—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.

One of the three empty beds in my room is soon occupied by a frail skid-row drunk who hobbles in from the bathroom, cautiously lowering himself onto its edge. The clothes-filled garbage bag is his. His hair is thin; the skin hangs from his face as if it might slide off, exposing his sorely aching brain. He has barely any color, as if his body doesn’t have the strength to pump much blood. When he sits on the bed, the nurse reappears. The nurse kneels and grabs the man’s oil-stained construction boots from under the bed. Apparently he was a tradesman before succumbing to alcohol. His hands are shaking too hard to take the boots from the nurse, let alone tie his shoelaces, so the nurse slips the boots on his feet and ties them for him.

It way my good fortune to be considered a good risk by the state. I got fully funded for four days in detox and 28 days in rehab. The rehab was decent as far as welfare joints go, far better than the bleak detox unit that was attached to it. There was plenty of food, my counselor was kind, if not expertly skilled, and while I slept wearing every shred of clothing I brought with me because a hole in my bedroom wall let in gusts of January air, in the end my stay there apparently did the trick. I’m still clean and sober years later.

Now that I'm working as a social worker, I realize  I could have done a lot worse. Some publicly funded inpatient rehabs are downright horrific, replete with dried blood and excrement on the walls, collapsing urine-smelling furniture, roach and rodent infestations, and staffed by orderlies who trade cigarettes for blowjobs from jonesing prostitutes just in from the streets.

After rehab, I attended a standard urban community behavioral health outpatient program. These facilities are typically packed to capacity, since they make money off meager Medicaid payments. As a result, addicts get little individual attention and groups are too large to be therapeutic. The counselors tend to be either inexperienced women straight out of college, or older men educated in recovery by NA meetings and jail time.

The smoking pit is a narrow concrete slab where sick addicts congregate in tight circles lighting and smoking one cigarette after the next, snubbing and saving their half-smoked “shorties” for later. Just like at jail, cigarettes are a precious commodity here, and patients try to make their well-hidden tobacco stashes go as far as possible. Bummed smokes are shared, passed around like joints by a few patients who are reduced to begging for them. The pit itself is a rectangular space between buildings, hardly large enough to adorn with benches or bushes. It mostly serves as a repository for snuffed-out cigarettes. There are probably a thousand abandoned butts suspended in the January ice.

Another factor influencing the welfare rehab experience is the ever-expanding role of criminal justice. An inpatient rehab, because of confidentiality protections, is a great place for a drug dealer to hide out from cops and vengeful street associates; there were many in my rehab cohort. But criminals coming in straight from jail or appeasing probation officers can make maintaining basic order difficult. When you take unmotivated people, many of whom barely qualify as substance abusers, and put them in group settings focusing on addiction recovery, they can become disruptive in ways that make it harder for motivated addicts to recover.

Last week, at a Philadelphia welfare treatment center, an illegal gun transaction between two clients went bad, resulting in the seller pistol-whipping the buyer right outside the detox's front door.

At my detox, like at most others of its kind, the patient's common area is racially segregated. There’s no visible tension, since most of us are still too tired or sick to muster up any energy. But lines are clearly drawn and allegiances clearly stated. I heard the groups talking shit on each other as I walked the room’s perimeter, looking for my niche. Many patients have done jail time, and there’s a prison vibe to how the room segregated itself. It’s ironic that here, too—among those clinging to the bottom rung of society’s ladder—the urge exists to drawn lines, to say that someone else is not qualified to occupy the same space as you.

Many indigent addicts are homeless, having spent years living in “abandominiums,” as the blighted addict squat houses that dot North Philly are dubbed on the streets. These addicts can stay in 'recovery houses,' publicly funded sober houses where they’ll at least get three hot meals and a cot during outpatient treatment, bunking four to a room in cavernous, converted old brownstones that sleep up to 30 at a time. Recovery house quality, like every publicly funded service, varies wildly; the list of the recovery houses Philly addiction professionals keep in their desk is as thick as a phone book.

A small handful of regulated houses qualify for additional city funding, above the welfare general assistance money most residents use to pay rent. Regulated houses are generally decent, with clean and tidy surroundings and strict rules. There are also the unregulated joints, which are basically crackhouses where addicts queue outside the bathroom each morning waiting to bang bags of dope. While visiting a client, one of my coworkers once saw a rat crawl from the drain in the kitchen sink, flop on the floor by his foot and scurry away. Some disreputable houses even provide entertainment, bringing prostitutes from nearby hooker strolls to serve male residents.

Leaving rehab we exchanged numbers (or email addresses among the few who used it). In weeks to come we called one another, gossiping about who was using again. The number of phone calls I got quickly dwindled; after a month nobody was around to report on who got high because by then everyone but me had relapsed. Then one of my detox buddies nearly ran me down in South Philly, his car careening around a corner out of control, heavy eyelids weighed down by heroin. As he blew past me, he shouted something out the window too slurred to be understood. Another detox buddy ran up on me in North Philly while I was working; he was covered in sweat, mid-crack binge, begging me for five dollars to get a blast.

All this may sound discouraging, but public funding for addiction treatment dramatically reduces social costs that otherwise rise exponentially the longer addiction goes unchecked. No matter how tattered the facility, effective treatment can prevent years of incarceration, welfare dependence, foster care placements and expensive medical care for chronic health disorders. And there are recent positive developments in the field; training in proven techniques like motivational interviewing, cognitive behavioral therapy, trauma-informed counseling and peer-based, ongoing community recovery supports aimed at preventing relapse are being integrated into community behavioral health by state mandate.

My own case testifies to the value of publicly funded addiction treatment. For the past eight years I’ve contributed taxes while working as a social worker.  I work mainly with urban addiction and mental health programs that demonstrably improve lives and cut costs. With adequate resources, treatment for the poor and uninsured would be much more effective, using evidence-based practices rather than just rehashing the same NA literature available for free. But when I was an addict, both in recovery and as a social worker, I’ve seen even the hardest of the hard cases recover. It pays to not give up on people.

Unfortunately, many cash-strapped states and cities have taken an axe to their addiction treatment programs. Though they might save some dollars in the short term, they're just ensuring expensive problems in the future. Without public funds to help pay for treatment sick people only get sicker and healthcare costs get costlier. For a healthy society, quality addiction treatment shouldn’t be limited to those with the money to pay out of pocket for luxury accommodations—or to tragic TV celebrities. Where's Dr. Drew when you need him?

Jeff Deeney is a Philadelphia social worker and a writer who is in recovery. His column, "Street Beat," runs biweekly in the The Fix.

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Jeff Deeney is a social worker, freelance writer and recovering addict in Philadelphia. He is a contributor to the Atlantic and has written for the Daily Beast, The Nation, and The Marshall Project. Follow Jeff on Twitter.