Philip Seymour Hoffman was an artistic icon and, for me, a sober icon. According to The New York Times, Hoffman had spoken of having 23 years of sobriety under his belt before he relapsed on prescription drugs and then, ultimately, on heroin. From that moment of relapse on, one of the greatest actors of our generation was in mortal danger: Years of sobriety had reduced Hoffman’s tolerance, but his brain craved the drug as much as ever—and he had given that brain another taste. In May of 2013—perhaps realizing the disease was back in force—Hoffman checked himself into a detox facility for ten days, once again resetting his tolerance to zero. His brain was at war with itself: his healthy sobriety brain versus his voraciously hungry opiate receptors. It’s why, unfortunately, overdosing is tragically common for once-sober heroin addicts who relapse.
To be sure, we don't know the precise treatments or care Hoffman was under. And with 23 years of sober time, he no doubt availed himself of any number of healthy habits and solutions to maintain that clean lifestyle. But his death does fit a pattern about what we know about opiates like heroin. It’s true of the actor Cory Monteith, too, who overdosed on heroin not long after leaving an abstinence-only treatment facility. His tolerance was compromised; his cravings were amplified.
A big part of the problem is rehab itself, which is almost universally based on twelve-step work, like Alcoholics Anonymous or Narcotics Anonymous. But AA was developed in the 1930s, in the absence of brain science and in the presence of unimaginable stigma. As Anne M. Fletcher writes in her excellent book Inside Rehab, contemporary rehab is still based on “the folk wisdom of recovering people, particularly through the perspectives of Alcoholics Anonymous and related twelve-step programs." Don’t get me wrong, AA is an incredible program and a true American achievement for the millions of addicts around the world who desperately needed help when absolutely no one else was offering it. I think founder Bill Wilson should be sainted. I, myself, found sobriety in the rooms of AA, where fellowship and rigorous honesty probably saved my life. But AA is not a medical program, and it is not based on science. It is an abstinence-based program that may not be right for every addict. Particularly opiate addicts.
Here’s a more detailed explanation of why: The brain’s own opioid system (e.g., endorphins) becomes suppressed by the high concentrations of opioids used by addicts, and many people’s brains never recover full function. That means no matter how sober they are, they cannot experience ordinary pleasure, they feel vaguely ill all the time (like a low-grade flu), and they are constantly craving opioids. Which is why long-term opiate-replacement therapy—that is, taking a small amount of an opiate under the supervision of a doctor indefinitely—may be an answer for the most intractable addict or for the recently relapsed addict. For many opiate addicts, abstinence alone basically results in a chemical deficiency that leaves them totally vulnerable to opiates. Buprenorphine and methadone restore this brain function to normal. It’s similar to giving insulin to diabetics. And the twelve steps or “working the program” can’t fill that void—any more than support groups could treat diabetes.
For years, buprenorphine and methadone have been prescribed for opiate addiction. Opiates that are less addictive and produce a less-intense high, these drugs offer a substitute for the addict’s drug of choice, replacing the effects and limiting withdrawal. Then there’s Suboxone, a mixture of buprenorphine and naloxone. Suboxone binds to opiate receptors to mimic the effects of opiates; it also resists abuse by making the addict sick if they try to shoot up the drug.
This dual approach has provided remarkable outcomes in young-adult users compared with those who received a standard short-term detox and counseling. In one study, patients taking buprenorphine integrated the drug into their normal day and lived otherwise-drug-free healthy lives; but, once off the drug—even after tapering and counseling—close to 100 percent of patients relapsed. Addicts given Suboxone were “less likely to use opioids, cocaine and marijuana, to inject drugs, or drop out of treatment,” according to the National Institutes of Health.
Long-term use may be vital to a healthy life for an addict. Opiate replacements can literally be the difference between life and death. As Mark Willenbring, M.D., founder and CEO of Alltyr—a scientifically based addiction-treatment center—and the former director of the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health, told me:
The evidence is clear: there is only one proven effective treatment for opioid addiction, and that's indefinite maintenance on another opioid. … It is commonplace for overdoses to occur after abstinence-based rehab and/or detox, because tolerance is lost. I don't know whether [Hoffman] was offered the choice of opioid medication treatment and rejected it, or was told that if he "worked his program" he would succeed. Either way, detox killed him.
Without opiate maintenance, what’s an opiate-starved person to do? When you have an insulin deficiency, what do you do? You replace it. Sometimes for life.
But what about potential for abuse? As an addict myself, I know that it’s all too easy for me to think, If one buprenorphine pill is good, two pills must be better. Luckily, there has been a lot of progress on this front, too. Crush-resistant pills stymie those who would snort or shoot their meds. And new improvements in extended-time-release pills are making it possible, for example, for addicts to take just one pill a month. If you have to go to your doctor every month for that pill, it’s pretty hard to abuse. Of course, it’s possible to abuse any drug if you try hard enough. But potential for abuse doesn’t mean we should throw out a possibly life-saving method—especially when the science is sound. It’s time that the mainstream twelve-step abstinence/detox movement and the scientific community had a long talk.
In Owning Mahowny, Philip Seymour Hoffman electrified with a wrenching portrayal of a desperate addict—a gambling addict—who said, “The thing is, I guess that my secret life is a bit less secret than everyone else’s right now.” If only those words weren’t so true.