Last week I wrote about my friend Joy, a woman who has dealt with sexual violence, homelessness, substance abuse, humiliation and criminalization since she was in her early teens. A few days earlier she had tried to end her life. Precipitating the suicide was her realization that if she kept using heroin she would not survive. She made the tough decision to go onto methadone, and enrolled in a methadone clinic. Though she told the clinic about the extent of her heroin use, she was given too low a dose to stave off painful withdrawal symptoms. (Clinics sometimes give doses that are too low to be effective out of fear that patients are trying to trick the staff into giving them more methadone than they really need.) To supplement the methadone she went back to the streets and sex work for the money to buy heroin. The day she tried to kill herself she felt, as she told me later, “What’s the point? I try to do the right thing, go on methadone, and that doesn’t work. There’s nothing left for me.”

Today Joy called me again. She sounded great. She’d had two weeks of a safe bed to sleep in and nutritious meals to eat in the psych ward of a hospital near my house, and the doctors there had gradually raised her methadone dose to a point at which she was no longer dope sick.

“How did you get them to keep you for so long?” I asked, reminding her that last week the hospital had told her that she couldn’t stay there for more than a few days. “They tried to find a place to send me,” Joy explained, “but the social workers couldn’t find anyplace willing to take someone who is on methadone and coming from a psych ward. So they tried to send me to a homeless shelter but I told them that if I went into a shelter I’d be back on the streets and I’d jump off the roof, so they had to keep me because I said I was suicidal. I actually wouldn’t jump off the roof, but sometimes,” Joy added, “you’ve got to finagle a bagel.”

“What now?” I asked. “Well they just gave me my phone back and I’m waiting for the detox [facility] to pick me up.” “What are you detoxing from?” I asked. “You haven’t used drugs. You’ve been in the hospital for the past two weeks.” “Methadone,” she replied. “They decided to send me to detox to get me off methadone because that is the only way I can get a placement in a halfway house or rehab.”

Sounds crazy? Yes, it is. But those are the rules.

Joy has been around this block before, and she doesn’t expect the system to make sense. I, far more naïve than she, repeatedly find myself hoping that this time the doctors, the social workers, the nurses and the caseworkers who advocate for Joy will be able to arrange an appropriate, permanent placement. But even the best medical and social service personnel (and she has been assisted by many wonderful professionals) cannot create a rational plan out of the current hodgepodge of short-term public and private programs.

No Magic Bullet – But Some Sensible Recommendations

There is no magic bullet that will cure Joy. The social conditions — and especially the gender inequality and sexual violence that cause her misery continue to be our reality. But there are steps we can take both at the policy and the programmatic levels that can increase Joy’s odds of survival.

One, we must bring the jumble of programs for people who are struggling with substance abuse into a coherent system in which a given individual can know that she has a therapeutic “home” that she can turn to, a home that knows her history and in which there is at least a fighting chance of developing some level of mutual trust. Joy cannot even remember all of the programs she has been sent to over the years, but when we tried to brainstorm we came up with a list of more than three dozen different facilities and programs — each with its own intake and assessments, each with its own medical protocols, each with its own rules. Right now, I am still fuming over the idiocy of putting Joy on too low a dose of methadone in an outpatient clinic, increasing her dose in an inpatient psych ward, and then sending her to a detox facility to withdraw from methadone so that she can get into a “holding” program while waiting for placement in a rehab program.

Two, we need to change the criteria for participation in mental health programs and in substance abuse programs in order to serve the needs of people like Joy with “dual diagnoses” (mental illness and addiction). The fact is that the majority of people who overuse psychoactive substances are, in one way or another, self-medicating their misery. The ersatz distinction between mental illness and addiction reflects out-dated ideas about what constitutes criminal behavior. It is neither realistic nor helpful.

Three, we need to know when to say “enough” to drug treatment programs. Joy has been through so many programs that, as she once told me, “I could teach the classes myself.” Rather than send Joy to detox and still another program, it would be far more sensible to provide her with secure housing where she will have access to on-going healthcare and emotional support, where she won’t be kicked out for breaking the rules or for “relapsing” (which, I acknowledge, she likely will), and where she will have at least a fair shot at putting down the roots and building the social networks that, in the long run, may be more salutary than methadone.

Over the next few weeks I will post additional recommendations for addressing the suffering experienced by Joy and other women I have come to know in Massachusetts over the past decade.You can read more about my work in Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility.