Cory Monteith's death less than three months after finishing a 30-day rehab program has some scratching their heads: Shouldn't rehab have cured the actor of his problem, preventing him from overdosing?
That's not how it works, addiction specialists say.
"People have the impression that treatment is complete when the person is sober. They're not using the drug anymore, so they're all better," said Dr. Stuart Gitlow, president of the American Society of Addiction Medicine. "In chronic lifelong disease, treatment is never complete. It's not at the point where we can cure it."
Gitlow said addiction is much like any other chronic disease, such as diabetes, in that it requires lifelong care. But to their detriment, recovering addicts and the people around them don't always realize that.
Even if an addict isn't actively using drugs, that person still has the discomfort associated with addictive disease, Gitlow said. This can be the result of genetic predisposition, but in many cases, drug use permanently damages the brain.
For example, crystal meth causes a surge of dopamine, the chemical responsible for pleasure, but it permanently damages the brain's dopamine receptors. So someone who uses or used meth can't feel pleasure normally.
Cocaine, methamphetamines and heroin alter brain physiology the most, causing addicts to crave them even years into recovery, said psychiatrist Raymond Isackila, who works at University Hospitals in Cleveland. There are anti-craving medications for drugs like heroin, but not for cocaine or meth.
Dr. Paul Rinaldi, who directs the Addiction Institute of New York at Roosevelt Hospital in Manhattan, said people tend to view rehab as the "gold standard" in drug addiction care, but because of that, they don't think much about what should happen afterward.
"It's a lot easier to be in rehab and be clean," he said. "You come home and you're in an environment with triggers that trigger you to use."
Triggers can be internal or external, said Isackila. Internal triggers include feelings of anxiety and depression, while external triggers can simply involve being in the same place or with the same people that an addict used to use drugs with.
Even though time after rehab is important toward recovery, many people never get help at all, doctors said.
Of everyone in the United States with an addiction problem, only 5 percent get professional help, said Dr. Westley Clark, who directs the substance abuse treatment center at the federal Substance Abuse and Mental Health Services Administration.
This is, in part, because treatment is expensive and not covered by all insurance plans. He said he hopes that the Affordable Care Act will make drug treatment more accessible.
The failure of addicts to get treatment also may be the result of stigmas associated with drug use and people's unwillingness to talk about it, Clark said, adding that the secrecy can be like how cancer patients used to hide their illness.
Isackila said the public doesn't always recognize that addiction is a health problem. Gitlow agreed.
"The public still feels addiction is a choice and not an illness," Isackila said. "So there's not a lot of politicians standing up, saying, 'You know what we need?' ... I've never heard it."
"Public expectation seems to be, 'I can get better on my own or I can get better without seeing a physician,'" Gitlow said. "We would never think twice about someone with diabetes having ongoing care from an endocrinologist. ... That's the kind of treatment necessary for someone with chronic life-threatening disease. If you have addictive disease, that's the kind of treatment that's necessary."