You might already know the story of Hillbilly Elegy, J.D. Vance’s memoir that argues that a variety of social ills in Appalachia—low birth rates, declining religious affiliation, domestic violence—can be attributed to “hillbilly culture.” At the end of last year, Hollywood ran the book through a few spin cycles, bleaching its film adaptation of Vance’s virulent right-wing commentary, which places blame on government welfare programs for incentivizing perverse behaviors that tear families and society apart. Naturally, most critics scanned Elegy for its politics. However sanitized the movie is of Vance’s beliefs, it was still destined for the front lines of the culture war.
But something else drew me to watch Elegy. Drug addiction, per Vance, is another manifestation of “hillbilly culture.” For years journalists have dubbed Appalachia the epicenter of what’s now referred to as the opioid epidemic, never mind that heroin addiction has been endemic in major cities among older Black men since the 1970s (for that story you must watch the 1995 film Dead Presidents). With Vance’s sharp political edge sanded down, what’s left is a family drama about addiction and generational poverty in rural America. But this, too, is political. And like most films that portray addiction and treatment, Elegy does have a politics, but its makers, and some of its audience, just don’t know it.
There’s a scene where J.D. Vance’s mom, Bev (Amy Adams), is in the ER after surviving an overdose. Bev has no insurance, and the likelihood of finding a “bed” (implying somehow a place to sleep treats addiction?) in a treatment program is nil. Vance’s family is begging the nurse to do something, anything, to help. After all, Bev was once a nurse at the very hospital where she’s now a patient. She was fired years earlier for sneaking pills and being high at work, and Bev’s addiction escalated after losing her job. The nurse says the hospital is going to discharge her with no real treatment plan, so J.D. (Gabriel Basso) demands to see the manag—er, doctor. Within earshot of Bev’s room, the attending physician tells J.D., “The best you’re gonna do is a Suboxone prescription for her to take home.”
For a brief moment, I was surprised. What the physician suggested is actually the best thing a doctor can offer in this scenario. Witnessing a medical professional use medication to treat addiction is rare in film and TV. The bar is that low. After the physician suggests Bev take a medication that would cure her withdrawal symptoms, satiate her cravings, and drastically reduce the likelihood of another overdose, the audience hears nothing from J.D. As soon as the doctor mentions Suboxone, he suddenly stops speaking the same language. Not a single follow-up about what the drug is, whether it works, whether Bev has tried it before, or whether she even wants to try it. No one is expecting J.D. to be fluent in addiction medicine, but when a doctor suggests a prescription for a loved one, isn’t it odd that, given how dire the circumstances, one would respond so incuriously?
In film and TV, the life-saving potential of a treatment like Suboxone (the brand name for a drug formula of buprenorphine and naloxone, which from here on I’ll refer to as just buprenorphine) is either totally ignored, like in Elegy, or explicitly portrayed as the wrong approach. Aside from Gus Van Sant’s exceptional 1989 addiction drama, Drugstore Cowboy, characters who take maintenance drugs—methadone or buprenorphine—to treat their addiction just don’t really exist. It’s an especially curious omission from fictional worlds because, in reality, many people do recover from opioid addiction through medication. Some studies find that patients undergoing inpatient, abstinence-based treatments, which usually entail only counseling, are twice as likely to die from a fatal overdose as those who receive maintenance medications on an outpatient basis. That means residential rehab, which film and TV almost exclusively portray as the right approach, is more expensive and less effective than simple outpatient office visits. But it’s more than just that: What our culture calls “rehab” is a method trapped in time, focused on restoring people’s character and morality rather than providing truly effective health care. Yet almost all the depictions you see valorize archaic methods that fail the majority of those who try it. What is lost by not showing treatment and recovery from addiction in all its unique and varied forms?
Among the few films that even mention medication treatments, they tend to do so in misleading ways. Take for example a scene in Permanent Midnight, the 1998 film starring Ben Stiller and adapted from screenwriter Jerry Stahl’s addiction memoir of the same name. The real Stahl has a cameo in the film as a doctor at a clinic, where he says, “Methadone’ll get rid of the shakes, but you’re basically trading one habit for another one.” That’s medically false, and when Dr. Tom Price, then President Trump’s health and human services secretary, said this very same line about medication during a cross-country “opioid listening tour,” he was promptly corrected and rebuked by physicians. Methadone is dismissed in the most well-known movies about heroin and withdrawal, like Trainspotting, where it’s portrayed as just another form of dope. Not much has changed. In today’s dramas depicting the opioid crisis, like Ben is Back, Euphoria, Beautiful Boy, and 6 Balloons, the audience doesn’t see or hear much of anything about treatment medications. (To their credit, some recent shows and films show naloxone, the opioid overdose reversal drug, the best being Knives Out, a film that has nothing to do with addiction.)
With medications perpetually excluded or diminished, what audiences see instead is that, in order to recover from opioid addiction, one must endure days of withdrawal, and then it’s off to group counseling, tough love, and a life of 12-step meetings. (To be clear, 12-step groups don’t consider themselves treatment; they’re nonprofessional, free-of-charge self-help groups, and indeed, that support helps many.) Usually, all this takes place at a posh “rehab” center, which the show BoJack Horseman effectively satirizes as quackery for the rich. The ideal marker of “success” in this framework is total abstinence from all psychoactive substances, which can even extend to prescription drugs that are medically indicated. Caffeine and cigarettes, the socially acceptable signifiers of recovery, are of course perfectly acceptable (tobacco kills over 10 times more people than heroin). In The Sopranos, when Tony’s protégé Christopher (Michael Imperioli) checks into treatment after accidentally suffocating his fiancé’s dog while nodding out on heroin, the staff confiscate all of his Milky Ways and Snickers bars. Temperance is taken to extreme levels of abstemiousness, recalling a parody of a Beverly Hills rehab center in Arrested Development named Austerity, whose motto is “A Full-Service Way to Live Without.”
Banning candy bars, denying medicine, petting horses (“equine therapy”) on a ranch—none of this makes any sense unless you understand the mainstream view of addiction treatment and recovery, which dictates that a spiritually driven quest for abstinence is the most acceptable form of recovery. Anything else, and you’re not only doing it wrong, you’re teetering on self-destruction.
Watching hours upon hours of films and shows that feature addicted characters to write this piece, I came to realize a drab and dreary sameness running across the genre. Whether the character is an exurban white twentysomething, like Ben (Lucas Hedges) in Ben is Back, or a bipolar Black teenager in Los Angeles, like Rue (Zendaya) in Euphoria, the same themes and slogans permeate the character’s treatment and recovery.
Audiences are subjected to the same recycled stories and character arcs, flattened of complexity, full of one-size-fits-all approaches for what is maybe the most complex and confounding human condition—an insatiable desire for the very thing that’s destroying your life. Instead, what we most often see play out is moral turpitude followed by an exercise in character-building.
Take Euphoria’s recent holiday episode, where Rue begins using again after her girlfriend, Jules, dumps her. Rue meets up with her sponsor, Ali (Colman Domingo), in a diner on Christmas Eve and he proceeds to give her a righteous, tough-love sermon. “You’re not a drug addict because you’re a piece of shit,” Ali tells Rue. “You’re a piece of shit because you’re a drug addict.” Rue doesn’t quite like the sound of this formulation, and why should she? Ali pivots. “It isn’t a question of willpower. It’s not about how strong you are,” he says. “That is the disease of addiction.… And you got it. Why?” Ali shrugs. “Luck of the draw.”
Moments later, Ali, who is Black and converted to Islam, alludes to racism, poverty, and the drug war as the structural poisons that further drive the need to seek relief through substances. But that deeper explanation of addiction—occurring outside the brain—stands in opposition to his explanation of Rue’s addiction as a bad roll of the genetic dice. In the end, Ali tells Rue the only cure for her “disease” is spirituality, and that she must find a God who can restore her to sanity. In short, she needs rehabilitation.
Euphoria’s diner scene is ridden with incoherent recovery bromides that feel out of step with how seriously the show’s first season portrayed Rue’s drug use as inextricable from the pain caused by the state of her mental health. I thought the show was presenting something different, but the same old tropes crept in. I came to realize, though, that the biggest problem isn’t that these films and shows are inaccurate in representing what recovery actually entails; the real problem is that they are accurate. To understand why cultural renderings of addiction treatment feel so similar, you have to look at the real world of treatment that all these writers draw from.
“The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care,” a five-year-long landmark study by Columbia University’s National Center on Addiction and Substance Abuse concluded, after surveying the treatment landscape in the United States. For decades, the medical system neglected to treat addiction as a real illness, which the report says “led to the creation of a separate and unrelated system of addiction care that struggles to treat the disease without the resources or the knowledge base to keep pace with science and medicine.”
Columbia published the center’s report on addiction treatment in 2012, but its findings remain truer than ever. The treatment industry today is rife with fraud and abuse. Some programs even rely on forced labor. Studies also find that fewer than half of registered treatment facilities in the United States prescribe any of the FDA-approved medications to treat opioid addiction, while the vast majority rely solely on counseling, group therapy, and 12-step-style programming for everyone who walks through their doors, no matter their personal histories. No other illnesses are treated this way.
All of the absurd cruelties, contradictions, injustices, moralism, and falsehoods embedded in our real-world addiction treatment system go unchallenged in film and TV depictions. Even worse, it’s all presented as normal. But the way addiction is treated in America is not normal.
Treatment in the world is full of antiquated ideas and punitive practices, and that’s what audiences see reflected back to them. The problem of entertainment’s depiction of treatment is much larger than a problem of representation as such. The sameness that permeates the genre encloses our imagination of what treatment can and should be, and perpetuates the ubiquity of moralistic and ineffective treatments in the real world. Treatment shouldn’t be a place where people endure humiliating methods that attempt to restore them to a previous, drug-free self. Rather, treatment should be a space where people can become themselves more fully and connect with the world more deeply, where they can understand their compulsions and unlearn the harmful labels society throws upon them—to learn that they are more than their addiction. The question remains if writers and creators will continue to reinforce the suffering plaguing addiction treatment, or if they’ll decide to tell new stories.