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What If Jackson Maine Had A Different Disease?

- An Addiction Doctor's Take On 'A Star Is Born'

*Spoiler Alert: If you haven’t seen A Star is Born, consider reading this article

AFTER you’ve seen the film!*

A Star Is Born was released several weeks ago, but I didn’t see it right away. Based on the trailer and multiple interviews with both stars, envisioning music icon Lady Gaga as a singer wasn’t a stretch, despite this being her first leading role. I was not convinced, however, that Bradley Cooper – multiple Academy Award nominations notwithstanding – could pull off the singer-songwriter part. I was wrong.

Cooper’s country rock star persona was completely credible. But I was most impressed with his portrayal of unrelenting, alcohol-induced self-destruction. Credit to his acting acumen, no doubt. But he was also able to draw upon his own experience with - and ultimate recovery from – long-time alcohol use disorder (AUD).

As a director, Cooper accurately depicted what I hope all audience members will appreciate – and that very few Hollywood films acknowledge – which is Jackson Maine’s addiction was a chronic brain disorder. He was a slave to his disease. He could not function without drinking immediately before and after each show.

At the height of his illness – and the event that prompted entry to rehab – Jackson, delirious from alcohol and pills, stumbled on stage during the pinnacle of his wife’s fledgling singing career (her Grammy acceptance speech), stammered incoherently and ultimately urinated himself. Later in rehab, his sobbing face covered by his hands, riddled with guilt, Jackson could barely face his wife.

This is addiction. Alcohol, opioids, tobacco and other addictive substances impair parts of the brain that control cravings, emotions and decision-making. In moments of lucidity, the person is overcome with profound guilt and shame.

As a movie fan, I was captivated by the performances from Cooper and Lady Gaga (who has also been open about her past substance use). But as an addiction medicine physician, I am disheartened by Hollywood’s portrayal of countless men and women with substance use disorders (SUD) following the same, predictable path: stress/trauma; drug/alcohol use; guilt, shame, scorn from loved ones; temporary sobriety; more stress/trauma; relapse; lose everything and/or die.

It’s frustrating because it doesn’t have to be this way. In fact, most people with addiction – once connected to the appropriate treatment and recovery services – GET BETTER.

Trust me, I know because I’ve seen countless patients in my practice return to work or school, take care of their families, earn their diploma and become productive members of society. Some become mayors of major cities, like Boston’s Marty Walsh. Others become international, multi-award-winning musical superstars, like Elton John or Lady Gaga.

If only Jackson got help. Again and again. Relapse is expected in ALL chronic illnesses: diabetes, heart failure, asthma. But people with these diseases are not stigmatized the way people with addiction are. When Ally visits her husband in rehab, she says what I wish every person with addiction heard: “It’s not your fault. You have a disease.” She did not judge. She was compassionate. How refreshing. If only Jackson heard this at age 13.

As an internal medicine physician who has seen patients with hypertension and COPD relapse numerous times but then improve with treatment, I can’t help but wonder how Jackson’s life might have had a different outcome had he experienced a different disease.

If his multiple sclerosis flared up, I guarantee his driver would have taken him to a hospital and not to a bar. If he collapsed on stage because of crippling rheumatoid arthritis, I’d bet good money his bandmates would have given him medications rather than carry him to a sofa to “sleep it off.”

If he had cancer, he’d be referred to a cornucopia of specialists – medical, radiation and/or surgical oncologists, nutritionist, counselor. He would have received a battery of tests then perhaps chemotherapy. He would also have follow-up appointments for the next decade or longer to monitor for recurrence of cancer.

Instead, Jackson was chastised, repeatedly. After passing out on the street and taken back to his friend’s house, Ally said “I will not hunt you down again.” His father-in-law threw him in the shower after he lost bladder control at the Grammy’s. His older brother, played brilliantly by Sam Elliott, constantly referred to him as a “drunk.”

Genetics played a big role as Jackson was “dad’s drinking buddy.”

Last week, I admitted a man in his 40s to my addiction treatment center. At age five, he had his first drink, given to him by his father. By age 12, he said, “I was an alcoholic.” At the end of the interview, after I thanked him for coming in and reassured him that he’d get the care he needed and deserved, he started crying uncontrollably. “Booze is all I’ve ever known. I didn't know any different.” Neither did Jackson Maine.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly half of all people with severe mental illness have a co-occurring SUD. While it was not explicitly stated, based on his early suicide attempt, Jackson likely experienced longstanding and untreated depression (or possibly a substance-induced mood disorder).

Based on decades of medical research and evidence, the following steps could have led Jackson Maine and anyone else with drug/alcohol addiction to a path of long-term recovery:

  1. Refer for help – If you’re a friend/colleague/family member, refer the individual to a professional (physician, psychologist, social worker, counselor). He may not be ready the 1st, 2nd or even the 8th time. Persist; don’t abandon. He’ll ask for help when he’s ready.

  2. Medications – Three medications are approved to treat AUD:

Naltrexone (daily pill or monthly injection) can decrease cravings, heavy drinking days and increase length of abstinence;

Acamprosate also decreases cravings and duration of withdrawal symptoms (two pills three times/day can be an obstacle for some); Disulfiram makes you sick after drinking thus compliance is poor, but it can be effective in highly motivated or supervised individuals.

For opioid use disorder, methadone and buprenorphine have been shown to be most effective in achieving long-term recovery; injectable naltrexone may work for a small subset of patients but there’s far less data to support its long-term efficacy.

  1. Behavioral Therapies – Led by health professionals, studies have shown that psychosocial treatments can reduce alcohol consumption and increase abstinence, with or without medications.

  2. Mutual Support Groups – When combined with treatment led by health professionals, 12-step programs such as Alcoholics and Narcotics Anonymous can provide invaluable peer support.

  3. Mental Illness – Co-occurring SUD and mental illness is not uncommon. Treatment can be challenging, but an integrated approach using medications and behavioral therapies/counseling is most effective.

A Star is Born was a beautiful albeit tragic love story. But with treatment and care, the 16 million people in the U.S. with alcohol use disorder needn’t be destined to the same fate. Help is available. Please talk to your doctor or reach out to any number of resources: National Institute on Alcohol Abuse and Alcoholism, SAMHSA, National Institute on Drug Abuse, American Psychiatric Association, American Society of Addiction Medicine and American Academy of Addiction Psychiatry, to name a few.

Lipi Roy

I'm a doctor who writes about addiction, nutrition and mindfulness.

I am a physician board certified in addiction medicine, currently serving as medical director of an addiction treatment center in New York City. I am also a clinical assistant professor at the NYU Langone Health. Previously, I served as Chief of Addiction Medicine for NYC jails including Rikers Island, overseeing substance use treatment and recovery services at the nation's second largest jail.

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