What can we learn from the circumstances of Kurt Cobain's suicide a decade ago? As a clinical psychologist who specializes in the treatment of addictive behaviors, I continue to ask myself the question of how his untimely death could have been prevented.
In the suicide note that he left on the date of his death on April 5, 1994, "he cited the pressures of fame, his lifelong stomach pain and the culpability he felt at not enjoying music anymore." ("Kurt Cobain: 10 years gone" Seattle Times, April 5.)
Cobain also wrote about his struggles to cope with stomach pain and the relief that heroin gave him in his "Journals" (Riverhead Books, 2002). "I decided to use heroin on a daily basis because an ongoing stomach ailment that I had been suffering from for the past five years had literally taken me to the point of wanting to kill myself."
After Cobain's suicide, Jonathan Poneman and other representatives from Sub Pop records contacted our center at the University of Washington about the possibility of establishing a memorial fund in honor of Cobain's life. It was agreed that the funds would be dedicated to setting up a drop-in center for youth who were having problems with injection drug use, including heroin and crystal meth. It was to be known as the "Come as You Are" Center, named after one of Nirvana's songs. Active drug users would be welcome to "come as they are" without any preconditions for admission.
Unfortunately, the offer for funding from Sub Pop records was subsequently withdrawn after the company was sold. During meetings with Sup Pop officials, I was told that during the "intervention" meeting prior to his reluctant agreement to attend the rehabilitation program in Los Angeles, Cobain tried to reach out for help by asking his family and friends if someone would be willing to "meet him halfway" in dealing with his heroin use. According to these reports, Cobain spoke about his continued problems with stomach pains and said that he was unable to make a firm commitment to total abstinence from all heroin use.
When Kurt Cobain asked if someone could "meet him halfway," he was calling upon the help of what is now known as the harm-reduction approach to dealing with active drug users. Harm reduction has as its goal any steps that are designed to reduce the harmful consequences of continued drug use, including reduction of HIV risk by implementation of needle-exchange programs.
Recently, harm-reduction programs have come under increased political scrutiny in the U.S. because of criticisms that this policy is somehow "pro-drug use" and that it coddles or enables users to continue unabated in their drug use. Other countries, such as Canada, have adopted harm reduction as a humane and pragmatic approach to helping save the lives of injection drug users.
Although my hometown of Vancouver, B.C., is just a few hour's drive north of Seattle, it is light years apart from contemporary American drug policy when it comes to the acceptance of harm reduction as a public-health approach to working with injection drug users.
Vancouver officials have adopted a "four pillar" approach: prevention, treatment, enforcement and harm reduction. As a result, Vancouver is now the first city in North America to offer safe-injection sites for active drug users who need a place to go and "shoot up" without fear of dying of overdose in a back alley.
Active users are encouraged to "come as they are" without fear of persecution or condemnation. Future plans in Vancouver include the establishment of a heroin maintenance prescription program for addicts who have not responded to traditional abstinence-based or methadone maintenance programs. Canadian health authorities are conducting research to determine the effectiveness and utility of both the safe-injection sites and the proposed heroin maintenance program.
Perhaps if harm reduction were presented as an alternative to total abstinence in the "intervention" session Cobain was subjected to 10 years ago, there would have been an effective response to his request for someone to "meet him halfway" in his efforts to cope with his continuing use of heroin as a self-medication for his chronic stomach pains.
Like many users, Cobain was not quite ready to give up his drug use as the first and only step to recovery. One of the key concepts in the harm-reduction movement is this: Do not attempt to take away a person's main means of trying to cope with pain and suffering until you have another effective coping strategy in place.
Cobain deserved this choice, and his message continues to ring out for all those who continue to have addiction problems.
G. Alan Marlatt is professor of psychology and director of the Addictive Behaviors Research Center at the University of Washington.