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Everyone’s lives have been touched, in some way, by addiction — and over the last ten years, more and more people’s lives have intersected with the rehab industrial complex. For some people, rehab has really worked — while others, and their loved ones, have struggled to figure out why it doesn’t. The answer is complex, because addiction is complex, but one of the reasons rehab doesn’t work for so many is actually quite simple: it’s run as a profit center.
Shoshana Walter is a powerhouse investigative journalist — and she’s written a real stomach punch of an investigative book. She follows the stories of four different people who traveled through the rehab system, illuminating the various ways the system has expanded to exploit the vulnerable. This is really eye-opening shit; read on to understand the extent of the scandal.
You can buy Rehab: An American Scandal here — and read more about Shoshana’s work here.
Last month, I published an interview with Melody Glenn about her book, which interweaves the story of Dr. Marie Nyswander, who fought to mainstream methadone maintenance treatment, and Glenn’s own path as a burnt-out emergency physician whose mind was gradually changed about the medical establishment’s understanding and treatment of addiction. It’s a really excellent companion to your book, but it got me thinking about timing.
There was a wave of books (and journalism) grappling with the reality of the opioid epidemic, and now it feels like there is a wave of journalism grappling with our pretty abject failure to confront it. So before we get into the meat of your reporting, I want to hear more about how you’re thinking of this moment in the larger timeline of opioid addiction and treatment.
Over the past 25+ years of the opioid epidemic, our country has undergone something of a transformation in regards to addiction. During the crack cocaine epidemic of the ‘80s and ‘90s, addiction was almost universally viewed as a moral failing, deserving of punishment and incarceration — especially of Black and Brown drug users.
And then the opioid epidemic came around. It started as a pain pill epidemic, mainly impacting White communities. And the approach to addiction became something completely different. Suddenly, lawmakers — including notably tough-on-crime Dems such as then-Senator Joe Biden — were referring to addiction as a disease deserving of compassion. And the solution to this drug crisis was not prison, but addiction treatment. Biden in particular really championed this effort to find and launch a pharmaceutical “cure” for addiction. And lawmakers undertook this enormous expansion of our treatment system. We entered into partnership with a for-profit pharmaceutical company to launch the gold standard treatment med Suboxone, and the Affordable Care Act expanded treatment access to millions of Americans.
Then we saw this huge demand for accountability, and Purdue Pharma and the Sackler family were cast as the villains of this story. There were waves of books and television shows about the company’s malfeasance and profiteering and corruption. The company declared bankruptcy, and waves of lawsuits forced drug manufacturers and distributors to pay up.
So where are we now?
More than one million people have died since the start of the epidemic. Today, about 80,000 Americans die of overdoses every year. We’ve seen some decline in overdose deaths, but we’re still near pre-pandemic levels. And that doesn’t account for the people whose overdoses were thankfully reversed, or the millions of people in this country who continue to struggle with substance use or addiction, or who have family members or friends who do. The expansion of our treatment system did not solve this problem, nor did the punishment of Purdue Pharma. These hard-won and well-intended efforts served as compelling narratives, but ultimately fell short.
I think — I hope — the country may be at a place where we can all acknowledge that this isn’t working, and try to figure out something that does.
With that established: how does “rehab” live in the popular imagination — and how does that image contrast with the reality of the system, which, as you argue, is ruled by profit and punishment? (Secondary question, of course, is how that first image is put in place to distract us from the profit-minded, punishment-rooted reality)
We’re all familiar with rehab (or think we’re familiar with rehab) because we’ve all seen those books and movies and stories about out-of-control celebs who check themselves into rehab, especially the fancy ones in Malibu, stay for a month, and then leave with a new lease on life.
These programs are typically insurance or private-pay-funded. They often rely on a curriculum that has been developed around Alcoholics Anonymous or the 12 steps. And they often last a maximum of one or two months. The reality of these 30-day programs — even the ones with the best of intentions — is that they often fuel relapse. People leave without the support system from which they benefited within rehab, they return to regular life, and they relapse.
In fact, someone who completes a 30-day treatment program is much more likely to overdose and die in the year following treatment than someone who failed to complete the program altogether. That’s because these programs often require prolonged abstinence from a person’s drug of choice, leading to reduced tolerance for that drug. So when someone leaves rehab and relapses — taking the same amount as before — it is now suddenly too much, and it leads to overdose. In the age of fentanyl, that can be detrimental or even deadly.
And this is the system that exists for people with some semblance of means. For those without, there are longer-term programs (typically not insurance-funded) that are often faith-based, unlicensed by any regulatory authority, bar evidence-based medications, and often require uncompensated work. These programs often employ behavior modification techniques that are very punishment-driven and aim to push patients to rock-bottom in order to build them back up.
With very little oversight, these kinds of programs can very easily go off the rails. I found programs all over the country that effectively utilized their patients as a temp labor force. One program I wrote about in the book sent patients to work at Exxon and Shell oil refineries, working up to 80 hours per week. Their only pay: a single pack of cigarettes per week. Residents rarely received counseling or adequate medical care. And this was a program that was licensed. Many regulators and judges that were sending people to this program were not only aware of these practices — they endorsed them. Even with the the cultural shift around addiction, there is still this enduring belief that addicted people deserve and need punishment in order to change.
There are some institutions in American society that, when run well, absolutely resist profit optimization. Daycares are one of them. Treatment centers, to my mind, is another. But one of the throughlines of the book is that once these centers came to be understood, by capital interests, as potential profit centers, they also became increasingly unsafe for many of the people who needed them most.
There are so many places in the book where staff break their own protocols (or legal guidelines) in order to save money, or keep someone in their treatment (instead of transferring them to a place where they could get the care that matched their needs). Can you talk about a few of the most egregious ways rehab centers have standardized the prioritization of profit over care?
Addiction treatment used to be this niche territory, occupied by palatial retreats solely for the wealthy, or rag-tag government-funded nonprofits. Then the Affordable Care Act expanded insurance coverage of addiction treatment to millions of Americans and completely transformed the treatment landscape. Suddenly, treatment became a viable business, and insurance-funded programs proliferated, offering care designed to maximize profits through billable services. These programs are limited by what insurance companies are willing to cover.
Even high-quality treatment programs are frustrated by those limitations: I spoke with many treatment company owners who were frustrated by the 30-day maximum often imposed by insurance companies. One owner referred to this as a “cycler.” Rehab patients come in, they leave, and then they relapse and come back — often starting with detox, a more expensive (and profitable) level of care.
In fact, many treatment facilities have now made these high relapse rates a part of their business model. That same facility employed staff who would call former patients to find out if they had relapsed, and if they had (especially if they had high-paying insurance), they would re-enroll them. This was the rehab’s “after-care” service. Instead of providing ongoing support after rehab, the program would simply bring them back in for another round.
And when it comes to for-profit treatment, what I’m describing is just the least of it. Finding a quality treatment program in the United States is treacherous. Many programs utilize marketing companies who use online ads and 1-800 numbers to recruit patients with the best insurance policies to specific programs. Some utilize “body brokers” who get paid thousands of dollars per patient, sometimes even passing on that payment to the patients themselves. There are recovery influencers, such as Michael Lohan (the father of actress Lindsay Lohan), who have easily found steady streams of patients to place in exchange for kickbacks. Some patients actually sustain their drug habits by selling themselves into rehab. I got great insight into all this from a former marketing company owner who made millions doing this work but felt immense guilt and abandoned the industry after seeing dozens of his brokered patients overdose and die.
Rehabs are able to afford the cost of brokers and marketing companies by overbilling insurance companies for unnecessary services, such as urine tests, which are so lucrative they have become known in the industry as “liquid gold.” I reviewed financial records from one mom whose son died of an overdose immediately upon returning home from 88 days in rehab. Soon thereafter, she received a bill for $202,860 for 42 urine tests (that’s more than $4,800 per test). There is no evidence that such frequent drug testing is necessary for someone in treatment.
And then there is the lack of regulation and oversight. In California, which is one of two main hubs for treatment in the United States, outpatient programs are not required to be licensed. Nor are sober living homes. Patients can file complaints about any rehab program, but regulators do not investigate facilities that don’t require licensure, and the investigations they do pursue are often cursory and glacial. There are currently about 2,000 licensed facilities in all of California, mostly concentrated in Southern California. Yet there are only five investigators located in that region of the state.
One of the people I follow in the book is a grandmother from Los Angeles named Wendy McEntyre. Wendy decided to make it her mission to root out corruption in the for-profit treatment industry after her own son died in a sober living home. Her methods are often extreme: while I was reporting her story, Wendy was arrested for felony kidnapping after she helped a teenager escape an abusive facility. Several programs had filed restraining orders and libel lawsuits against her. She operates a 24-hour hotline that feeds directly to her cell phone, so that anyone can reach her at any time of day or night to report an abusive facility.
Wendy investigated a treatment program in the San Bernardino mountains that had a pattern of overmedicating patients to the point of impairment. One such patient, 21-year-old Donavan Doyle, fled and disappeared into the snow and fog. His remains were found months later, a mile down the side of the mountain. At least two other patients died after receiving powerful cocktails of medications that records showed were not actually prescribed to them.
Wendy investigated the hell out of this facility. She sent hundreds of emails and filed dozens of complaints with regulators and law enforcement. And yet neither the state nor law enforcement ever shut the place down. The owner closed the facility himself after going into debt following a series of wrongful death lawsuits.
When I spoke with the owner of this facility, he told me that he had good intentions — and that how he operated his program is industry standard. Sadly, I do think there’s some truth in that. So many of these programs are detrimental for patients, yet no one is doing an adequate job of looking out for them.
So many pieces of the various narratives in the book gesture to a need to understand rehab not as a place you go, or even a meeting you attend, but a whole web of interlocking services and safety nets. The more access you have to that web — psychological care, reliable transportation, family with means — the more effective treatment becomes.
Can you talk about how that reality played out in the lives of the people whose lives you catalog in the book, and how we see it playing out in the larger statistics, particularly as pertains to race and location, when it comes to relapse, incarceration, and overdoses?
Yes, and I should preface this by acknowledging that treatment can be life-changing for many people. Most people go to treatment three or four times before entering long-term recovery. There’s a substantial portion of people who go six or more times. That speaks to the problems in our treatment system, but also the difficulty of recovering from addiction. And multiple bouts of treatment can be beneficial.
But I found in my reporting that it’s often what happens after treatment that is just as important — maybe even more important — than the treatment itself. Research emphasizes the importance of “recovery capital,” the mixture of internal and external resources that people draw from in order to enter and sustain recovery. This can include community and social supports, but also financial stability, a job, housing, food, transportation, healthcare. The more recovery capital a person accrues, the greater their chance of success.
The longer someone remains in their addiction in the United States, the harder it is to retain or grow recovery capital. Because of our country’s drug policies, addiction has all sorts of collateral consequences. It can trigger additional physical and mental health problems, lead to incarceration, and the loss of civil rights and government benefits. It can make it impossible for someone to find housing, a job, or obtain loans. If addiction came without consequences, some people would never find the motivation to recover. But at some point, the consequences of addiction become as much of a barrier to recovery as the addiction itself. Those obstacles become impossible to overcome, keeping many people in the cycle of addiction, without the resources and ability to climb out.
And access to recovery capital is unequal. The same structural barriers that create inequality along race and gender lines also impact someone’s chances of recovering from their addiction. In addition, there’s massive racial disparities in who has access to treatment, especially addiction treatment medications like buprenorphine, which can reduce overdose deaths by more than 50 percent. Studies have found that Black patients are the least likely to enter addiction treatment and least likely to finish it, in large part due to the socioeconomic stressors they face in the outside world. These patients also face disproportionate risk of arrest and incarceration for drug offenses, and someone who is recently released after a period of incarceration is at exponentially higher risk for overdose death. In fact, even as we’re seeing overdose deaths ticking down nationwide, we are seeing rates rise in Black and Indigenous communities.
As always, mothers experience the worst of this. We’ve known for decades that treatment programs that allow mothers to remain with their children have the best outcomes for families. About 70 percent of women struggling with addiction have children. It’s one of the top reasons women cite for not entering treatment. And yet, since the start of the epidemic, the number of facilities catering to mothers have drastically declined. Today, less than five percent of all programs nationwide provide child care for patients, and fewer than three percent allow patients to bring their children with them. Pregnant women are routinely turned away from treatment programs, while others come up against months-long wait lists. Meanwhile, the overdose death rate among mothers has been skyrocketing. Mothers are literally dying — or being forcibly separated from their children — because they can’t find treatment.
You can see these different trajectories play out in the lives of two people in my book: April Lee and Chris Koon. Chris is a middle class White guy from Louisiana, who was court-ordered into a program that required him to work up to 80 hours per week without pay. After getting injured on the job and failing to complete the program, he returned home and assumed he would be sentenced to prison. Instead, the judge gave him probation, and Chris moved in with his dad, who helped support him as he got on his feet. His parents helped Chris pay for Suboxone, and Chris finished a welding program, got a job, married a girl and moved on with his life. It was still very difficult for him, he faced obstacles, but recovery capital made it much easier.
April, on the other hand, was a Black single mom of three living in poverty when she was sexually assaulted and addiction took over her life. As the sole caregiver and breadwinner, April did not feel she had the capacity to take time away from her kids to get better. Eventually, her kids were removed by child welfare authorities, and April went off the deep end. She became homeless, sustained herself through sex work, and then desperate to stop the cycle of addiction, she got herself arrested. Even though she was incredibly motivated, it took April a lot longer than Chris to get on her feet, and even longer to reunite with her kids because she did not have the same amount of recovery capital.
You see celebrities with all the privileges in the world entering rehab and coming out. Many of them relapse. They still don’t lose it all. If recovery is this difficult for them, imagine how difficult it is for people who don’t have anything to lose.
The full title of the book is Rehab: An American Scandal. Sometimes, when we spend so much time with a subject, we’re no longer scandalized by the realities: we understand them, we despise them, but they’re….just how it is, and how it feels like it will continue to be. What scandalized you first about this larger American story — and what scandalizes you most today?
I was shocked to learn that someone who completes a 30-day program is at higher risk of overdose death than someone who didn’t complete that program. Or that someone who is recently released after a period of incarceration is 40 times more likely than the general population to overdose and die. These are two of our country’s main responses to addiction: an insurance-funded, short-term residential stint, or incarceration. And yet these methods increase the risk of death.
Then you have lawmakers and judges endorsing rehab programs that work people to the point of injury or death. And moms dying or being separated from their children because they can’t access treatment. I mean, I still can’t believe it. This is the gist of my book and I am honestly still scandalized by it.
Time and again, lawmakers in our country have gone through periods of supporting treatment as a “cure” for addiction, and when those efforts ultimately fail to live up to their promise, there’s a swing in the other direction, toward more punitive policies. I think we’re seeing that now, with the federal government declaring a war on fentanyl, with states cracking down on homelessness and passing mandatory minimum sentences for fentanyl-related offenses. These policies are likely to further marginalize addicted people, and make it that much harder for many of them to escape addiction.
Studies show that longer-term treatment, often within someone’s own community, works better for most people. What works is ongoing support, especially with peer specialists or community groups, and with treatment medications such as buprenorphine and methadone. And most essential of all, what works is recovery capital. There are good programs across the country doing this work. It is not impossible. And I believe this with my whole heart: we can do better. ●
You can buy Rehab: An American Scandal here — and read more about Shoshana’s work here.
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I worked at what is probably the busiest syringe exchange in the country, and while it all felt woefully inadequate for meeting the needs of our participants, as a low-level person working at the exchange, I felt like just being there and being able to take time to talk with people and try to get little needs met beyond basic supplies (someone needs a pair of shoes, some cat food, someone to talk to about something that happened or a book they're reading, etc.) made it feel like I was doing some small thing in the face of massive, intractable societal cruelty. The job was brutal and low-paid but the sense of purpose kept me coming in every day; as a person without a college degree and some life issues of my own, I was honored to be in a position to professionally engage with people who tend to get written off.
When I was promoted to a "navigator" position, in charge of helping interested participants get into treatment programs, I was psyched to have an increased ability to actually do something for the people I was working with. I'm embarrassed at how naive I was: shocked to discover that rehabs rarely had beds available, and that open wounds (common in a city where the drug supply is so adulterated with xylazine) or pregnancy were disqualifying, or that actual supervised detox, important for people coming off of certain drugs or combinations that are increasingly the norm, was even harder to get into than rehab.
People would come to me at their most vulnerable, finally willing to ask for help and commit to a painful process and major change despite all the obstacles and lack of resources, and I'd have them pee in a cup, fill out a form, and then wait around all day (usually starting to withdraw) while I made unsuccessful phone calls, finally telling them (usually homeless and in severe addiction, with unpredictable lives) to "check back in a few days" for updates. Needless to say, next time I saw them, if I ever saw them again, they were fully resigned to things staying the same and I'd lost their trust even to tell me about their day or make the small requests I used to be able to help with as a lower-level employee. I stopped getting out of bed or showing up for work, and have been unable to return to work in the field despite it being the most meaningful thing I've ever participated in. The more people like Shoshana Walter bring this whole system out into the light, the better.
I worked in substance abuse treatment for a little while, for a company that I believe was genuinely trying to do recovery right. They build a complete hub of levels of care, from essentially an addiction emergency room to inpatient rehab to sober living to long-term medication assisted treatment plus outpatient therapy plus case management plus peer support. They included data collection and research work in their model so that they could be flexible to whatever new best practices they discovered. They involved the local medical school and got the competing hospital systems in the area to all go in on “solving” addiction together.
And I gotta tell you, based on my experience, very little about this interview surprised me. I mean, okay, the “body brokers” did, since we served a largely Medicaid population in a state that was in the top ten 20% for overdose deaths, so we always had more clients than we could handle and a mile-long waitlist. But my experience was that the funding source and partnering institutions had so many baked-in assumptions about what people in recovery “needed” and how providing each of the services “needed” to look and “needed” to connect with other services that they basically assumed away their ability to innovate—or even hear what clients actually needed. E.g. obviously an addiction emergency room should work architecturally and functionally exactly like a general emergency room! (Despite the fact that clients were very likely to be there for 24-48 hours waiting for a bed to open up at a rehab that accepted Medicaid.) Obviously clinical biopsychosocial interviews are the equivalent of medical exams and therefore should take the same fifteen minutes or less! (Despite the fact that the norm for mental health intake interviews is 90 minutes.) Obviously outpatient programming spaces function exactly like any other kind of office and therapists and case managers can share a cubicle farm! (Despite the fact that mental health workers largely have individual offices for HIPAA compliance reasons.) Obviously, if our “obviouslies” turn out to be wrong, it’s not that we made the wrong assumptions, it’s just that staff members are insufficiently committed to The Cause!
You may be unsurprised to hear that staff morale and turnover were both abysmal, and that this program that opened to great fanfare early in the pandemic has already gone out of business.