Policing the Addiction Treatment Industry

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There are an estimated 14,500 alcohol and drug treatment rehab facilities in the United States, but not all are effective, trustworthy or honest. There’s not even an agreement on what rehab is.

When most people think of rehab they think of Alcoholics Anonymous (AA) and its Twelve Steps, a quasi-religious, incremental process in which addicts must accept that they are helpless in their addiction; accept God and ask him to remove their addiction and other related flaws; make a list of those they have wronged and try to make amends to them; and live their life according to this message and carry it to other addicts.

Judges have continued to order people into AA, Narcotics Anonymous, and similar 12-step programs, despite two major objections.

First, multiple courts have ruled that such an order violates the Establishment Clause of the First Amendment because of the explicit mentions of God (sometimes camouflaged as a “higher power”).

Second, 12-step programs are not really rehabs. They are not evidence-based or scientific, and there are no trained professionals directing therapy or treatment. They are more like support groups—a fellowship of addicts—sharing personal stories and camaraderie to help each other avoid relapsing.

Because of their anonymity, their success rate is hard to determine, but it may be as low as five percent.

Courts in Oklahoma, Arkansas, Texas, and Missouri also have considered Christian Alcoholics & Addicts in Recovery (CAAIR) a rehab, though it also was known as the Chicken Farm, and the addicts (and in at least one case someone the judge didn’t even consider an addict) were court-ordered into the program mainly to work in a chicken processing plant, not work on recovery.

It is laudable that judges want to save money and avoid sending addicts to prison, but CAAIR programs, according to the Center for Investigative Reporting’s Reveal, are “little more than lucrative work camps for private industry.”

CAAIR is being sued by three of its former “Chicken Farm” inmates in effect for slave labor (the addict workers are not paid, seemingly in violation of at least Arkansas state law). CAAIR was an alternative to a traditional prison sentence, and if an addict couldn’t work due to factory-related injury, they were sent to prison after all.

Clearly, AA, NA, and CAAIR are not rehabs, but even treatments considered as traditional rehab don’t have an official definition. Most rehabs do share some conventions, however.

There are at least two kinds of rehabs: residential, or inpatient, and non-residential, or outpatient. In residential rehabs, the patient with an addiction is expected to remain in the facility for a set period of time—usually a week, a month, or three months—depending on the severity of addiction and ability to pay. Non-residential treatment takes place for a certain period during the day, but the patient returns home at night.

Ideally, an evidence-based rehab for substance abuse should offer medically monitored detoxification, medical staff, behavioral therapists and counselors trained in addiction medicine, medication-assisted treatment (MAT)—drugs such as methadone or buprenorphine to help wean addicts off other, harmful drugs such as heroin—and follow-up monitoring and therapy known as aftercare.

Rehab also can offer many other non-evidence-based alternative treatments as additions or alternatives, from spiritual to philosophical, exercise to meditation, even yoga and so-called equine therapy (basically riding a horse).

In some states, such as Florida, anybody qualified to be a landlord can open a sober home, a residence for recovering addicts receiving outpatient addiction treatment elsewhere.

$35 Billion Industry

The rapid increase in drug rehab facilities and insurance coverage—it has become a $35 billion industry—has led to what even the National Association of Addiction Treatment Providers (NAATP) admits are “bad actors” who attempt to take advantage of the addicted, their families, the insurance companies, and the federal and state governments by engaging in practices such as “patient brokering”, paying fees or “kickbacks” for referrals regardless of the appropriateness of the rehab. With that much money in play, it is inevitable.

The problem is that this new way of looking at addiction, as something more like a disease than a lack of willpower or a moral failing, is new to the nation as a whole. Addiction medicine is a relatively new specialty. Law enforcement and the courts seem to favor punishment; it’s in their natures.

How much of addiction is a choice, if it should be treated instead of punished, is still a new concept to a populace more conditioned to send problem drinkers to Alcoholics Anonymous and drug addicts to prison.

Even worse are “body brokers” who recruit addicts to fill a rehab bed to bilk the insurance company. Far from trying to help addicts into recovery, body brokers actively maintain their addiction, supplying them with drugs and milking them for frequent and unnecessary laboratory tests of their urine (which, because of insurance reimbursement, is sometimes known as “liquid gold”). Some of these addicts were even used for prostitution. Not surprisingly, some of these addicts overdose and die.

Florida sober home operator Kenneth Chatman has been convicted, but there are many more. Rehabs with warm weather, ocean views and other vacation resort-type amenities are the major culprits, such as in Florida and California, but questionable rehab clinics have been found in other locations, such as New York and Massachusetts.

Given this lack of standards, where to go to get help for drug addiction can be a difficult question. Reviews online can’t always be trusted. Some seemingly authoritative sites may be owned by rehabs.

NAATP endorses (“values”) “a comprehensive model of care that addresses the medical, bio-psycho-social and spiritual needs of individuals and families impacted by the disease of addiction” using “research-driven, evidence-based treatment interventions that integrate the sciences of medicine, therapy and spirituality.”

NAATP seems to favor inpatient or residential care, or at least says nothing about outpatient care (naturally), although the success rate seems to be about the same for both.

One Size Doesn’t Fit All

Drug rehab is not one size fits all. The treatment that works for one person won’t necessarily work for another. Most people who become addicted to a substance don’t require help to stop—you don’t hear much about them because they don’t become a societal problem—but “no help” isn’t a solution that will work for all addicts. (Some, such as AA, don’t even consider such individuals addicts because they were able to stop.)

The problem of catching and shutting down “bad actors” is another matter. Some politicians and courts want to rely too heavily on abstinence-only (“Just Say No”) or the Twelve Steps or forced labor such as CAAIR (it gives them a “work ethic”). Studies show MAT works better, but “that’s just exchanging one addiction or drug for another”, say these critics.

No, not any more than diabetics are exchanging one drug (insulin) for another (sugar). Addiction is a chronic brain condition like a disease that is caused by many factors, including a genetic predisposition. If medications such as methadone or buprenorphine will keep an addiction under control, allow the person with an addiction to keep a job and function in society without getting high, then it won’t hurt if they are on the medication for a week or 10 years.

Other harm reduction solutions, such as needle exchanges and safe-shooting sites (with testing to make sure that the drugs aren’t contaminated or laced with fentanyl), also save more lives than prison.

There also aren’t enough rehabs or qualified people to staff them. If every addict wanted help, they couldn’t find it. Doctors must be encouraged to add addiction medicine to their training.

Law enforcement, too, must be trained in recognizing and dealing with addicts. Drug Recognition Experts are a start, but they’re only focused on arresting someone who they perceive is intoxicated.

Vigilance by the friends and family of the addicts also is required. Warning signs of a bad actor, according to law enforcement, include offers to pay for travel to a faraway rehab or to waive fees, co-pays and sober home rent. If it sounds too good to be true, it might be. Give that gift horse a thorough oral exam.

Increased scrutiny of the drug addiction treatment industry is needed, according to West Palm Beach attorney Susan Ramsey, by law enforcement—she’s already seen it cause some bad actors to close—the insurance companies who are being defrauded—Chatman was under investigation by the Federal Bureau of Investigations for two years because of a tip about insurance fraud but was caught because someone OD’d—and by the industry itself.

Stephen Bitsoli

Stephen Bitsoli

NAATP may be trying better self-regulation now. At its annual meeting last month it announced its new Quality Assurance Initiative “designed to confront abuses in the treatment field, establish operational competence, and restore public trust in addiction treatment.”

It’s about time. In 2016, Marvin Ventrell, then executive director of NAATP, warned that “If our procedures for self-policing and transparency aren’t improved, the industry is going to be seriously harmed.”

Those chickens may have come home to roost.

Stephen Bitsoli, a Michigan-based freelancer, writes about addiction, politics and related matters for several blogs. He welcomes readers’ comments.

2 thoughts on “Policing the Addiction Treatment Industry

  1. I know that there are fraudulent rehab facilities around this country, bilking the addicts, their families, the insurance companies and even the government out of (likely) tens of millions of dollars. This, to me, is a shameful and deplorable practice! God bless those who are legitimately trying to help their fellow man break free of the addictions that plague them!

  2. Quoting the opinion column (I really wish TCR would more clearly label “opinion” or “analysis” as to distinguish it better from “research findings” or “news reporting”, but that’s a separate issue) which is very thoughtful, but troublingly biased toward one modality of treatment: MAT. The author rightfully notes “Drug rehab is not one size fits all. The treatment that works for one person won’t necessarily work for another.” A fundamental truth, that seems to be contradicted by so many zealous advocates of MAT, who choose to ignore the tens of thousands of persons nationwide who have benefited from peer-supported abstinence-based programs, like AA, NA and others. Instead, they are labeled “not evidence-based” because statistical data is sparse. Then again, maybe they get no “love” from the “professionals” in treatment because they are not generating billings of insurers or connected in any way to the pharma industry which, have benefited from today’s opioid use disorder epidemic more so than any other sectors. Most troubling is the increasing resignation of some providers of MAT that sobriety is no longer a goal – that continued opioid-replacement maintenance is an acceptable long-term health outcome. Sometimes, a short-term objective of stabilization with MAT is a better pathway for some persons with SUDs, and the road forward for one person with a SUD may differ from another’s. But ALL roads should be leading to the same goal of safe, healthy & sober lifestyle.

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