Safer Solutions: Our Conversation with the Author of Rehab: An American Scandal

We’re trying something new for this installment of Safer Solutions: diving into insights gleaned from a recent virtual event. Last week, R Street’s Jessica Shortall spoke with investigative journalist Shoshana Walter about her new book, Rehab: An American Scandal. Here, we’ll share two key insights from Walter’s reporting that intersect with our own harm reduction work.

1. Mothers face additional barriers to accessing treatment.

In Rehab, Walter shares the story of April Lee, a low-income Black mother in Philadelphia whose drug use was part of a multigenerational cycle. Lee had limited economic and social resources and faced years of barriers to getting the care she needed.

Walter told us that about 70 percent of women struggling with addiction have children and that treatment programs that allow women to bring their children have the best success rates for families. She identifies a lack of child care as one of the top reasons women give for not going into treatment; however, only about 3 percent of treatment facilities nationwide allow women to bring their children with them, and fewer than 5 percent provide child care. Some programs refuse to treat pregnant women at all.

Lee’s story puts these numbers into focus. Though she was using drugs, she was stable and parenting three children when a sexual assault plunged her into crisis. Her drug use escalated, but she did not have access to a treatment option that would allow her to keep her children with her. When she finally found a family friend to stay with them while she focused on her recovery, she returned to find that the state had removed the children. It took her years to get them back, which Walter says “created issues [of generational trauma] for her entire family.”

For more on mothers, addiction, and harm reduction, read a piece from our R Street archives on how state and federal laws around medications for the treatment of opioid use disorder (MOUD) in pregnancy affect pregnant women in recovery.

2. Our systems are not consistent in regulating treatment.

Rehab presents a picture of an addiction treatment infrastructure that is highly regulated and scrutinized in some areas—to the point of hindering access to evidence-based care—and under-regulated in others, potentially leaving individuals and families at risk.

Walter told us that when Suboxone (a formulation of buprenorphine and naloxone) came on the U.S. market in 2002, “it came along with many restrictions,” including patient limits and oversight by the Drug Enforcement Administration (DEA). She told the story of Dr. Larry Ley, an Indiana doctor who became one of his region’s largest prescribers of buprenorphine, a “gold-standard” MOUD. According to Walter, Ley “found a number of ways to get around the patient limit that was preventing him from treating all the people who were … desperate for help.” His practice drew the attention of the DEA, and he and several colleagues were arrested and charged with crimes. Ley was eventually acquitted, and the charges against his colleagues were dropped. But this disruption in care took away access to the medication that was helping Ley’s patients stay stable and well. With few other options, some returned to the illicit drug market, leading to some overdose deaths. Ley’s experience and others like it could have had a chilling effect on the willingness of providers to prescribe MOUD.

In her book, Walter contrasts this highly regulated and scrutinized picture to the story of Cenikor, a nonprofit work-based rehab program. Cenikor residents—some sent to the facility by court order in lieu of prison time—were contracted out to private companies and required to work dangerous jobs for up to 80 hours per week without pay. Walter found that this schedule made it almost impossible for some residents to receive counseling and other care for their addiction and behavioral health needs. She also found years’ worth of complaints and failed inspections at Cenikor, including reports of abuse and exploitation on which regulators never imposed any real consequences.

Walter discovered through her research that many rehab programs are not licensed at all. Some do not provide evidence-based medical care, such as MOUD or appropriate psychiatric medications. She describes this as a “massive regulatory loophole” for programs that are “often utilized by the courts” and people with no other options due to lack of insurance.

For more on regulatory and other barriers to accessing MOUD, read pieces from our R Street archives on how methadone overregulation harms competition and patient care, how barriers to buprenorphine access impact rural communities, and how regulatory barriers hinder the opening of new methadone clinics.

Walter’s investigation into the multi-layered challenges faced by people with substance use disorders uncovered a complex system that is too often misaligned with patient and provider needs. Smart policies can help remove barriers to evidence-based treatment while holding facilities accountable to standards that reflect their healthcare provider status.

If this piqued your interest, check out Rehab: An American Scandal and read up on pragmatic policy solutions at rstreet.org/harm-reduction.