In the summer of 2015, a twenty-four-year-old Louisiana man named Chris Koon went on a weeklong meth binge. The week came to an end when police raided the house where Koon was staying. He was looking at a five-year sentence for felony possession — but the prosecutor offered him an out. He could avoid jail by spending 18 to 24 months at a residential rehab program known as Cenikor. How could he say no?
Koon, who is one of the four central figures in Shoshana Walter’s deeply reported Rehab: An American Scandal (Simon & Schuster), soon found that Cenikor was unlike any rehab he’d ever set foot in. Participants were woken up at 2 am and told to scream at each other for minor rule violations. Actual counseling was minimal. Instead, Koon and the other participants were farmed out across Louisiana as low-wage laborers. In his time at Cenikor, Koon worked as many as 80 hours a week in restaurants, chemical plants, and a grain silo. Cenikor pocketed all of his wages; Koon was given three packs of cigarettes a week. When Koon tore a rotator cuff in an accident at a spice plant, he was told that he’d need to leave the program and go to jail if he wanted medical attention. “The work is not optional,” a director told him.
When the Affordable Care Act kicked into gear in the early 2010s, a flood of new resources became available for treatment of substance use disorders. Private insurance plans were now required to offer at least limited coverage for addiction treatments, and new streams of money became available through Medicaid. But, as Walter painstakingly explores in Rehab, the post-ACA era of addiction care has fallen far short of its potential. Tens of thousands of people who need help are being steered into programs that are hyperpunitive, careless, grifting, or all of the above.
Part of the problem is a lack of state capacity. Even as new public money has poured into addiction care, state and federal governments have failed to build a regulatory apparatus that can keep an eye on providers. According to Walter, residential-rehab operators in California aren’t required to have any domain-specific expertise. At one point, the state had only sixteen inspectors to monitor more than 2000 licensed rehab centers. Beyond the licensed residential centers, there is an even less regulated tier of “sober-living homes,” many of which are excellent, but some of which rake in Medicaid reimbursements while completely neglecting their residents’ needs. (The Baltimore Banner won awards this year for exposing an especially sketchy operator.)
If underregulation is part of the problem, addiction treatment in the U.S. has also been hamstrung by overregulation. As Walter demonstrates, the federal government was for many years far too cautious about allowing primary care physicians to prescribe Suboxone, a medication that effectively helps people wean themselves from opioid addictions. Where France and other countries made Suboxone and similar medications broadly available via prescription, the United States put up barriers. Doctors who wanted to prescribe Suboxone had to obtain a waiver by completing a lengthy training. Until 2022, they were permitted to prescribe the medication to only a limited number of patients. Because there were too few providers to fill the public’s need, some people living with opioid use disorders started to buy Suboxone on the black market to help ease their withdrawal symptoms. This illicit trade in Suboxone in turn drew the attention of the Drug Enforcement Administration, which started to show up at Suboxone prescribers’ offices, demanding to see their patient records.
Walter tells this story in part through the figure of Larry Ley, an eccentric Indiana physician who, along with his practice’s entire staff, was arrested in 2014 and charged with dealing in a Schedule III controlled substance. Indiana authorities claimed that Ley and his colleagues had sloppily dispensed Suboxone without properly validating their patients’ addictions or offering them counseling to assist with recovery. Ley was eventually acquitted at trial, and the charges against his colleagues were dropped. But at that point he was a nearly broken man: While awaiting trial he had picked up a couple of DUI arrests and had lost his medical license.
In her account, Walter concedes that some of Ley’s clinical choices were sketchy. “And yet,” she writes, “the sad reality of the treatment landscape meant that he had still done a better job of facilitating his patients’ survival than many other treatment programs.” Ley’s instinct to put Suboxone in the hands of as many people with opioid use disorder as he could was a correct instinct.
Meanwhile, even after the federal government’s belated 2022 liberalization of Suboxone, the law continues to treat the medication as a threat. As Walter reported in a separate project this summer, newborn infants are still sometimes removed from their mothers’ care if Suboxone is detected in their system, even if the Suboxone was properly prescribed for addiction treatment.
Many lives have been needlessly lost over the last twenty years because of the slow rollout of Suboxone. That’s not solely a story of federal misregulation. Suboxone’s manufacturer didn’t help matters, Walter argues, as it sometimes behaved as if it were more concerned with extending its patents than with getting the drug into the hands of all the people who needed it. And even if federal regulators and drug companies had acted pristinely, there would still have been an uphill battle to persuade primary care providers to make addiction care a routine part of their practices.
Chris Koon, the Louisiana man who was forced into what amounted to indentured servitude at Cenikor, eventually caught a break. After two years of exhausting labor, he was kicked out for alleged noncompliance with house rules (at just the point when he had logged enough months that he would have been allowed to keep some of his wages). This was a bad moment. Having “failed” Cenikor’s residential rehab program, Koon could have been forced to complete a five-year jail term. But a judge took pity and allowed him to go into supervised probation instead. As of the end of Walter’s narrative, Koon had started a family and was maintaining sobriety, in part with the help of Suboxone.
Cenikor is hardly the only rehab program to have been accused of exploiting participants for cheap labor. As Walter reported elsewhere, the Salvation Army has been sued for similar alleged malpractice. Rehab operators can milk the system in other ways, as well: They order huge numbers of urine toxicology screens for which they’re amply reimbursed (the tests are known in the industry as “liquid gold,” Walter tells us). In some cases they also have financial incentives to overmedicate their residents. Walter relates the story of two patients who died within a short span of time at a California rehab center after being given absurd cocktails of multiple sedating medications.
The story of the U.S. rehab industry across the fifteen years since the ACA’s enactment gives us more proof, if any were needed, that access to health services is not enough. A universal health insurance system — if we should ever get there — won’t be enough. In addition to a generously funded treatment system, we will also need robust oversight that places patients’ voices at the center. If a rehab center exists mostly to exploit its participants for low-wage labor, the state should have the capacity to shut it down. If government regulations are denying people access to actually-effective interventions like Suboxone, it shouldn’t take decades for the system to correct itself. In addiction care, as in every other kind of health care, the system needs to be built around patients’ actual needs.