Unethical care, shoddy care, and the “poverty industry”

July 3, 2021
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As someone who spent 25 years working for a nonprofit providing long-term residential addiction treatment, I’m of two minds about the state of residential treatment in the US.

On the one hand, our agency struggled mightily to maintain high-quality, ethical, evidence-based care that kept patients engaged and supported them through the treacherous first 1-2 years of recovery. We pioneered services like recovery housing that allowed us to reduce length of stay, get patients participating in community life sooner, reduce costs, and improve outcomes. We did this with unsustainably low reimbursement rates and raised charitable funds to keep the lights on.

On the other hand, I’m very well aware of the shady practices, shoddy practices, and profiteering that occurs in the industry. We put a lot of effort into distinguishing ourselves from those programs and we publicly criticized unethical practices in the industry. I want them to change or get out of the business.

I also know that these kinds of problems are not confined to residential treatment. There are widespread problems in buprenorphine prescribing, recovery homes, lab services, etc.

So… on the one hand, I know there is fraud/waste/abuse and I want it exposed and punished. On the other hand, I know there are good providers out there and I don’t want to throw out the baby with the bathwater. Most importantly, I want people with addiction and their loved ones to be able to navigate systems of care and find treatment of adequate quality, duration, and intensity, and to have their preferences about things like medications respected.

Earlier this year a “secret shopper” study was published and got a lot of attention. It confirmed the unethical practices that I’ve been complaining about for decades, but it bothered me for a couple of reasons. First, it was framed as proof that residential treatment is problematic and should be a thing of the past. Second, it was used to elevate other treatment approaches that also have problems with unethical and shoddy practices.

Rather than just condemning a treatment model (that people seek for rational reasons), wouldn’t it be better to help consumers and referring providers distinguish good providers from bad providers?

Why didn’t they do that? Maybe there weren’t any ways to distinguish?

The Recovery Research Institute just published an analysis of the study and highlight an important pattern:

non-profit admission practices differed considerably from those of for-profit programs. Non-profits were less likely to offer admission over the phone, less likely to exclude patients based on their psychiatric or substance use history, and less likely to use recruitment tactics. Non-profits had longer wait times for admission on average and a lower likelihood of encouraging the patient to take on debt to pay for treatment. In comparison to for-profit programs, non-profit programs have less than half the same-day admission rate and about three times the average wait time. For-profit program costs, on average, were more than twice the amount of non-profit programs per day.

This is all right there in the paper. It’s not even buried in statistical mumbo jumbo. Why didn’t the researchers or the media highlight this to help consumers narrow residential searches and find an ethical provider?

To me, their conclusion indicates a lack of interest in helping patients differentiate between good and bad residential providers.

We found a pattern of high costs and active recruitment, frequently without clinical evaluation, in a national audit of residential treatment programs. Some of these behaviors were more common among for-profit programs, but others were similar across both for-profit and nonprofit organizations. Given that outpatient opioid agonist treatment should often be a first-line treatment for patients with opioid use disorder rather than costly and potentially less effective residential treatment, these findings raise concern about the benefits of investing in access to residential treatment as a policy priority.

Fellow contributor David McCartney’s recent post exposes a flaw in this approach.

His post, reporting on a recent Rec-Path blog post evaluating recovery in policy and practice on both sides of the Atlantic by UK academic, Professor David Best and American economist, Sonia Martin.

They could be understood as suggesting that the we might do well to put less emphasis on the particular modality of treatment and more on its recovery-orientation.

It is notable that almost no funding has been allocated to researching recovery-oriented systems of care in the US or UK in the last decade.

Martin & Best, 2021

Martin and Best report that the system’s failure to re-orient itself toward recovery has resulted in what some call a “poverty industry.”

The shared concern in both the US and the UK is that increased investment and increased public concern and attention have not led to new ways of thinking but have largely ended up in doing more of the same. More treatment workers, more treatment services and very little of the crucial lessons from recovery – jobs, houses and pathways to community capital and resources. In Scotland, McGarvey (2018)[2] has referred to this as the self-preservation of the ‘poverty industry’.

Martin & Best, 2021

I’d suggest that good residential providers are recovery-oriented and are effective at addressing things like “jobs, houses and pathways to community capital and resources” in ways that are very rarely seen in other treatment modalities.

We might all be better off if advocates and providers of other modalities paid more attention to the reasons many patients seek residential care and what works well for good residential treatment providers, and then seek to integrate those lessons into their treatment modality. (And, to be sure, we’d all be better of if residential providers, even the good ones, did the same thing.)

It all takes me back 20+ years, with Bill White telling addiction professionals something like, “All these arguments you’re having about TSF vs. CBT vs. MET are stuck in the wrong paradigm. We need to orient ourselves toward recovery.”

It feels like we need to relearn that lesson.

UPDATE: David McCartney commented below. I’m adding it here, to make sure it gets the attention it deserves:

“Given that outpatient opioid agonist treatment should often be a first-line treatment for patients with opioid use disorder rather than costly and potentially less effective residential treatment, these findings raise concern about the benefits of investing in access to residential treatment as a policy priority.”

Mmmm. Does what people want from treatment not matter? Should there not be a menu of treatment options available with risk mitigation for those modalities that are not based on MAT?

Perhaps just as important is the issue around what ‘less effective’ means. In recovery terms, MAT is not strongly evidenced to help people reach recovery goals. While preventing overdose and death is an essential first step, as Eric Strain said: “Not overdosing is an insufficient endpoint for treatment or for societal and medical interventions – it’s a starting point.”

In the UK, as Prof David Best was saying just this week, the policy pendulum has swung from harm reduction to recovery and back again. Unless we do some sensible and joined up thinking, it will continue to vacillate. We need a variety of treatment options because we have a variety of people with different substance use disorders who have varied goals which can vary over time.

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