The Health Divide: Q&A: Why does rehab keep failing those who need it most?

The Affordable Care Act extended health insurance, including coverage for addiction treatment, to millions of Americans. And that powered the growth of a multibillion-dollar industry that fuels relapse instead of recovery, journalist Shoshana Walter writes in her new book, “Rehab: An American Scandal.” 

While there’s scientific consensus that addiction is a disease, Walter shows how rehab programs often exploit, harm, and sometimes kill the people they’re supposed to heal. 

 

Meanwhile, almost no residential programs admit pregnant women or women with children, though motherhood can be a powerful motivation to stop using drugs. And three decades into the opioid epidemic, the gold-standard treatment for opioid addiction — the medication buprenorphine — continues to be underprescribed. Black patients are less likely to receive it than white patients, and women are far less likely than men.

 

I spoke with Walter, an investigative reporter who covers public health and criminal justice for The Marshall Project, about the failures of the system and the stories she’d like to see journalists tell. The conversation has been edited and condensed.

The law barred insurance companies from denying someone insurance coverage simply because of this preexisting condition they might have, which is addiction. And it expanded the length of time that someone could remain on their parents’ insurance policies. Suddenly you have all these people in their early 20s who previously would have been unable, potentially, to access addiction treatment. Now they can, through insurance providers.

Once addiction treatment became something that would be paid for by insurance companies, treatment became a viable business. All these programs opened up, many utilizing practices that are not evidence-based and offering services that are motivated not necessarily by what’s best for the patient, but by what’s most profitable.

Typically, when it comes to residential treatment, the most that insurance companies are willing to pay for is 30 days. We now know that with these 30-day programs, people go in, they come out, and they often relapse. Someone who completes a 30-day program is actually at greater risk of overdose death than someone who fails to complete a 30-day program. So there’s a way in which we’re funding a form of treatment that drives the cycle of rehab and relapse.

A person is at far greater risk of overdose death in the year after treatment — and also immediately after leaving incarceration. That’s because these programs typically require abstinence from a person’s substance of choice. During that period, a person’s tolerance level drops. Once they leave rehab without the needed supports, patients often relapse, using the same amount of drug they previously used. But because their tolerance level for the drug has dropped, that amount now is more than they need. And when fentanyl is in the mix, that amount is too much or even deadly.

I was genuinely surprised that a form of indentured servitude would be considered addiction treatment.

We have decades of studies showing that treatment programs that allow mothers and their children to stay together have better outcomes. But over the course of the opioid epidemic, the number of treatment facilities catering to mothers has declined. About 70% of women with addiction have children. Overdose deaths of mothers are skyrocketing, yet only 2.5% of facilities nationwide allow women to bring their children with them. Only 4.5% of facilities nationwide provide child care. It's a problem across the board, but it's especially a problem for low-income women.

April had so much unresolved trauma from her childhood that she had not been able to deal with because she had responsibility for her three children. When she was struggling with her addiction and trying to take time away to figure out what she should do, she was accused of abandoning her kids, and her kids were taken from her. There were so many years of traumatic separation that didn't just impact April — it impacted her children, too.

I think we all understand that addiction typically leads to criminal justice involvement. There’s less awareness about how often mothers with addiction and their children are swept into the child welfare system.

 

 April’s story also highlights how structural racism compounds the recovery struggles for people of color.

There are huge racial disparities in who has access to addiction treatment, the span of time that someone remains in addiction treatment, and how likely someone is to finish addiction treatment. Many of these disparities come down to the conditions in someone’s life. When someone faces economic instability, housing instability, food instability, all of this, it affects their ability to find, enter and complete addiction treatment. And once someone leaves treatment, they need community and social support to facilitate making a life change and sustaining long-term recovery. 

We go through these periods when lawmakers and the public want to find a more compassionate solution to drug addiction, and they try it, and then it doesn't work the way they want it to, because there's no magic cure for the problem. So we swing back to punishment. We’re almost seeing that again right now. There are crackdowns on homelessness. States across the country are passing mandatory minimum sentences for fentanyl. We may start to see incarceration rates begin to climb up again. Inevitably, these efforts disproportionately impact Black and brown people.

When I started, my approach had been to try to meet people who are in active addiction and try to understand from them what the barriers to care were. I interviewed many, many unhoused people. Then COVID hit and I was pregnant at the time, and that became impossible. I realized I needed to reconstruct narratives, rather than be present for so much of the narrative. So it became a matter of finding people who could be good partners in telling their stories.

We talked very frequently, multiple times a week, for hours at a time, for years. Also, April is a beautiful writer. During her active addiction, and during her time trying to get sober, she had kept all these journals, and she'd written all this poetry and saved all these records. She let me read all of it. I interviewed family members, some of her treatment providers, someone she had been unhoused with. I went and visited her in Philadelphia. She gave me a walking tour of everywhere she had been during that time period. You know, where she would buy her cherry-flavored honey bun every morning, and the grassy plot near the community center where she slept on a cardboard box. 

I had to give up control a little bit. There were things that we talked about that were really traumatic from her past. And I told her we didn't have to include every single detail. 

I also read her the sections of the book about her out loud before turning the book in, to make sure she was comfortable with everything that I had put in and she was not surprised by anything. And to fact check. That was very important.

I would love to see journalism that monitors and tracks the impacts of cuts in treatment and harm reduction services. What does this literally look like for someone who is addicted and needs treatment? 

I had a book event in Kansas City last week, and I was speaking with this woman afterwards, a mother whose son has been in recovery for eight years thanks to methadone. She said prior to that, he had gone to rehab two dozen times and always relapsed. Methadone saved his life. Medicaid is paying for his methadone treatment. So she's really worried about what is going to happen.