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SPECIAL REPORT: Addiction treatment at an ethics crossroads

March 12, 2013
by Alison Knopf, Contributing Writer
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(First in a series)

Addiction treatment providers may be getting a free ride when it comes to what they promise and what they deliver, and the Internet is giving them some extra fuel in terms of getting what they depend on: patients. But who is policing what is being promised on the Internet, as well as by the call centers interwoven into the marketing strategies of treatment providers? Who comes between the desperate family member looking for help right now and the treatment provider, to guarantee that the treatment is evidence-based, worth the money, and likely to produce a good outcome?

The answer: Right now, if the program is not a public program, nobody, at least not from a federal standpoint, and not in the two states—Florida and California—that we will take a closer look at later in this series.

Public programs—those paid for by taxpayer dollars such as the Substance Abuse Prevention and Treatment Block Grant, Medicaid, or Medicare—are more closely scrutinized than private programs, as this series will show. And treatment providers know it.

“In the public sector you have to be pretty accountable for those dollars,” says Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association (FADAA), which represents treatment facilities in the state. “You get sanctioned if it’s not appropriate.” But for private programs, paid by insurance companies or increasingly by “self-pay” patients who go into debt to afford the treatment, there is no such accountability—not in Florida, not in California, and not in the federal government.

The “treatment locator” of the Substance Abuse and Mental Health Services Administration (SAMHSA) lists any program that is state-licensed. There are no ratings—SAMHSA depends on the states to do the monitoring.

The single state authorities (SSAs) in the states are responsible for monitoring treatment programs that receive federal block grant funding. Licensing authorities in states are responsible for making sure that programs adhere to licensing statutes.

The bottom line: Programs must not break laws. But as the top lawyer-physician in SAMHSA, H. Westley Clark, M.D., J.D., director of the Center for Substance Abuse Treatment (CSAT), told Addiction Professional in an interview for this series, “Just because something is legal doesn’t mean it’s ethical.”

Questionable practices

Here are the most common practices we heard about that are taking place in the addiction treatment industry, and that are considered unethical by leaders in the treatment industry and by government officials. Many of these practices, especially those involving kickbacks, are also illegal if performed by providers that are paid by taxpayer dollars:

·        Using call centers to share patient prospect information with and between treatment providers.

·        Paying bounties for referrals.

·        Giving large gifts to interventionists with whom a program works.

·        Claiming to take a patient’s insurance, when in fact the anticipated reimbursement is very low.

·        Paying kickbacks to labs that are overcharging insurance companies for drug tests performed on a facility’s patients.

·        Promising a cure.

·        Using nutrient supplements that are proprietary and billing the patient.

·        Using brain scans and other unproven treatments and billing the patient.

·        Internet marketing scams.

“Why are most of these practices occurring on the private side?” rhetorically asks Michael Cunningham, acting director of the California Department of Alcohol and Drug Programs (ADP), the SSA for the state. “I would surmise it’s because that’s where the dollars are.”

That leaves licensing, but licensing has its limits. In California, ADP’s Licensing and Certification Division conducts an initial site visit to review health and safety issues and program policies. Compliance reviews are conducted once within each two-year licensure period. If a complaint is received, ADP initiates an investigation. But ADP’s licensing division doesn’t give any advice to consumers. It is simply the licensing authority, with its mandate to follow.

Clearly there are many ethical and high-quality providers in the addiction treatment field. But at a time when addiction treatment is continually blasted by negative press and patients are saddled with stigma, it is equally clear that unethical providers—however legal their operations may be—can hurt the whole field.

As David Lisonbee, president and CEO of Twin Town Treatment Centers in Los Alamitos, Calif., observes, “We all get painted by the same brush.”

And there is another phenomenon at work here. Everyone is now going to be under more scrutiny under the Affordable Care Act (ACA), where many patients will be covered by Medicaid. And if they’re not covered by Medicaid, they will be covered by an insurance company. Unless the addiction treatment field becomes entirely self-pay, with programs operating under the radar of public and private payers, it not only will be locked out of the biggest expansion of healthcare in decades, but it will turn back the clock on its place as a valid medical treatment for a medical disease.

In essence, addiction could find itself in the same category, fairly or not, as other predators on the Internet looking for the desperate, who will pay anything to save a loved one.

Continue to Part 2



Fascinating report. Please tell us how the research was conducted. For instance, how many programs were surveyed in each state? What was the prevalence of these problems?

Anne Fletcher, author of Inside Rehab (Viking)

Anne, Thank you for your comment. In keeping with Addiction Professional's role as a magazine, all of our articles are based on interviews of key sources/experts as well as the background information we have collected from past reporting/coverage.

Gary Enos, Editor

Great to point out the seamy side of our field! Thankfully, ethics is a required course for addiction counselor trainees in higher education. Many of my students encountered questionable practices at their internship sites, which of course puts me in an ethical dilemma learning of them. First day at the practicum, a student was given the job of writing fake progress notes as the program was being audited the next day. Another was made to actually hide poorly kept files in a storeroom. Others were not cautioned to take care not to overstep boundaries with clients, blurring the roles of AA sponsor with that of counselor, reversing roles and telling the client all their problems. A counselor had a card with his name followed by SAC. In NJ this stands for the coordinator of prevention and intervention for a school district, which this person was not. He then said it stood for Substance Abuse Counselor (his title at the facility). Not a credential! Program posing as an extension of AA/NA, going against the Traditions of AA/NA. That's a sample. Thanks, Alison and Gary! Peter L. Myers, Ph.D. www.incase.org

Dear Gary

I will submit to you that your article will cause various individuals connected to very shady or shadier than normal operations to come after you or question your credibility or research methods. Is like the criminal who stares at his door and knows is only a matter of time before the law comes knocking on it. Administrators with no ethical accountability to any board or licensing entity feel entitled to deceive the public with their internet scams. From the inside of the operations I have seen the horrible deceit and bad conditions that take place AFTER you give them your credit card number. The worse we ever had around here was a horrible place called " South-coast Recovery " in san Juan Capistrano. And yet the state never responded to the calls and complaints from the families who were defrauded and the clients who were even sexually abused. Eventually the place imploded, thank God. This is an industry that in my view will eventually implode. And all of this while California gets ready to shot down it's Department of Drugs and Alcohol, the only possible way to shot these scammers down. Is really all very disturbing. Thank you for having the courage to present these to the public at large.

Another excellent article from Allison Knopf. She's one of the few voices that clearly and credibly accumulates pertinent information and lays it our for our evaluation as a field. I have seen all of the warning signs detailed (ie call centers, kickbacks etc.) do tremendous damage to individuals, their families and our industry. If CNN's expose doesn't wake us up, nothing will. Interestingly, Allison references public payment for addiction services indicating a higher level of oversight and accountability. If the private sector is lagging behind the public sector, than how dangerous are the events occurring in programs across the country. Good job Allison, and Gary Enos for having the conviction to print more than articles focused on inane topics.

Let me say I love the topic, but dislike the broad-stroke characterization of "Internet Marketing scams". Why do that? Why not say "scams" or speak specifically about specific "scams"?

Ignorance drives negligence and abuse. You know that, and it's part of what's wrong with the types of treatment industry practices you are highlighting and questioning. Tacking on that poorly-considered bit at the end about "Internet Marketing" doesn't help your cause any, and hurts mine. I do Internet marketing for treatment, among other activities.

Would you like to know more about lead-generation, Internet Marketing, and the online aspects (real or theoretical) of Continuum of Care? I don't get that impression.

I'm very qualified to discuss the FACTS about marketing treatment online and the treatment industry. I'd love to engage in positive, development discussions of the disruptive Internet technologies and models of information dissemination, treatment, and care.

But so far, few make any effort to know the details. Few, not even the "academics" granted time for fruitless study, look beyond the marketing or what comes up in Google.

Perhaps a boogeyman is needed? Perhaps it's too much work or there is too much fear of the technology that drives a large portion of the commerce that delivers information and treatment to those who need it?

It's easy to complain. It's even easier to point fingers and accuse. Such blaming improves nothing -- it's ignorant commentary. To say we need to stop those "Internet marketing Scams" - LOL.

I'd love to connect with true thinkers and influencers on these topics, and help educate and inform (myself as well as others). But it seems most are locked up by the basics. Hidden behind private LinkedIn resumes, closed Twitter accounts, and Facebook cliques... or else restricted to insider groups that meet in person a few times per year.

And the successful websites are quickly bought out by big business and turned into revenue machines, or used in attempts to scale efforts aimed at the 80% low-hanging-fruit.

The Internet is a revolution. It is the people seeking transparency, willing to sacrifice personal risk, because the existing system of referral, information, and care has not delivered adequately. Since 1995!

If you find yourself trying to control the Internet, or those who are using it to satisfy demand, I suggest you are part of the problem.

Instead, why not work with it, and help it evolve to do a better job? That's what the people really want... they want those who are qualified to help, to help. Improve information access and the quality of services delivered. Yesterday.

john onyma
* never wrote a book
* not a certified addictions anything
* persuading people to get the help they need, 24x7 every day

http://www.ripoffreport.com/ and do a search there. the worse of the worse are being exposed here.

Thank you so much for this article!! It means a lot<3. It really will really for the youths in our society.

Treatment Programs Scammers and cheaters have been operating in California without any respect for ethics or even the law with impunity for years. we seem to have the worse of the worse here in Orange County where major programs have advertised services they don't really intend to provide, post pictures of facilities they don't have to defraud clients and their families. Interventionists with shady agendas are everywhere and their internet soliciting and deceit goes on without any accountability.

Frankly I left the field disgusted with just about all of the companies I worked for as a Counselor. When the general public finally finds out what is going on with these providers, they will be shocked into action.
planning to check on a treatment program? go to http://www.ripoffreport.com/ and do a search

I was amongst the lucky few who stayed inpatient back in 2013 when(prefer not to mention)the dual diagnosis track was opened. I have been sober ever since(March 2013) that stay yet I unfortunately had a mental breakdown Christmas eve that put me back into their inpatient program . So sad how everything has changed for the worse there. I would and will NEVER recommend this facility to anyone. I just read some reviews that are on Google and more than 1 (5 star rating) was submitted by staff! Ridiculous. The staff was so inappropriate and unprofessional with clients and each other as a matter of fact I felt extremely uncomfortable and basically appalled with what I was witnessing. To top it all off, after day 2 I realized that a couple of factors unrelated to my recovery contributed to me running into their facility in the first place and triggered me, basically I wanted to leave. I wasn’t and am not suicidal or homicidal and was not using yet they blocked my departure for 2 more days for a total of 4 days there. I laughably just received an outrageous bill from them for $3100 with which $850 was my personal responsibility. I immediately called my insurance company to report their vague fees and billing codes and was asked to be transferred to the fraudulent claims department. My therapist and another administrative staff member threatened me with "if I leave you will not be allowed back" and then a few days later two other staff members called me two days in a row to basically ask me to return (under the guise of "how are you doing?) They charged me $2500 for a "mental health crisis intervention " which I was then told is an AMA blocker!! That's what they put on my file, I AMAed. Absurd since I was of sound mind and body; clearly wrote in my journal and gave to my therapist (i was hoping she would include it in my file NOT) my own reasons for coming and why I felt it appropriate to leave. Nope I was still leaving against their medical advise. The urine analysis they conducted was unprofessional and unethically administered with NO supervision of any female staff member. That's against protocol, period. For that they charged me $1750! I couldn't believe what I was reading. I personally work and have family who work in this industry so I know the inner workings of some of the underhanded things that go on, especially with price gouging insurance companies taking the client for all they're worth. Mainly keeping most for longer stays to so they can rape their insurance company. It's just disgusting and is part of why the recovery "business" and especially here in South Florida is evil and despicable with their practices of so called "helping" those of us with the disease of addiction /mental health challenges. I just felt it was necessary to tell the truth for those who read these articles on ethic practices in the field of addiction. We're here to help human beings, not bankrupt them for little or no sustaniable and real results.

I need to write 500 word essay about addiction treatment at an ethics crossroads. Any info on this subject will be useful!