- Later on, Synanon kind of became something of a cult.

I mean, the founder enriched himself through this program.

They made millions and millions of dollars he would start ordering vasectomies for, for people in the community.

Shaved heads, forced marriage.

Exactly.

And it kind of went off the rails, but it really showed how this model that requires work can become something exploitative.

- Welcome to Forum, I'm Alexis Madrigal.

In the mornings walking from BART across the Mission to the station, I often wonder about the lives of the people I pass doing drugs on Cap Street and the alleyways of the neighborhood.

Sure, they've made bad choices.

They impose costs on everybody else in the city, but how can it be that our region, our state, our country, cannot help people even after 1 million Americans have died of drug overdoses?

The failure is so profound that I think a lot of us have developed some ethical loopholes about people suffering from addiction.

They're lost to us.

No treatment works once someone goes down that road.

It's too late, et cetera, et cetera.

But one thing that Shoshana Walters' book irrefutably shows is that when it comes to addiction treatment, when it comes to helping people who want help, we are just failing people horribly up and down the socioeconomic ladder, but especially those at the bottom.

And even worse, a small number of people are profiting off, exploiting the vulnerable here to share more about her book, rehab and American Scandal, and the reporting that informed it, we're joined by Shoshana Walter, an investigative reporter with the Marshall Project.

Welcome.

- Thanks so much for having me, Alexis.

- So the narrative that I have in my head about drug treatment in this country is that because the opioid epidemic hit a broader swath of American society than crack before it, our country decided to take a gentler, more treatment based approach to drug addiction.

But your book shows that we didn't really do that.

What, like what went wrong?

What happened?

- Yeah.

I mean, exactly like you said, during the crack cocaine epidemic, our app, our country's approach to treating a drug drug addiction was to criminalize, to punish.

And that led to mass incarceration of drug users, disproportionately black and brown Americans.

Then the opioid epidemic came around.

It was more of a pain pill epidemic, mostly affecting white communities.

And so there was this major transformation, a well intended transformation, and a widespread acknowledgement that addiction is a disease.

It's a, it's a disease that's worthy of medical care and worthy of treatment.

And so over the past 25 years, we've seen this enormous expansion of our treatment system.

First with the launch of Suboxone, the Gold Standard Addiction Treatment Med in 2002.

And then with the Affordable Care Act, millions more Americans suddenly had coverage of addiction treatment.

But the system is really not working the way it, it was intended.

You know, some of these, a lot of these issues, and specifically these issues that I lay out in the book, Have to do with people still being punished for their addictions, being sent to treatment programs that send them to unpaid labor jobs, working for some of the largest companies in America.

We have medication assisted, medication assisted treatment like Suboxone.

That's still so hard for patients to access.

Many doctors don't wanna prescribe it.

And then we have insurance funded treatment.

Oftentimes these 30 day inpatient programs that people come out of and they relapse.

You know, we now know that someone who completes a 30 day treatment program is much more likely to overdose and die in the year after treatment than someone who doesn't finish it at all.

- Which is just, I mean, it just goes to show how poorly we're doing this.

Like this is the exact opposite of what one might expect.

Like treatment is supposed to make you better, not worse.

- Right.

Right.

Exactly.

And I think, you know, even the best intention treatment programs, you know, some, some of them feel really frustrated with this limitation that's often imposed on them by insurance companies.

And then some treatment programs have taken advantage of it and view it as part of their business model.

Hmm.

You know, there was one treatment company owner I interviewed who, you know, in his treatment program, they were overmedicating patients to the point of impairment and contributing to overdose deaths in their own program.

You know, even he was frustrated by this limitation.

He called it a cycler, you know, and, and his company staffed employees to call people who would leave their 30 day program, find out if they relapsed, and if, and then if they did, especially if they had very good insurance, re-enroll them.

Re back.

Yeah.

So they would just, it was just a cycler going in and out.

- Oh, we're gonna go deeper into all these issues, the suboxone, different types of rehab centers, and why some of them don't seem to work or, or work in ways that are seem cruel and unusual to me.

But let's talk about how you got into writing this book.

You know, it was like eight years ago you started looking into some of these treatment centers and you found people working as part of their drug treatment for some reason in a, in like a chicken processing facility.

Tell, tell us more about that.

- Yeah.

I was a reporter at Reveal from the Center for Investigative Reporting at the time, and I just kind of stumbled across this program that a lot of drug courts and diversion courts in Oklahoma, Oklahoma and Arkansas were using and were people who were supposed to be receiving addiction treatment instead of incarceration.

You know, it sounds great, but when I looked into this rehab program, I discovered that it was founded by poultry, former poultry industry executives.

And these rehab participants were being sent to work unpaid at chicken processing plants, where they were making chicken products for KFC, Popeye's, Walmart, PetSmart, Rachel Ray Nutrish, you know, these products that every American, almost every American consumes these participants.

That was their, predominantly, their sole form of treatment was just this unpaid labor.

- You know, and you trace some of this in the book, and this company arises called Senacor, that one of the main characters in the book goes through at least some of their program.

Where did they come from, and where did this idea that putting people to work with kind of minimal actual counseling and other things might do something for them?

- Yeah, this Senacorp's model was this program called Synanon that was founded in 1958 by a former oil salesman who struggled with alcoholism.

And he had tried aa, and he hated it because he felt like people relapsed and lied about it in aa, and he didn't wanna let himself or other people get away with that.

So that was kind of the underlying premise for this new entity.

- Tougher love was needed.

- Exactly.

And this kind of became like the pre precursor to rehab in the United States.

It started out as this community where people got together and like called each other out on the BS and screamed at each other and confronted each other.

And then it grew and grew and grew.

And it ended up becoming these recovery communities that existed across the United States, including in the Bay Area, where people lived and worked and held each other accountable via these what was later called attack therapy, also known as the game.

These circles of calling each other out.

And these program participants would work, they would work unpaid jobs to kind of fund the program.

And at the time, this Synanon really gained popularity during the sixties and seventies.

And it grew and grew and grew.

And it was adopted by a lot of other programs, including the Senate Corps Foundation.

Later on, Synanon kind of became something of a cult.

I mean, the founder enriched himself through this program.

They made millions and millions of dollars he would start ordering vasectomies for, for people in the community.

Shaved heads, forced marriages.

Exactly.

And it kind of went off the rails, but it really showed how this model that requires work can become something exploitative.

- I mean, on the face of it, it seems a little crazy.

Is it that for some people it did work though.

And so they became kind of like the key advocates for the organization.

Like, well, look at me.

It worked for me.

It could work for you.

Right.

- Yeah, I think so.

And I think there's something really compelling narratively about people going into a program and just, you know, completely transforming their lives.

You know?

And you know, one participant, when I was at Reveal, we did a podcast series called American Rehab, and my colleague interviewed some former Synanon participants, one of whom was like, yeah, we brainwashed people.

You know, 'cause their brains are dirty.

We brainwashed them.

I think the problem is though, that, you know, what ended up happening is people would go into this program and they'd stay sometimes for years, and they would leave and they would relapse.

- Hmm.

- So, and that's a very common theme in different models of treatment that we've tried over the years in the United States.

People entering, they're there for a period of time, and then they leave and it doesn't work anymore.

Yeah.

- I mean, is there anything to the idea that once people are really deeply addicted on to drugs in particular, there's not that much we can do or not?

- No, I think there's so much we could do to help people recover from addiction.

I mean, a lot of people recover from addiction over time, you know, on their own.

Some people don't even need treatment.

I think people age and grow, and naturally that's what occurs for a lot of people.

They actually grow out of it.

I think the problem with our, with our drug policies in the United States is that when someone is in their addiction for a long period of time, it increases their level of marginalization.

And it becomes harder and harder to find your way out of it.

Because then you're lacking things that you really need in order to, in order to sustain long-term recovery, such as housing, such as job, financial resources, social supports, transportation.

You know, the longer you're in your addiction, the harder it is to accumulate these things that are so important.

And then there are other barriers to recovery and treatment that exist too, that I detail Yeah.

A lot in my book.

- Yeah.

You call it recovery capital, right?

Or, or that's a, a term that is used in the field.

- Yeah.

Yeah.

I spoke with a lot of researchers who told me about this, about how important this, this idea of recovery capital is.

These are the resources that people can draw from to facilitate change in their life, to even be able to envision change in their lives.

And it's, you know, everything that we just described, you know, all the things that you need to really, to really build a, a new life for yourself.

Community, housing, transportation, food, financial security, you know, without these things, you go into a treatment program, you leave.

It's almost like relapse is inevitable.

- Hmm.

We are talking about America's drug treatment systems, and the rehab and addiction recovery industry.

We are joined by Shoshana Walter, author of "Rehab in American Scandal."

She's now an investigative reporter for the Marshall Project.

I wanna hear from you.

Have you had experiences with the rehab industry as a patient or as a provider?

What was your experience?

You can give us a call.

The number is 8 6 6 7 3 3 6 7 8 6.

That's 8 6 6 7 3 3 6 7 8 6.

You can email us forum@kqd.org, all the social media things, Bluesky, Instagram, Discord, or KQED Forum.

I'm Alexis Madrigal.

We'll be back with more right after the break.

Welcome back to Forum, Alexis Madrigal here.

We're talking about America's drug treatment system, and its failures.

Joined by Shoshana Walter, author of Rehab, an American scandal, now an investigative reporter for the Marshall Project.

You know, one of the kind of probes for this system that you use in this book is the way that American, the American healthcare System has or has not deployed the drug Suboxone.

So, first of all, tell us what that drug does, and then tell us about like, sort of the American regulation around it versus say how it has been done in France or other countries.

- Yeah, so Suboxone is actually buprenorphine.

It's, it's a drug that operates similarly to methadone.

It operates similarly, almost, I would say, to like nicotine gum in that it's like a substitute for illicit opioids.

And if you take it and you're, if you're an opioid user and you take it, it quells your cravings, it, it gets rid of any withdrawal symptoms.

It kind of just makes you feel normal, - Kind of hitting the same receptors in your brain, but without the same kind of high.

- Exactly.

Yes.

Yes.

And you know, during the, this, this, so US drug policy for almost a century did not allow doctors to prescribe narcotics to peop to patients who are known to be addicted.

So around 2000, when we were dealing with our own opioid epidemic, lawmakers were really interested.

Parti, particularly then Senator Joe Biden were really interested in developing and launching a treatment for opioid addiction that could finally be prescribed by a doctor out of a doctor's office.

And so, at that time, you know, back in 1995, France had had dealt with its own heroin epidemic where people were dying, particularly of, of HIV and aids.

And so their response to this was to release buprenorphine as widely and as a, as widely available as they can make it, you know, with, with any doctor able to prescribe it with any pharmacist able to dispense it.

And within four years, their overdose deaths dropped 79%.

It was wildly effective.

You know, they didn't have any kind of limits on it.

In the United States, instead of releasing buprenorphine to the American addicted, public government officials wanted a special formulation, which would, would be come to be known as Suboxone, that combined buprenorphine and this drug called Naloxone.

So that if you tried to misuse it and injected it, it would cause immediate withdrawal.

So basically it would deter people from misusing it.

We created this brand new medication, and then because it was a brand new medication, the company that developed it, the private pharmaceutical company, received this special status from the FDA called orphan drug status.

And that gave it seven years of exclusivity on the market, a total monopoly on this addiction treatment.

No generics would be allowed to enter the market during that time.

And when lawmakers finally passed a law, allowing suboxone to be released to, to patients, there was still a lot of concern among certain government officials, particularly the DA, the DA, - Yeah.

- Yes, exactly.

About, you know, they didn't want, they didn't want a France, they didn't want this drug to be as widely available.

- Why, why is that?

Like, what was the concern?

Actually, - I think this is a holdover from that century of, of drug policy where, you know, and, and also the DEA, you know, they're concerned about drug diversion.

This was a little bit before we understood that pain pills were being distributed via these pill mills, and - There - Wasn't as widespread acknowledgement of that going on.

But the DEA, I think was concerned about creating kind of like another drug epidemic that maybe by releasing this, this medication as, as widely as France, they would create another drug problem in the US - Because like if me a non opioid user were to take this drug, I would experience it as some kind of high.

- Exactly, yes.

Like, if someone who is not a drug user takes buprenorphine or Suboxone, it is possible to feel some sort of high from that.

It's not, it's not as intense as other drugs.

Like what I've heard from so many researchers is if you have your, you know, an array of options before you, that's not the one you would necessarily choose.

But I think there was this major concern from the DEA that they would create this, this other drug problem.

And I think there's just this still long still to this day, this stigma against these opioid substitutes or, or treating drug addiction with a medication.

You know, there's this feeling like, you know, if you're gonna be sober, you should do it without any assist.

You need to pull up by the bootstraps and just do it.

And so I think that's, that's still a kind of a stigma against addiction treatment medications that persists.

- So what has happened in the time, you know, just like, say the last five or 10 years, I mean, access to Suboxone has increased.

Right?

At least that's my understanding.

It's become easier for doctors to, to prescribe it.

Does, is it having its intended effect?

Is it working like, you know, if if access was increasing at the same time when we also had, you know, drug overdoses spiking during the pandemic, then, then kinda what's the relationship between these things?

- Yeah, it's a really good question.

And I, I'll say, you know, earlier in the epidemic, when we were still dealing with pain pills, and then we were dealing with heroin researchers I've talked to have said that was the really the crucial period of time when expanding access to Suboxone and methadone and buprenorphine would've made such a difference, you know?

And then heroin turned to fentanyl.

And we, throughout this time period, and still to this day, there are significant issues getting access to these medications.

There are, there are lots of prescribers who just are not willing to provide it.

They don't wanna treat addicted patients.

And even though more people have access to these medications than ever before, there's still these barriers that prevent people from accessing care quickly.

And that in the, in the, you know, in the time interim time between people wanting treatment and actually getting access to treatment, you can easily overdose.

- Hmm.

Let's bring a collar in here.

Let's go to Chris in San Francisco.

Welcome, Chris.

- Hi.

I, I wanna confirm what she described as the need for ongoing treatment.

Mm.

What I, I worked, I'm a psychologist.

I worked in a residential treatment program for five years.

I've done two formal postdocs in substance use disorder treatment.

And there are people who are going to need support ongoing, a higher level of care for life.

What we say in treatment is, when is recovery over, when is recovery done?

When are we done in recovery?

Never.

Recovery is for life, literally.

- It's so tough.

Thank you so much, Chris.

Yeah, thank you.

It, it, I mean, just taking a step back as like a society, if let's let, like, let's just say that's right.

That, like, for a lot of people, they're gonna be in recovery for life.

What would the sort of optimal approach be to this?

Like, not, not what we have, but what maybe if you could just design it and dream, like, this is what we would do if we actually wanted to help people who are very deep in addiction to recover and get on their feet for a very, you know, for, for - Life.

Yeah.

I mean, there's so many things we could do.

I think making it easier to access treatment, particularly addiction treatment medications is really crucial because these medications reduce deaths by 50, by more than 50% in some cases.

So that, that alone, I think would save a lot of lives.

And then researchers I've talked to have also pointed out that treatment duration could get better.

This 30 day treatment program model just really isn't working.

And then, and then I think this is something we've been talking about, this recovery capital question.

It's, it's a kind of broader question of what people actually need in order to recover.

And I think what happens after treatment is sometimes more important than the treatment itself.

- Hmm.

- You know, and I, and there are some, you know, there's some programs and states that are increasing access to the ongoing support that Chris mentioned.

For example, you know, they're funding peer navigators, peer coaches who can continue along with someone who's struggling with addiction and provide them with that sup, with that support if they're having trouble finding it.

And then I think treatment programs themselves could do a lot to help reduce the barriers that exist for people once they leave treatment.

You know, if they have a criminal record that that bars them from, from accessing jobs or, you know, I've talked with some, some people who are on Suboxone and find themselves barred from certain jobs just because of the discrimination against people with this who are taking this medication.

You know, I think reducing those barriers for people and helping people accrue recovery capital would really help people sustain their long-term recovery.

- You know, one of the difficult things that you get into in the book is the relationship between treatment and, and addiction and mothers and their children.

I think it's not difficult to see why people working for Child Protective Services might see someone who's using drugs very intensively and say, you, your kid should not be with you.

You're not a safe parent.

You're not providing a, a safe home.

One of the things you suggest in the book is that recovery addiction services should allow more women with children in.

Right.

Have you, do we have any examples of that working or where that, that has been able to help people?

- I mean, hearing you talk about this, I think a lot about April Lee, who is someone that I follow in my book, and she, you know, she witnessed her own mother struggle with co crack cocaine addiction and kind of how the local law enforcement treated her predominantly black community at that time.

And for her mother in the 1980s, there was really no treatment available for her.

And she was a single mother of nine children.

So when she wanted to, using the only option available to her was to take all of her kids to the homeless shelter.

During that time period, there were, there was a lot of awareness, there was a lot of concern about the lack of treatment for mothers.

There have been study decades of study showing that women fair better in treatment when they're allowed to remain with their children.

And that produces better outcomes for those kids too, when they're allowed to.

- Yeah, that was my question.

Is it better out for the kids too?

- Yeah.

I mean, kids wanna be with their parents pec, you know, parents who are well and who are able, who are stable and able to take care of them.

- Hmm.

- So there's a huge body of research that shows that these, that families fare better when they're able to remain together and when a parent is able to obtain treatment.

And this was such a concern actually during the crack cocaine epidemic, surprisingly, that federal lawmakers, you know, really tried to push states to spend more money on treatment for women.

And states, of course, did expand options a little bit, but not by much.

And then this continued, this has continued to be a huge issue during the opioid epidemic.

I mean, so many children have been removed from their families due to substance use over these many years of the epidemic.

And still, you know, I was looking through the numbers and try to try to determine how many options there are out there for, for mothers.

And over the course of the opioid epidemic, the number of treatment programs that allow women to bring their children or that provide childcare have dropped dramatically.

I mean, in 2023.

And these numbers have probably gone down even further at this point.

But in 2023, only 2.5% of facilities nationwide allow parents to bring their children with them.

And only 4.5% provide childcare.

Hmm.

So this kind of places mothers in like almost an impossible position.

You know, they, they need to take care of, they want to take care of their children, they need to take care of their children, but they can't take a break from their children if their children are, you know, if they're the only source of support for their children, they can't take a break from their children to go to treatment.

You know, so it's, it really puts a lot of women in this huge, huge bind.

And, and I think this is even all the more dire, because while overdose death rates overall have been declining the past couple of years, the maternal overdose death rate has been skyrocketing.

And so mothers are literally dying because they lack treatment.

- Hmm.

Let's bring in Bill in Menlo Park.

Welcome, Bill.

- Thank you.

Can you hear me all right?

- Yeah, sure can.

Go ahead.

- So in our experience taking off from the last caller, this 30 day programs just are not long enough and there's no follow on support.

What has worked, what we've seen is programs that are four or five months, - There's - A terrific one in Southern California, and that's followed by the addicted person staying connected to a sober community for many years after.

So it's, again, it's, it's this long term process of recovery, the 30 day programs, you know, it's just not, just not enough support.

And what really the key is, is after the program, that there is a sober community that, you know, provides discipline and structure for all the members and helps them stay sober for the long term.

- Yeah.

Hey, appreciate that, bill.

Thanks for sharing your, your experience.

You know, there are complexities though, right?

To some of these sober living situations.

Right.

One of the things you document, and I'm not saying this happened in, in Bill's case or not Bill himself, but you know, - Yes.

- People Bill knows these sober living houses can, can also have an exploitative edge as well, right?

- Yeah, yeah.

I mean, it's, it's been a, and it's been a source of a lot of concern in California, that sober living homes are pretty much devoid of oversight.

I mean, there's no regulations over them at the state level, and, and there's no place to really file complaints about them.

And I think what's happened now too, in the treatment industry, is that a lot of treatment programs are, you know, opening up their own sober living homes.

And so these are people who patients go to live in these sober living homes, and then they go to that program's outpatient program, intensive outpatient program.

And if the program doesn't really have their best interests at heart, you know, they're, it's not, it's not, it's a situation where they're not empowered to live brand new sober lives.

They're kind of under control of this treatment program that may be using them for profit.

And so I think sober living programs really are so crucial for people who are new to recovery.

And it's, it's, it's especially important for people who are living there, yes.

To have accountability, but also to have a sense of ownership over these, you know, this new phase of life that they're embarking on.

And oftentimes what we see is treatment programs using them as a way to escape oversight.

- A few listener comment here, Christina writes, the way the speaker describes Suboxone is hitting the same receptors as opioids without the high sounds, a lot like the way Ozempic and Wegovy work in relation to food cravings, which is now pervasive and widely accepted in our country.

Just saying - Another listener.

- Yeah.

Interesting.

Yeah.

Another listener writes, I'm the mom of a heroin addict, and I put my son in jail after a pond off family heirlooms before that he graduated from Pomona College.

He's now 30 years clean as a successful person.

But life is not easy when you have a record and many jobs are not available.

- Mm.

So true.

- I mean, it's, yeah, it's so tough.

We're talking about America's drug treatment systems and the rehab and addiction recovery industry with Shoshana Walter, author of Rehab in American Scandal.

She's now an investigative reporter for the Marshall Project.

We, of course, do want to hear from you if you've had experience with the rehab industry as a patient or as a provider, what do you think the industry is doing, right?

What do you think it's getting wrong?

You can give us a call.

The number is 8 6 6 7 3 3 6 7 8 6.

That's 8 6 6 7 3 3 6 7 8 6.

You can email us your comments and your questions to forum@kqd.org.

You can find us on social media, blue Sky, Instagram, et cetera, or KQED form.

And of course, there's the discord as well.

Another comment as we go into the break here, Alex writes, I lived in Boston from 2017 to 2019 along Massachusetts Avenue by Boston Medical Center.

This stretch was known colloquially as Methadone mile.

I volunteered at the Boston Healthcare for the Homeless program and worked with people that were actively in treatment with Suboxone or methadone, even Boston, with its panoply of some of the world's most top tier institutions and facilities seemed to struggle.

What's the greatest impediment for making a broad acute impact on the population?

We'll be back with more on that.

Alex, I'm Alexis Madrigal, stitch tuned.

Welcome back to Forum Alexis Madrigal.

Here we're talking about America's drug treatment systems, rehab and addiction recovery industry with Shoshana Walter, author of Rehab and American Scandal.

Right before the break, we, Alex, listen, Alex asked, you know, what's the greatest impediment for making a broad acute impact on the population?

And I, I was just thinking, I mean, is it basically that in this country we kind of half as it, when it comes to actually doing the evidence-based kind of harm reduction stuff, we kind of wanna do that?

'cause it sounds good politically.

On the other hand, we've kind of put this in the hands of like profit making entities.

We've sort of built this sort of strange Frankenstein of a system.

- Yeah, I mean, I think that these issues with rehab speak to the limitations of our healthcare system treatment alone.

I think the fact is the treatment alone is, is often not enough.

It's these other facets that are really, really important.

You know, part of my reporting process for the book that actually didn't make it into the book was I shadowed providers at the Bridge Clinic at Highland Hospital in Oakland.

And so I got to sit in with patients and follow some of the patients who go there.

And a lot of those patients are unhoused.

You know, I was surprised at how many of them like made the trek from where they were sleeping on the street all the way to Highland Hospital.

There was one guy I remember, he would pick flowers along the way from people's front yards and then bring them to the receptionist at the Bridge Clinic.

And, you know, he was in his sixties and had been in his addiction for decades.

And what motivated him to start taking Suboxone was he realized that he had reached the age when his own dad had passed away from his addiction and the problem.

You know, so there were tons of people in this clinic, a very low barrier entry clinic, you know, that were on these medications and sober, sometimes not sober sometimes, and sometimes succeeding in, in their sobriety.

But these other aspects that they needed to really fully recover and move on with their lives and make a change were unattainable.

You know, the, the social worker at the clinic that was trying to get people hou into housing programs or, you know, ongoing supports.

And it's just a huge challenge because there's not enough.

- What do you think, you know, one of the things that we hear on the show a lot from listeners is that, you know, San Francisco has tried harm reduction and it has failed.

What do you think?

- I mean, I haven't done too much reporting in San Francisco on this.

The, the bulk of my reporting really took place during the COVID-19 pandemic.

So that kind of limited my ability to really go deep locally.

- But - I think there's been a lot of great reporting that San Francisco Chronicle has done great reporting on this.

The Atlantic just came out with a podcast about San Francisco.

So I, I can't speak to the, the cha the specific challenges that San Francisco faces, but I, I think that this resource challenge is, is a big one across the United States.

You know, healthcare providers are that, first of all, a lot of healthcare providers still aren't providing addiction treatment.

That's still a huge, huge problem.

And then the ones that do, the ones that are committed that are really trying to help people, they find that they can't do it all.

They can't do it all.

- Let's bring in Shauna in San Francisco.

- Good morning.

- Yeah, go ahead.

- Sorry.

Can you Yeah, also, sorry.

Yeah.

So quick two comments.

One, I used to work in the general assistance building as a psychologist, and I used to also work at general here at SF General with UCSF.

And both my work is around substance and unhoused and moms recovery from substance use.

And I would say as far as like the resources in the city, they're very limited, particularly for moms in recovery.

When we used to have moms deliver their babies and stay with their babies.

'cause we're one of the only counties that do that.

There's maybe three or only four places that we could really send them to.

But even then it's so impacted that it was hard to find the right sources for them.

- Yeah.

- And there's other counties, like we got moms from like Santa Cruz County or maybe over in Oakland 'cause they just don't have the services or the policies laid out.

And I, I just wanna say like everything you're saying is so spot on that like, just as a provider who's trying to do the work, but also find collaborations like that is probably like the hardest thing - Do - Is like, we might be able to do it, but when we're looking for the support, there's few to none or no space.

So absolutely comment.

- Hey, thank you Sean.

I really appreciate that.

- Yeah.

- Experience with the system.

You know, Kate writes then to say, I'm curious if your guest views or approaches the topic of addiction differently based on the substance.

After losing my brother in 2019 to a fentanyl overdose, I immersed myself in learning all I could about opioids and the crisis that was unfolding.

I gathered that an opioid addiction is completely different from alcohol or other drug addictions and requires a very different recovery response approach.

Specifically the approach by friends and family to help someone with opioid addiction.

Do you think the broad quote addiction category is flawed?

- Oh my gosh.

I love that question.

And I don't know if I feel equipped to, to fully answer it, but I do think that, that, particularly with opioid addiction, addiction treatment, medications are really important, especially with fentanyl.

And I'm so sorry to hear about your brother.

You know, fentanyl is, is can be so deadly, especially after these 30 day treatment programs where you suddenly develop this abstinence and your tolerance goes down.

It's can be very dangerous to enter that kind of program and then come out of it and, and use again.

And so these treatment medications are really crucial because they prevent people from, from dying and, and there's not perhaps not as great of a risk of overdose deaths with other substances.

But I think that among researchers who study addiction, there's, there's this kind of consensus that there's a real need for medications to assist people with recovery from other substances as - Well.

Meth in particular.

Right?

Yeah.

I - Mean, that's - What I've really heard is that, you know, you Suboxone could at least theoretically help someone with their addiction if you're addicted to meth.

It's like, sorry.

- Yeah.

- You just have to muscle through.

- Yeah.

- Johnny w writes, why isn't personal responsibility the solution?

Because whatever the good hearted people are doing is not working at all.

And it could be argued that the problem is getting worse.

- Hmm.

I mean, I think personal responsibility is part of the solution when it comes to recovering from addiction self, the sense of self-efficacy that you are in control of your life, that you can make changes in your life is super important.

But also, if you don't have the capacity to do that and you need help, that's important too.

- Hmm.

Let's bring in, in Michael in Vallejo, welcome.

- Hello.

Thank you.

Thank you for having me on, and thank you for the show.

So my question or comment, I have 17 and a half years clean and sober, and that happened.

Congratulations, because I went Thank you.

I went through a long-term program.

Now this was the second time I went through a long-term program.

The first time I went through was in 2001 and I didn't follow instructions.

It was a six month program, and I didn't listen to the instructions they gave about building.

What I just heard was recovery capital.

The second time I went through a program was in 2007 in San Rafael in a program called CenterPoint.

And it was a six month program, which then provided transitional living and continuing care.

I went to groups as I was building up my recovery capital at the end, and I continued into aftercare while I was building up that support network.

- Mm.

- Afterwards I joined and started working in recovery.

And I've been working in recovery for 17 and a half years.

And what I've noticed over the years is insurance companies, both private and Medi-Cal, are shortening the time that they're giving for a person to recover, which the science says that the longer a person is engaged in the treatment and recovery process, the better their chances.

Yet I see insurance companies providing less funding, which seems to be inhibiting people in recovering.

Is there a way that we can write laws that stop insurance companies from going against what's already proven in science to work?

- Yeah.

Thanks for that, Michael.

Appreciate you sharing your experience with us.

No, that's great.

Thank you.

- Thank you.

Yeah, I mean, I absolutely, I think that there are even some bills on the table in California right now that kind of address this, these insurance barriers and insurance companies prematurely cutting off treatment.

And if this is something you're really concerned about, I really encourage you to write your lawmakers about it.

- Hmm.

Let's bring in Phil in Burlingame.

Welcome, Phil.

- Hi.

I I just wanna make a small point, which is, you know, when we think about, I grew up in South Florida and I've seen a lot of addiction and, you know, our friends and family, and we can't really talk about drug addiction as though it's like a standalone thing.

It's a symptom.

It's not the disease really.

I mean, the symptom is often child abuse, childhood child abuse or dysfunction.

It's a mask.

It's a self-medication for some other things.

So the idea of a 30 day program, you know, getting somebody's head straight, you know, I mean, even on the smaller level, you know, are you addicted to, I mean, we all have addictions, you know, there's, there's this regulatory issue.

It's not just about, you know, drug treatment.

That, that's, that's my small point.

- Yeah.

Appreciate that, Phil.

- Yeah.

Thank you so much.

Yeah, I think there's a, there's a theme that we're hearing and, and it's spot on that this is a long-term process.

And, you know, most people who recover, who've gone through treatment, have gone through treatment three or four times on average.

More than 10% people of people go, have gone through treatment six or more times before they fully recover.

- Hmm.

- And I think that's a testament to some of the problems we've been describing in the treatment system, but it's also a testament to how difficult it is to recover from addiction and how it's a long-term process of change for a lot of people.

- A couple of different experiences coming in from listeners as well.

Rosa writes, our experience with addiction treatments has been very difficult.

Our 21-year-old son died from an accidental overdose, I'm so sorry, Rosa.

He spent the last 20 months of his life going through different addiction treatments, lasting no more than two weeks each time.

And he had a concurrent condition, psychosis.

He was almost 20 when we found out about his addiction.

So we could not make him involuntarily commit to long-term treatment from the very first time he came out of a psychiatric residence treatment, his drug use and psychosis worsened.

He was not capable of taking care of himself or making rational decisions, yet he would be released to the streets time after time.

You know, Rosa brings up an incredibly, you know, difficult point and obviously has lost her son there.

Terrible experience.

This has been a really difficult topic, I feel like in addiction treatment of when and how should someone be involuntarily committed.

Right.

Because there's sort of a, there's a civil rights issue at, at play and there's also this sense of like, how can someone just be left to die on the street, you know?

- Mm.

Yeah.

- When you talk to people, you know, I know for this book you talked to hundreds of people who've gone through recovery and are associated with the system.

Like, what did they say about it?

Someone like Rosa's son.

- I mean, Rosa, I'm so sorry to hear about what happened to your son and it's definitely an experience I've heard about time and again, and, you know, I, I, I think that there's a, you know, among the researchers that I've talked to, there's not even a full consensus about the right approach.

And I think that, you know, this may feel really unsatisfying to hear and it is and satisfying for me to say.

But, you know, there's like, there's no magical cure for addiction.

Different things are gonna work for different people.

And, but I, I do think that, you know, one of the things that Rosa mentioned, these short spurts of treatment, it becomes a revolving door and that's clear, clearly not working and, and doesn't work for most people.

And you can see how tragic the consequences of that can be.

- Yeah.

And just worth remembering, because I do think it's one of the takeaways from your book that there are people for, for-profit treatment facilities that are benefiting, vary directly from people going in and outta that door over and over.

- Absolutely.

I mean, yeah, especially, you know, there are treatment programs that, that hire people to go out and find patients with the best highest paying insurance policies.

And, you know, they're very eager to welcome those patients back after they relapse.

It's part of the business, the business model for a lot of these treatment programs, and it makes a lot of money.

- Yeah.

You know, the other type of long-term treatment that we've discussed in this hour has been a lot of these kind of work programs.

The other thing I wanted to, to make sure people take away from this book is how little time people get in actual therapy group, individual, whatever the, the, the methodology is, right?

- Yes.

- If you're working, I think one in the facility that you describe in, in a lot of detail in the book, they ran the numbers and a lot of people working 60, even 70 hours a week, right.

- Up to 80 hours per week.

Yeah, yeah, yeah, yeah.

This program, you know, when Chris Kuhn, this is the person that I followed in the book, entered that program, they told him that he would be working and living there for two years.

He'd be able to save money, he would get counseling, he would get medical services.

And then when he entered the program, he quickly learned that actually the vast majority of the program would be spent with him working, being contracted out almost like a temporary, temporary labor force To different private companies.

Yeah.

And he worked up to 80 hours per week.

He was paid with nothing but a pack of cigarettes per week.

And he rarely had time for counseling.

I mean, I talked to one of his counselors who had an, a huge number of people on her, on her caseload.

She was supposed to see him at least once a week.

And she said that he was working so much.

Sometimes she would just like go and visit him when he was in bed, say, how are you doing?

And then he'd say, fine.

And she'd count that as a counseling session.

So, you know, it was almost like the work was the treatment and, but it had the opposite effect for Chris and many people who went there just made them feel exploited and made them feel powerless and made them feel like they had no time or energy to really explore any of those underlying reasons for their addictions or really even envisioned, you know, what else they could have in their futures.

Aside from this, - Wanna get to a couple of last listener experiences here.

Jenny writes, hi, 12 days of inpatient rehab for marijuana addiction.

Worked for my 20-year-old family member, but the facility declined to accept him for ongoing counseling support unless he completed their online daily group sessions.

He had school and work and could not complete the online part.

He relapsed six weeks later.

I wish the rehab facility would accept people in their group without such requirements.

I would've paid money.

They told me it's just their rules.

Kathleen writes, I am a licensed clinical social worker who has worked for over 20 years in addiction medicine.

And I am concerned that you're not focusing on alcohol as well.

It is a highly addictive drug that is embedded in our society.

People need to understand how easy it is to abuse alcohol and then progress into addiction.

It's also an epidemic.

People die from alcohol abuse every day.

Kaiser has a continuum of care for the disease of addiction, which is fairly comprehensive, but still needs more resources.

I'm not aware of any other insurance company who provides this level of care.

Yeah.

Anything to, to note about either of those things?

Kai, - I mean, I, the book mostly focuses on, you know, the policies that I've, that we've erected in response to the opioid epidemic that I I totally hear that.

I think alcoholism is a, a major issue in this country.

And certainly some of these changes to our addiction treatment system would benefit people who are struggling with alcoholism.

- We have been talking about America's drug treatment systems and rehab and addiction recovery industries with Shoshana Walter, author of the enraging new book, "Rehab: an American Scandal."

She's an investigative reporter for the Marshall Project.

Thank you so much for joining us.

- Thank you so much for having me, Alexis.

Thank you.

- I'm Alexis Madrigal.

Stay tuned for another hour of Forum ahead with Mina Kim.