Why Rehab Often Fuels Relapse Instead of Recovery

The opioid crisis has been a quiet, deadly presence in America for a quarter-century now. Since 1999, it’s killed more than 800,000 people in the US. That’s more than the number of Americans who died in the Civil War. But in the background, another crisis has been simmering: the often-lawless patchwork of treatment centers and programs that make up America’s drug rehab industry. Many of the roughly 50 million Americans who battle substance abuse rely on this underregulated for-profit industry that too often exploits patients, fails to properly treat them, or even worse.

Journalist Shohana Walter has been reporting on the rehab industry for almost a decade. Walter, a staff writer at The Marshall Project, began researching the rehab industry at Reveal, where she reported American Rehab, our eight-part series examining work-based treatment programs in the US. Her reporting has repeatedly shown a lack of oversight for rehab facilities around the country.

“Even when rehabs are overmedicating patients to the point of impairment, exploiting patients for billable services, making thousands upon thousands off of urine drug screens, they often remain in business or just apply for a new license and start again,” Walter says.

On this week’s More To The Story, Walter sits down with host Al Letson to talk about the lingering opioid crisis and the many theories about why overdose deaths have started falling in the US.

This following interview was edited for length and clarity. More To The Story transcripts are produced by a third-party transcription service and may contain errors.

Al Letson: The opioid crisis has been a quiet, deadly presence in America for a quarter of a century now. Since 1999, it’s claimed more than 800,000 American lives. That’s more than the number of Americans who died in the Civil War. But in the background, another crisis has been simmering. The often lawless patchwork of treatment centers, and programs that make up America’s drug rehab industry. Many of the roughly 50 million Americans who battle substance abuse rely on this under-regulated for-profit industry.

Its exploited patients fail to properly treat them, and even worse, Shoshana Walter has been writing about rehabs for almost a decade now, and she first began reporting about it right here at Reveal. And with me today is one of my favorite people in the universe. Shoshana Walter, thank you so much for coming on. You are the author of Rehab: An American Scandal, and you’re now a reporter at the Marshall Project, but for many years you were a producer here at Reveal, and I’m so glad to have you on the show.

Shoshana Walter: Thank you so much for having me Al.

So, way back when I remember, now this is pre-pandemic. I remember my office was right across from your desk, and you, and Amy Julia were talking about rehabs, and that you found this story. I specifically remember because I think we were talking about chicken farms, or something like that. For some reason chicken farms stick in my head. Do you remember how all this got started?

Yes. You have a really good memory. So, I think beginning in 2017, I teamed up with another reporter at Reveal, Amy Julia Harris, and we started looking at drug courts, and diversion court programs, and the treatment programs that some of these courts were sending people to, and we basically stumbled across this model of rehab that exists across the United States that operates by putting court-ordered participants to work at for-profit companies without pay. And so, one of the first programs that we discovered, and this is what really got me going on this topic, was this program that was founded by a former poultry industry executive that was accepting court-ordered participants who had been ordered there by the court for addiction treatment. They were sending these people to chicken processing plants, mostly run by Simmons where they were making pet food for PetSmart, Rachel Ray, Walmart, a ton of huge companies were getting the proceeds of this unpaid rehab labor.

We found one that was sending… A rehab that was sending people to work at nursing homes, at a zoo where they were helping to dispose of dead animals, and then one called Cenikor Foundation that was sending people to work at Exxon, and Shell Oil refineries. After all these programs, it just got me thinking about how is it that in this day, and age in the United States, when we all seem to have accepted this idea of addiction as a disease that needs to be treated, why is it that judges, and courts across the US are considering uncompensated labor to be a form of addiction treatment? And it made me interested, and curious in understanding what exactly this whole landscape looks like, and if it’s even working the way it’s supposed to be working.

That led to you producer, and reporter, Ike Sriskandarajah, and producer, editor, and Laura Starchesky going on the road, and diving into American Rehab, which was a mini serial that Reveal put out. It’s one of my favorite things that we’ve ever done here at Reveal. Can you tell us a little bit more about that series?

Yeah. After we had uncovered so many of these programs at Reveal, we felt like we really had this unanswered question, how common is this? How often is this happening? How many rehabs are like this? And where on earth does this idea of unpaid labor as a form of addiction treatment come from? And so I teamed up with Laura, and Ike, and we looked at a specific program in Louisiana called the Cenikor Foundation, where we had discovered people had worked at Exxon, and Shell Oil refineries, and we interviewed this guy named Chris who ends up being someone in my book. And we just painted this portrait of how this kind of rehab works, and we investigated the origin of these types of rehab programs all the way back to the 1960s when a former oil salesman, and someone recovering from addiction decided to create their own model of rehab community.

He did not like Alcoholics Anonymous. He thought people in AA could just BS each other, and lie about their sobriety. So, he wanted a place where people could call each other out, even scream at each other about things that they had done wrong, or slip ups that they had had in their sobriety. And that was the beginning of a program called Synanon that started on the beach in California. And Synanon ended up becoming this multimillion dollar nonprofit operation that survived in part by putting participants to work unpaid, making money for the program. We ultimately found that more than 60,000 people per year go through a program like this.

So, you went from looking into rehabs, and addiction way back with American Rehab, and now in 2025 you are coming out with a book about it. So, talk to me about how the reporting evolved.

I had an understanding that I think a lot of Americans have about the opioid epidemic, which is that it was started by this company called Purdue Pharma. They manufactured Oxycontin, they got a lot of people hooked, and originally, initially, the communities that were disproportionately impacted by that opioid epidemic were white communities. And in part, due to that kind of changing face of addiction, a different way of thinking about who was impacted by addiction, lawmakers were really starting to feel the pressure to treat addiction differently. During the crack cocaine epidemic, which disproportionately impacted black communities, there was this approach of mass incarceration, and punishment, and that led to a huge number of black, and brown people entering the prison system.

So, then you fast-forward to the opioid epidemic there, there’s kind of a totally different approach going on where lawmakers are suddenly acknowledging that addiction is a disease, it needs to be treated with compassion. It’s not a moral failing, and so we need to offer treatment instead of incarceration. Over the last 25 years, we’ve seen a brand new groundbreaking addiction treatment medication come out. We’ve seen addiction treatment vastly expanded under the Affordable Care Act. And treatment certainly can be a really good thing. It can be a life-changing thing for people, but it also can be part of the problem. And this is what I found in the book, that it can actually fuel relapse rates, and overdose deaths rather than always providing people with what they need to actually recover.

Talk me through that. How is rehab fueling to go back to drugs? Where’s the failing?

Well, we know now that people who complete a 30-day rehab program are much more likely to overdose, and die than someone who started that rehab program, and didn’t finish it. 30 day rehab programs are the length of program that insurance companies most very often cover. So, the Affordable Care Act expanded insurance coverage to millions of Americans, and expanded addiction treatment coverage to millions of Americans. But at the same time, it also opened the door to practices that were designed to maximize profits often at the expense of patient care. So, once the Affordable Care Act came online, all these rehab programs started to proliferate, and the emphasis was really on billable services. What are insurance companies willing to pay for rather than what will actually help someone stay in recovery?

A 30-day rehab program where someone enters, and gets sober, and then leaves, places them at much higher risk of overdose death ultimately because once they enter a rehab, and get abstinent, they no longer have the tolerance for the opioid that they used to take. And so they leave rehab, they lack the support that they need to stay in recovery, they relapse, and then oftentimes that relapse can be really devastating.

You follow four characters in the book. One of them is someone named Chris. Can you tell me about him?

Yeah. Chris Coon is someone that I met while working at Reveal on American Rehab. He’s from rural Louisiana. He kind of was exposed to opioids for the first time when he was 15 years old, and got into a three wheeler accident trying to show off to his cousin, and he broke his ankle, and took a pain pill for the first time. And that kind of set off a period of very common adolescent experimentation with drugs. By the time he entered his twenties, he had developed an addiction to opioids, and also to meth, and he entered a rehab that was paid for by his dad’s insurance. It was a 30 day program. He went, he got something out of it, he left, and then he immediately relapsed such a common story. And not long after that relapse, he ended up going on a kind of like a drug binge with a friend.

And when he woke up, he was surrounded by cops, and he was arrested. He went before the judge. Instead of Chris entering into a plea deal that might’ve sent him to prison for five, the judge offered him the Cenikor Foundation. And so Chris ended up going into this program that was then located in Baton Rouge, Louisiana for 18 months. He refers to it kind of as cult-like where he was forced to tattle on the other participants in the program. He was forced to participate in this group called The Game, which was a regular circle of participants where they would kind of scream at each other about things they might’ve done wrong. And he was required to work sometimes 80 hours a week unpaid in these back-breaking manual labor jobs, not getting paid anything except for a pack of cigarettes. As a result of all that, he got injured on the job, and shortly after that he was essentially kicked out of the program, and sent back to where he came from, where he faced the possibility of prison again.

Wow. What happened with him?

So, Chris went back to the court where he faced the possibility of five years in prison in Louisiana, and the judge instead gave him probation, and he went back home. He moved in with his dad, and he had the financial, and emotional support of his dad as he tried to restart his life. I mean, he had a lot of trauma from his experience at Cenikor, and also this actually kind of a motivation from his experience at Cenikor of he doesn’t ever want to go back to a place like that again. And he was trying to restart his life. And then he had a minor operation where he was once again given pain pills, and he took one thinking he could handle it, and realized, oh, he definitely can’t. So, he asks parents for help, and they helped him get on Suboxone, which is considered the gold standard treatment for opioid addiction.

It’s a medication that kind of fills the same receptors in the brain as illicit opioids, and gets rid of the cravings, gets rid of the withdrawal symptoms, and just kind of helps someone who’s using illicit drugs to feel normal again, it can be very expensive. A lot of Suboxone programs except only cash. At the time that Chris was doing this, there were some insurance programs that weren’t even paying for it. And so he really needed the help of his parents who were in a position to help him pay for this medication. And the medication truly helped him. I mean, he got on Suboxone, he went to school for welding, and now he’s married, he has two step-kids, and is living outside of Austin, Texas, and doing really well.

Earlier in our conversation you talked a little bit about the racial gap. I grew up in, for lack of better term, like the crack era. Never nobody in my family was affected by it directly, but I was living in New Jersey as a kid. I moved to Florida when I was 11 years old, and the neighborhood that I lived in New Jersey was pretty much a middle-class, at least in 11-year-old eyes. It was a middle-class, mostly black neighborhood.

Moved to Florida, the crack epidemic kind of took over, went back to visit New Jersey. I think I was about 14, and the neighborhood looked absolutely different. I remember thinking to myself at 14 that it reminded me of something from a zombie movie. The house that my dad had worked so hard to renovate had turned into a crack house. Everything, the neighborhood just looked so different, and affected by this epidemic, and the way it was talked about in the media, because that drug was primarily hitting inner cities, and therefore black communities, there was no empathy at all. Like calling somebody a crackhead was definitely a derogatory thing. Fast-forward to the opioid epidemic, and the way this country looks at it is totally different. Like these people who get addicted to opioids are victims, and they need to be helped, whereas people who got addicted to crack are crackheads, and they are looked down at, and that’s definitely a racial issue.

Yeah, absolutely, Al. I mean, everything you described is so spot on, and I think one thing that’s interesting, or disturbing that’s going on now is now at this point in the epidemic, overdose death rates in white communities have gone down dramatically, but they’ve gone up in black, and indigenous communities, and as they’ve gone up, the rate in those communities is now higher than in white communities. As those rates in black communities have gone up, there has been a resurgence of punitive punishment oriented policies. There’s still, I think, a general acceptance that addiction is a disease, or at least that this concept is accepted. But we’re seeing new laws passed that require mandatory minimum sentences for fentanyl dealing, for example, and crackdowns on homeless encampments in cities, and all these policies that will lead to more incarceration, and more punishment that will once again disproportionately impact communities of color.

Does punishment ever work?

That’s a good question. I mean, I’ve definitely talked to a lot of people who feel like they found their motivation for recovery when they entered jail, or prison, and they were just like, “I don’t want this for myself.” But what studies have also shown is that especially for people who have fewer resources, particularly black people who are court ordered into treatment, it doesn’t work as well as offering better opportunities, more positive alternatives like educational opportunities, financial incentives. There’s this form of addiction treatment called contingency management where people are rewarded for maintaining their sobriety. And that has proven to be incredibly effective for helping someone enter, and maintain their recovery. So, I would say these types of addiction treatment drug policies are far more effective for many people in this country than punishment is.

So, I have a family member who has addiction issues, and they were on methadone for a very long time, and methadone in itself felt like, I don’t know, I just remember it feeling like it was another form of addiction, another chain, because my family member would have to go to a clinic at least once, or twice a week to get his refill of methadone, and it was a constant thing at least once, or twice a week. And then they’d give you the methadone, but only enough methadone to last so long, and then you’ve got to come back.

And I remember very clearly that Suboxone was what he wanted to get on, but it was really hard for him to get on Suboxone, and grown man didn’t want to get into his business. Do not know exactly why it was hard for him to get to Suboxone. All I know is that like Suboxone, from the way he would tell it means that he wouldn’t have to come to the clinic every week that he could get basically a prescription, and maybe he’s going every two weeks. Does that experience line up with what your reporting has told you?

Yes. That’s a perfect prime example of this kind of two unequal systems of treatment that we have going on in the United States. Methadone clinics really got started in earnest in the 1970s, and that was a complaint about them from the get-go. Like people who take methadone, which it can be a very effective treatment. It’s similar in some ways to buprenorphine, or Suboxone, but also also highly regulated, highly surveilled, so many rules, and someone who’s undergoing methadone treatment has to go regularly to these clinics that may not be in super convenient places, and some people have to go every single day. And that is itself a tether that prevents a lot of people from being able to get on with their lives. It’s like a chain around your ankle keeping you in that space. So, the reason why methadone programs are the way that they are dates back over a hundred years to the nation’s first federal drug law.

And what that drug law did, it was passed in 1914 during kind of a very different period of drug crisis, opioid epidemic, and it did a lot of things. But one of the things that it ultimately did was make it illegal for doctors to prescribe narcotics to people known to be addicted. And that included doctors who were prescribing morphine, or opium, or other drugs to people who were addicted to them as a way of maintaining them, making sure that they felt okay, or as a way of preventing their withdrawal symptoms, or even as a way of treating their addiction. So, after this law was passed, ultimately 25,000 doctors were arrested for prescribing narcotics to people known to be addicted, many of them for treatment purposes.

And that experience, doctors being arrested, being punished for treating addicted people, or providing medical care for addicted people has really stuck with us in the United States. I mean, even today, doctors are allowed to prescribe Suboxone to someone, to their patients, and doctors rarely do. It’s still incredibly uncommon for doctors to provide addiction care to their patients. So, this law, and the stigma that the law created has continued through all this time.

What sort of regulations exist for the rehab industry in the US?

It’s totally different state to state. Each state regulates it differently. But in places like Florida, and California, which have really become kind of like the rehab meccas of the United States, the industry has grown so immense. It’s really difficult for regulators to keep up. And oftentimes when issues are discovered at rehab programs, there’s not much that regulators are doing. There’s one program that I cover extensively in the book in California where people were literally dying after going to this rehab, and being given a cocktail of strong narcotic medications that can easily cause overdose that were not even prescribed to them. A doctor had not even prescribed these prescription medications to them. People died repeatedly in this program, and still it took years, and years for regulators to shut that program down. And ultimately they didn’t technically shut it down. That rehab operator kept on getting new licenses, and it was eventually deluge of lawsuits, and insurance, and expensive insurance policies that led him to back out of the industry.

So, what I’ve seen again, and again in my work is even when rehabs are over-medicating patients to the point of impairment exploiting patients for billable services like making thousands upon thousands off of urine drug screens, they often remain in business, or just apply for a new license, and start again. And what a lot of rehab programs are also doing is starting sober living homes, which do not require licensure at all in the vast majority of the country. And so rehab participants will go to this licensed treatment program during the day, and then come back to an unlicensed sober living home at night. And that’s where also a lot of deaths, and exploitative practices are occurring without any oversight at all.

Drug overdose deaths are actually down in the US. Specifically, why do you think that is?

People who research it, and know far more about that than I do, still don’t fully understand it. From what I understand, there could be a number of reasons for this. I mean, overdose death rates really escalated during the pandemic. So, the numbers that we’re seeing now are kind of at near pre-pandemic levels. They’re still not as far down as that. So, we may just be turning to where we were at before the pandemic, which was still devastating, totally devastating. More than 80,000 people died last year of drug overdoses. So, that may be what’s happening. I think there’s some other theories that have been circulated. Younger people are using drugs less, they’re taking fewer risks. Another really disturbing theory is that a lot of people who marginalized people who used fentanyl have basically died off, because fentanyl is so much more deadly than heroin was, than Oxycontin was.

Maybe there’s just fewer people who are now dying because they’re already gone. And the other theory is that harm reduction services like Narcan, overdose reversal drugs have really helped people too by bringing people back from overdose rather than allowing them to pass away. If that’s the case, we might start to see some of them go away, because funding for overdose reversal medications has been cut, treatment access has been cut. There’s a lot of gains that we’ve made that may be related to these policies that are now starting to be eradicated. So, there’s concern out there that we’ll start to see overdose deaths go up again.

And then I think also about the fact that, yes, overdose deaths have gone down, and that is something to be really happy about. But I think we also have to be cautious about our optimism around that because there are millions of people in the United States who continue to remain addicted, and we’re reversing a lot of overdoses, but those people may not be leaving their addiction, which means that they’re still experiencing the devastation that addiction brings to them, and to their families. And so I think that the metric of overdose deaths is limited in what it could tell us. There’s still an addiction epidemic going on, and until we have a better system for treating that addiction, we’re still going to have this problem with us.

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