If It Bleeds It Leads

March 2024

By Nikki Tierney, JD,LPC,LCADC, CPRS
NCAAR Policy Analyst

Recently, the New Jersey State Commission of Investigation released a report covering their findings and recommendations from an investigation into “abuses and corrupt practices in the addiction rehabilitation industry in New Jersey.” The report was entitled The Dirty Business Behind Getting Clean: Fraud, Ethical Misconduct and Corruption in the Addiction Rehabilitation Industry. A thorough read of the report reveals the title’s harkening back to William Randolph Hearst’s media phrase, “if it bleeds it leads,” referring to sensationalized headlines that provide enticing clickbait. The report, while making several broad, generalized recommendations, did not include the comprehensive policy analysis that would improve the dire situation people with substance use disorders face daily while seeking help. Certainly, predators who take advantage of people with substance use disorders through the use of “body brokering” are engaging in an abhorrent and greedy act; likewise, a report tasked with bringing awareness to this by vilifying the “rehabilitation industry” but overlooking the prevention and treatment profession, has the capacity for harm as well.

The report repeatedly conflates treatment professionals, who are duly educated, trained, and licensed, with people who self-describe themselves as somehow tangentially connected to “treatment.” The report references “owners and operators of addiction related businesses” and then assigns vicarious liability for their alleged fraudulent conduct to all who work in the treatment profession. One of the more obvious examples is the statement that owners and operators are more concerned with profit and their own interests “and less about getting their clients clean and sober.” Associative activation is a process by which, over time, our brain effortlessly assigns meaning and emotion to words and experiences. The use of the word “clean” in reference to those who abstain from using drugs is highly activating for many because inherent in the label of ‘clean’ is an implication that people who use drugs are ‘dirty’. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR), authored by the American Psychiatric Association, the medically correct terminology for no longer using substances is either “early remission” or “sustained remission.” Not clean, and certainly not dirty. The use of stigmatizing language throughout the report made it difficult for many to read it as an objective investigation and it also speaks volumes on the disconnect to the real issues plaguing individuals trying to access treatment.

Media outlets covered the report with the same sensational rhetoric. One headline brashly proclaimed, “Dead Toms River recovery coach John Brogan fleeced the system – report.” Of import, John Brogan was diagnosed with substance use disorder during his life and passed away from a substance-related death. The report refers to him as “[A] former heroin addict.” Notwithstanding any allegations against Mr. Brogan, referring to him in such a reductionist and stigmatizing way arguably does harm to the same people Mr. Brogan is accused of exploiting. While Mr. Brogan was described as an architect of the patient brokering system, it was also clear this was not just one bad actor in the rehabilitation industry, but an entire system of complicity in the very agencies that are meant to uphold the laws that protect consumers. The report drops a simple footnote to mention a $1 million dollar settlement by Ocean County for a wrongful termination and whistleblower claim filed against its Prosecutor’s Office for their relationship with Mr. Brogan and failure to respond to reports of wrongdoing. Arguably, it is also worth investigating the systems that receive millions of dollars to respond to the public health crisis New Jersey faces, such as the money wasted on mass incarceration and penal responses, which was at the heart of the lawsuit Ocean County settled.

Although not mentioned in the report, there are current laws in place to protect all “consumers” seeking treatment, not just people with substance use disorders. The New Jersey Consumer Fraud Act (N.J.S.A. 56:8-2 et. seq.), which provides for treble damages as a result of merchants who act, among other things, unconscionably, deceptively, fraudulently, or engage in material misrepresentation, applies to many of the situations mentioned in the report. New Jersey law allows for piercing of the corporate veil for the exact allegations against those who improperly used corporate funds for personal benefit. There are also extensive ethical rules for mental health and substance use disorder clinicians depending on their respective licenses and many New Jersey laws and regulations governing the practice of behavioral health treatment in general. Although the report despairs about policies and laws not providing sufficient ‘consumer protection’ for consumers, it highlights individuals who are not professionals. Unfortunately, there is no legislative model to prevent some of the alleged actions identified in the report. As Martin Luther King Jr. aptly observed, “[M]orality cannot be legislated.”

The report also focused on “so-called ‘peer recovery coaches’” acknowledging some of these individuals have not necessarily been trained, licensed, or even certified. However, New Jersey recognizes Certified Peer Recovery Specialists through The Addictions Professionals Certification Board of New Jersey, which outlines specific training, supervisory requirements, and best practices for certification. While the report warns against untrained and unregulated peer support, the fact is peer support groups have played a significant role in how society defines recovery. Twelve-Step groups, largely the historic model for abstinence-based recovery, have been mandated by courts and treatment programs for decades. The widely accepted groups are run by peers who also participate in the program and who do not require formal training, supervision, or follow any state or federal regulations. While many have achieved recovery as they define it in 12-Step groups, it must also be recognized that recovery is not a one-size-fits-all phenomenon and the tradition of insisting there is only one way to recover has made it difficult for people to accept the evidence-based medical approach of harm reduction to substance use and mental health conditions.

It was peers in New Jersey, many trained as Certified Peer Recovery Specialists, and others affected by substance use in the state, who played a key role in the State’s investigation. Peers provided interviews and referred others to work with the investigators to expose the “bad players” in the system. For decades, peers have been amongst the strongest advocates for safe affordable housing; evidence-based, person-centered treatment; recovery support services; and harm reduction services. They have long been the canaries in the coal mine, alerting all of us to ways we must improve the way we think about, and address substance use to ensure better health outcomes for our families and communities. Peers working in the industry have placed complaints through state call lines on many of the very issues presented in the investigation only to receive little or no response.

Most disturbing, however, is the report casts doubt on the important role individuals with lived experience have in supporting people with substance use disorders. There is an abundance of evidence establishing the benefits of peer services. For example, a systematic review conducted in 2016, concluded that peer recovery services for substance use have a positive impact on outcomes for clients in multiple areas.¹ A more recent study from 2021, which reviewed data from 3,459 participants engaged in services at 20 recovery community organizations, found peer support significantly improved individual recovery capital and increased connection with other recovery support services that reduced negative health events. ²

There is robust data and research that confirms New Jersey should be responding to this public health crisis via harm reduction, reducing barriers to evidenced-based treatment, and expanding access. According to New Jersey’s Substance Use Overview 2022, the unmet demand for substance use treatment by the adult population in the state is 62.7%.³

NJ Department of Human Services Division of Mental Health & Addiction Services

There are proven ways to expand capacity and the need for New Jersey to do so has never been clearer. One proven policy lever to expand capacity is increasing Medicaid reimbursement rates for substance use and mental health treatment providers.⁴ Medicaid is the largest source of federal funding for services that treat substance use disorders.⁵ Medicaid beneficiaries experience a higher rate of substance use disorder compared to those with other forms of health care coverage.⁶ Nationally, Medicaid covers nearly 40% of all individuals with an opioid use disorder (OUD) and a greater share in states that expanded Medicaid under the Affordable Care Act.⁷ Medicaid plays an even larger role for high-risk populations with substance use disorders, including pregnant women and justice-involved persons who are disproportionally insured by Medicaid.⁸ Out of the 393 facilities in New Jersey that participated in the National Survey of Substance Abuse Treatment Services, a mere 239, or 62.4%, accepted Medicaid.⁹ By expanding access to evidence-based care, individuals with substance use disorder will not be as vulnerable to exploitation by bad actors who are not affiliated with the professional treatment providers.

The report also bemoans the current “Questionable Financial Arrangements at Sober Living Homes” but did not note that on December 29, 2022, President Biden signed the Consolidated Appropriations Act, 2023 (Public Law 117-328). Section 1232, Developing Guidelines for States to Promote the Availability of High-Quality Recovery Housing, requiring best practices be made publicly available and published on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) website. New Jersey does not need to recreate the proverbial wheel but rather simply implement laws and adopt regulations consistent with best practices. The final draft of this report was released after this critical federal legislation and yet the investigation makes no mention of it.

In conclusion, while many of the allegations in the report were appalling and highly disturbing, they were not a fair portrayal of the real systemic issues impacting people with substance use disorders. The recommendations may not be practical or necessary and should be reviewed by those who are familiar with the barriers they navigate to support people on their journey to recovery. The report recommends that any patient brokering laws should apply to entities as well as individuals; however, it is not clear how fraud and unscrupulous behavior can be better addressed by patient brokering laws than by general criminal and civil laws addressing fraud and deception. New Jersey has plenty of existing laws to address the alleged behaviors outlined in the report. The real question is, why did the system vested with funding and responsibility for enforcement of such laws choose not to do so? Perhaps this report was written with good intentions, but the road to unintended consequences is often paved with such and New Jersey must stop wasting funds and assets on anything other than evidence-based responses to the current health crisis we face.