They discuss things people should look for when researching treatment centers, as well as things to avoid. He also explains the “Florida Shuffle” and what patient brokering is – and how this is happening all over the country. In addition, Dave shares ways to find legitimate treatment centers.
Dave Aronberg, welcome to Heart of the Matter. Great to have you here.
Great to be with you, Elizabeth. Thanks for having me.
I was curious, Dave, why did you get so involved in this? You’re Florida’s drug czar, and I’m just curious, you’ve been really sort of a leader in the nation on cracking down on these fraudulent bad rehabs. Why?
I never thought this is where my career would go. I’d never had personal demons and my exposure to some of these drugs that have affected so many, I haven’t had a close family member and I’m thankful for that. But I came into this as someone who was, I have to admit a skeptic from the beginning. I was an Assistant Attorney General for Bob Butterworth, this amazing attorney general in Florida, and I had just started, and he called me into his office and he handed me this magazine article about this new drug called Oxycontin, this was back in 2000, 2001, that was killing people in the Midwest. And he said, “I don’t…” In Appalachia, excuse me. And he said, “I don’t want this happen in Florida, you need to look into this.” And I admit, when I got that article, because I didn’t have any exposure or interest in this area, I was thinking, “oh, well, users are going to use, you’re going to blame the drug for people who want to abuse them?”
And my opinions changed almost immediately after I looked into the fact that you had this company, Purdue Pharma, that was making billions of dollars off the backs of people who went to the doctor because they had a back pain or because they had a workplace injury or a sports injury, and they ended up getting addicted and dying. And this was because of professional greed, and corporate malfeasance, and political apathy, and regulatory failure. And over the years, even as I’m the top prosecutor in the county, I have grown much more empathetic to people who have this brain disease of addiction. This is not a moral failing. This is how your brain changes and we must treat them with the proper compassion. And so I have grown as a person by being involved in this and I’ve continued my work from the investigator of Purdue Pharma, to the drug czar to shut down the pill mills, to the state attorney to fix the corruption in the rehab industry.
We have talked a lot about this whole issue with rehab facilities, sober houses not helping people, and in fact, taking advantage of people. Let’s start with how this started in the first place, because right now we have this weird reality where many people can’t afford to get treatment and can’t find good treatment. And at the same time, we have these facilities that are open and operating and basically taking advantage of the system and scamming people. How can both things be true?
Elizabeth, when the Affordable Care Act was enacted, it provided behavioral healthcare including drug treatment to millions of Americans who couldn’t get it. Unfortunately, because the Affordable Care Act reimburses providers on an old school fee for service basis, meaning the more services you provide, the more money you get, it has rewarded the worst players in the industry who incentivize relapse over recovery.
And so what you have is this skewed system where the big money is in failure, not in success, and people with good insurance are lured down to Florida to get help when it’s the worst possible situation when they’re lured by bad marketers and bad rehabs. And they leave Florida in an ambulance or a body bag.
Yeah, it’s created something that you’ve called, and in the press it’s been called the Florida Shuffle, explain what the Florida shuffle is.
The Florida Shuffle is this unending cycle of relapse instead of recovery where relapse is incentivized. So you come down here with a free one-way plane ticket, which in itself is a crime. Our laws have been toughened in recent years because of this. And then you’re sent by a marketer to a detox or inpatient recovery. You’re there for a couple of weeks and then the insurance runs out for inpatient care. And then you go to outpatient care and the decision on where you go, the detox, the inpatient care, the outpatient care is made by the marketer. The marketer gets a kickback. So these decisions are not being made by what gets you well, but what gets other people rich and everyone wins in this. The marketer gets money, the detox get money, the outpatient place gets money, the patient gets healthcare. And then where do you live when you’re in outpatient care?
You live in a sober home. A sober home is just a group home where people live together in a supportive drug-free environment while you’re doing outpatient care. And the sober homes, the bad ones are involved in this, the corrupted ones, because they’re giving you free rent. The marketer sends you to the sober home. The sober home gets money from the outpatient center and there’s money changing hands. And like I said, everyone’s winning until the patient relapses and overdoses and dies, and the taxpayers get screwed in this as well. And this whole system that’s designed for sobriety is instead designed for relapse and moneymaking, and it’s skewed and it hurts outcomes, and it damages the entire industry because the good players in the industry, Elizabeth, get hurt too because they’re seeing their patients leave to go to other places that are paying you, that are giving you special benefits you don’t get from the good guys. So this is the Florida Shuffle.
People just cycling in and out of detox, rehab, sober living, detox, rehab, sober living. And we are all told, and it’s true that relapse is part of recovery, but in this case, they’re actually monetizing relapse. And you say they’re actually encouraging relapse. How is that possible?
So after the outpatient benefits run out, the marketer will encourage the patient to relapse. And that way you get back into this vicious cycle because as I said, there’s no limit on how many-
But what does that mean? Are they providing them drugs?
… Sometimes they do. What happens is that after you are done with your benefits, you then are given money by the marketer to go in a local motel for the weekend, enough money to go on a bender. So you can see how when people with the brain disease of addiction, of substance use disorder, that they are in many cases willing victims because their brain chemistry changes and they’re being exploited by these bad actors.
You talk about the fact that they’re lured to Florida by the beaches and the warm weather. How much… I mean, it’s also a matter of fact that the pill mills during the opioid crisis really started in Florida. 90 of the nation’s top 100 opioid prescribers were Florida doctors. 85% of the nation’s oxycodone was prescribed in Florida. What is going on in Florida?
Well, I became the Attorney General’s drug czar in 2011 to deal with this problem. So Florida had the loosest laws in the country when it came to the prescribing and the dispensing of oxycodone. So the pill mills found a home in Florida where people from all across the country came down to Florida to get their drugs to use and then sell them back at home where it was much tougher to get. Florida did not have a prescription drug monitoring program until much later. I mean, our laws were so loose that you could be an ex-felon and own these pain clinics. And they had to have a doctor involved and they would find usually retired doctors who were looking to make cash, $3,000.00 a day at the time just to write unlimited scripts. I mean, these were drug dealers wearing white coats. And so when I got involved and I worked with then Attorney General, Pam Bondi, we shut down these pill mills.
We were able to help pass new laws and we shut them down. But then just because the supply went away didn’t mean the demand for it went away and people moved to heroin. And then now you have heroin laced with fentanyl. And you have in response all these drug treatment centers that have opened up. But what happens, Elizabeth, when the drug treatment centers are themselves corrupted? That’s the Florida Shuffle.
So these brokers, let’s start with how this whole works and how people get duped into this because it happens nationwide. You call, you go online, search a rehab facility, you’re desperate. Your family’s in crisis. You’re trying to get your son, your daughter, your sister, your brother, your loved one into a rehab because you know they need it and they probably need a detox first. And you go online to look, and I know I did this because I was trying to remember the name of a really good rehab in Florida, The Meadows, and I couldn’t remember the name The Meadows. So I remember Googling really great rehab in Tucson, Arizona. I knew where it was. And Dave, I had to go through pages and pages of that internet search, and I still don’t think I ever found The Meadows. All these other things popping up and a lot of those things have 800 numbers. That’s a red flag right there.
You would Google rehab near me, and if you were living in Arizona, up would pop a number for a rehab near you. And it turns out that rehab would be in Delray Beach, Florida because the person who advertised bought those keywords and got to the top of the Google search. So we empaneled a grand jury here as part of our Sober Homes Task Force to clean up this mess and one of the recommendations from the grand jury was to get Google to stop rewarding people who are just paying for their words. Just to the highest bidder they would sell ‘rehab near me.’ And they responded, Google did change, and now they vet all the providers through a third party. And it is better, not perfect, still have some issues, but much better. You shouldn’t have that issue.
But we even had the situation in Florida where if you want to look up the association that governed rehabs, it was the legitimate group and you want to talk to them about who are the best providers, the number that was listed in the Google search was hijacked by a scummy provider who then lured you to his rehab. And so this is what we were dealing with. It was so much fraud and abuse. We cleaned up most of it in Palm Beach County. But the problem is it’s going on in other communities, even if Google has changed its ways, what happens in another county when these people set up shop and they lure you to their counties and there’s no task force to investigate and arrest the bad providers. We’re the only county in the country that has targeted this problem. And until there’s a national fix, until the federal government fixes the Affordable Care Act and the Americans With Disabilities Act, which is another issue we can talk about, local governments will continue to have to fight this fight on their own.
So it’s basically every local government, city, and county fighting this individually?
Yes. And one of the reasons is that you have, well-intended federal laws, the Affordable Care Act that needs to be tweaked. You have the Americans with Disabilities Act, so I mentioned that. So that’s another well-intended law. But when you have sober homes, see, sober homes are unregulated group homes. There’s no treatment there. There’s no insurance reimbursement. It’s just a group home. You could lease out your place, rent out your place, three bedrooms. You can have six, nine people live there, all paying you rent. And when the city says to you, “Hey, Ms. Vargas, you cannot have nine unrelated people living in your home, in our city.” You say, “The Americans with Disabilities Act protects me. You must give me a reasonable accommodation under the law. We are considered disabled individuals under the law and the city must comply.” And so the cities and counties were being overrun by corrupted sober homes that were essentially flop houses. And local government couldn’t do anything about it because of federal law.
Now, we have devised ways that now we think cities and counties can improve the situation, but again, until the federal law changes, a lot of these terrible sober homes can continue to exist and thumb their noses at local governments.
So does nobody inspect these sober homes and who inspects these rehabs and these detoxes to make sure that in a detox there’s a doctor who actually knows the dangers? Because detoxing from alcohol, which by the way can kill you, is very different from detoxing from opioids, which won’t kill you, but will make you feel like you wish you would die because you’re so sick. You know what I mean? And there are medically assisted detoxes. There are ways to get a person through detox in a few days so that they don’t die and they’re not absolutely wishing they could die. So is anybody inspecting these detox facilities, these rehab facilities? And you’ve just said they’re not inspecting the sober homes.
Right. Well, the good news is that when it comes to detox, when it comes to outpatient and inpatient care, yes, they must be licensed by each state and/or local government. They have to be regulated because those are healthcare places where they get insurance reimbursements and they are not like sober homes, which are just a house. Sober homes are a house. They’re unregulated, uninspected, uncertified. The rehabs themselves are inspected. Now, the problem with some rehabs is that there’s no one standard of care. So you could go to-
I was going to say, I don’t know. Listen, I’ve been very honest about the fact that I’m in recovery. I went to two rehabs. One of them was first-rate and amazing, the second one was a complete rip-off and the most awful experience I’ve ever had. But one of the things they did is they promised, “oh, you’re going to meet with a therapist twice a week.” Guess what? Nobody was meeting with any therapist. This thing was just a holding pen. You sat around doing a lot of nothing and it didn’t help anybody. People were leaving AMA, using, relapsing, I remember thinking that can’t possibly be right, that both these two rehabs are quote unquote certified when the standard of care was A+ in Utah and F- in Tennessee.
Yeah. When you’re dealing with the brain disease of addiction, it is more of a soft science than, for example, if you had a broken arm, there’s a way to treat a broken arm, but a broken brain, you have a lot of different modalities. You have some people think, “hey, equine therapy is the way to go, and they’ll bill for that.” And others think, “no, it’s 12 steps. It’s abstinence.” Well, abstinence will work for alcohol, but it does not work as well for opioid addictions. I mean, I’m a big believer in Suboxone, Vivitrol, using drugs to battle your opioid addiction, but that’s another matter. That’s medication assisted treatment. We could do a whole podcast on that one. But when it comes to sober homes, according to the American Disabilities Act, cities and counties cannot require registration, inspection, and certification and so they thrive. And because of a federal law that’s meant to protect the residents from discrimination, in reality that federal law has enabled sober homeowners to do harm to their residents, the bad ones.
Mm-hmm.
So the way to fix this is that either the ADA must be tweaked, and we have some language that we asked the federal government to adopt and they have not done so, just clarify it. Number two, there are other groups out there. There’s the Oxford House, which does a great job in their sober homes. There’s a national group called NARR, National Association of Recovery Residences. They have state affiliates across the country, like in Florida called FARR, Florida Association of Recovery Residences, any sober home certified by FARR, or NARR, Oxford House, I think is generally a good sober home. That’s the best way you can separate the good ones from the bad ones. Even though you can’t require registration, local governments can also incentivize registration. Like for example, in Palm Beach County, we have a couple cities that say that we will not give a reasonable accommodation to any sober home that’s not certified by FARR.
So that way it’s not required, but the cities are saying, “Hey, if you want to get the reasonable accommodation, you need to be…”, it’s a carrot and stick approach. We’re worried that maybe that would be overturned by the courts, but it hasn’t happened yet. And then finally-
Because you do know that most rehabs do recommend that when people leave that they go to a sober living house. Rehabs are usually a 28-day stay. Sometimes it’ll be three months if somebody is really, really struggling and has a history of relapse. But the point is that you don’t just get well like that and then walk back out into the brave new world with access to all the alcohol and drugs that your heart could desire. That’s what sober houses are there for. They’re meant to sort of manage that recovery and ease you back into normal life. I mean, it is almost a standard thing that rehabs say, you should probably think about going to a sober living house.
… Right. And look, a good sober living house is really important. Relapse is part of recovery. We get it. But then you have the bad sober homes that are encouraging relapse, that are promoting it through drug use. The State of Florida did something that I think other states should follow in that if you want to refer people from your rehab to a sober home and vice versa, you can do so. But that sober home must be certified. That’s another example of a carrot and stick approach. Again, because of the ADA, you can’t require sober homes be certified, but you can incentivize it. You can incentivize it at the state level. You can incentivize it at the county level and local level. And so that’s why I urge anyone listening to this to urge their state and local governments to put things in law that incentivize good sober homes over the bad ones.
I was really struck to read an article about all the incentives that these brokers for these different rehabs and sober homes will offer people. They offer free rent, grocery store gift cards, cigarettes, even manicures in exchange for going to a specific treatment center. Isn’t that, I mean, I don’t know. People really fall for that? I would think if somebody was offering me free manicures to go to a certain rehab, I mean, I would be like, this is a joke, right?
And it’s all illegal. Now in the past-
But it still happens and people fall for it.
… It is because it goes on all the time so people think that’s normal. When we started our Sober Homes Task Force to clean up the industry in Palm Beach County, we stood up at the first meeting and said, “Everything you are providing is illegal. The free scooters, the manicures, the cigarettes all illegal. That’s patient brokering. That’s inducements and you can’t do that under the law.” And people were aghast. This is members of the industry. They said, “Wait, wait, wait. Everyone is doing this.” And we said, “Well, the next time you’re driving 85 miles an hour on I-95, tell the cop that everyone else is doing it and see how well that works.”
Yeah.
So what we had to do was to tighten the laws to provide real punishments because yeah, it’s true. Everyone was doing it even though it was illegal. But also you get a slap on the wrist. Now it’s patient brokering. It could be a felony and we shut it down.
There’s also another red flag that sort of surprised me. Some of these facilities will actually offer to help patients or their families enroll in insurance.
Well, you can help people who are entitled to insurance legitimately with the paperwork. You just can’t pay for their deductibles and copays. You can’t give them the free plane ticket to get them in the door in the first place. Now, if you want to help them with their insurance that they’re entitled to, it’s not necessarily illegal, but what happens is that they exploit that and they make sure the marketer works with you to get you into the place that’s going to get that place paid the most. Like the out-of-network facilities that get a higher reimbursement level, they’ll funnel you to that place because they’re going to get paid more. And so this is all about chasing the almighty dollar, and no one seems to care in this Florida Shuffle about the patient. The patient is just a commodity, not a human being to them. And that’s why once that patient dies or overdoses so badly they have to go home, they just replace them with another patient.
We have seen so many cases in the news just recently, we had two people overdose and die at a rehab in Indiana. I remember covering a story of a rehab out in near Malibu where the head of the rehab was found at a motel shooting up drugs with three of the young women who were clients of his. This is not just a Florida problem, it’s a national problem. And it seems to be as the opioid crisis continues to get worse, the mental health crisis continues to deepen. Something that people… It’s a real crisis that people need to be aware of and protect yourself against.
Yeah, absolutely. That’s why I’m so glad we’re doing this because people don’t understand what’s going on within the rehab industry unless they’ve really looked at it closely. I mean, when people send their children to rehab, a lot of times they’re just doing it based on an internet search, a Google search. I mean, they spend more time researching the purchase of a television than the healthcare facility to send their child. I mean, if your child needed a heart operation, you would research it left and right, up and down, but matters of the brain, you’re just going to rely on some marketer on the internet offering you free stuff? If anyone tries to offer you any free stuff in any inducement whatsoever run, that’s a red flag. And so it’s important that this gets out there because knowledge is power.
And I’ve always been surprised about how little is known about this scam amongst our legislators, our members of Congress. If you ask them what to do about the drug abuse problem, they’ll probably say more rehab. Yeah, but that’s part of the problem is that the current system incentivizes the bad rehab. So let’s fix that problem first.
What is your advice to families who are looking for good quality treatment? Because I mean, some of the things that I know from friends of mine who’ve gone… I have a friend of mine who actually does this, who used to run the Caron Rehab Center, which is a really great one in Pennsylvania, who now helps place people at appropriate rehabs. For example, you wouldn’t place a 50-year-old Catholic priest suffering with alcohol addiction in a rehab where most of the clients might be teenagers suffering from opioid addiction because you need to have, in order to recover, it’s good to be with people who have stories similar to yours and struggles that look a little bit like yours early on. So what are the red flags? If a family is thinking, “I need to find treatment for my loved one,” what should they do and what should they look out for?
They need to really do their due diligence. There are a lot of resources available. For example, the government has a site SAMHSA, S-A-M-H-S-A, that stands for Substance Abuse and Mental Health Services Administration, and they give tips on finding good rehabs. There are private organizations out there. I mean, look, talk to friends, like you said, Caron, Renaissance, Hanley, there are big names that are really good. They’re also small providers where people are just giving back because they went through it themselves. When it comes to sober homes, make sure your sober home is a certified sober home under the National Association of Recovery Residences or one of their state affiliates or an Oxford House, which has a different model of sober homes. It’s been very successful. Those are the tips I would give. You got to really do your legwork and look, you can call our Sober Homes Task Force if there’s any issues, even if you’re not in Palm Beach County, Florida, we take calls from around the country. I’ll give you that 1-800 number before I sign off here.
But we do take calls and we help people. We’ve had calls from people who’ve said, “Hey, my child’s at this recovery center. Is it a good one?” And we’ve had to say, “You need to get on a plane right now and get your child out of there.” So there are people out there willing to help you really do the legwork.
Here’s some of the things you said to look out for that they treat detox medically and practice evidence-based treatments. A lot of people say they’ll detox you, but they really just mean stick you in a room and let you go through agony. Is that what you’re talking about?
Yeah, because as we said, there is no one standard of care. You’ve got to know what the care is that they’re going to be provided. Is your care going to be equine therapy? They’re going to ride horses all day or play games all day? If that’s what you think is going to help, but if it’s an opioid addiction, you need medication assisted treatment, which is-
That’s not going to help. That’s not going to help any kind of addiction.
… Right. Yeah.
Riding horses and playing games all day long?
Right. Look, I have friends who believe in equine therapy, but that needs to be combined with other things. You are not going to beat an opioid addiction by riding horses all day. I’m sorry to chuckle because this is what we’re facing. I mean, we’ve seen people get off the plane in the Palm Beach Airport with a Polo saddle or golf clubs. Oh, yeah. Because they’re like hey, this is why I’m going to rehab. I’m going to go play golf every day or go ride horses every day. We’ve seen this. And so you need to find out what their model of care is, and I believe in medication assisted treatment, and that will help, but sometimes you just go blind. You just fly blind and you get there. And remember the F- place that you went to Elizabeth?
Mm-hmm.
You don’t know until you’re already there. And some of them make false promises and that’s why you have to do extra research to see who the charlatans are.
Well, they had lots of horses on their website too, although they didn’t offer equine therapy. All right, here are the other things that you should look for. They readily provide a day-to-day schedule of exactly what they’ll be doing. I would include in that to confirm how many times a week your loved one will be meeting with a licensed clinical therapist in addiction treatment.
Exactly.
Because most of these really bad places, like the one I went to in Tennessee, just park all these people in a house for weeks on end while they collect a lot of money, doing a lot of useless testing on urine or blood. Nobody has access to anything here. We’re sitting in a living room doing nothing all day long.
It used to be, Elizabeth, that the big money maker was just the urine testing. There’s green in that gold is what they used to say. But the insurance companies finally got wise of this and so now they’ve moved to other things like genetic testing. And so using 23 and Me to solve your drug addiction problem, I mean, you got to know what you’re getting into.
Okay, so day-to-day schedule, look what that day-to-day schedule is. That they include the family as part of the recovery process. Every good rehab facility has family weekend. It’s important not only number one that the family’s included because the family’s an inherent and an integral part of recovery, but number two, it’s the family’s way of seeing what’s going on in there.
True. And a lot of people who come down to Florida come down here from other states without any local support system. It’s better if you have a local support system or at the very least that they’re able to come down and help you on family days every week. We’ve heard horror stories from people whose families were not allowed to talk to them while they were in care, and that’s not the best. Now I understand if you’re in detox, you need to be, perhaps it’s a very intense and you can be isolated, but when it comes to inpatient care, outpatient care, family support will always help.
They should have a full-time staff with addiction counseling credentials, that there should be a very clear step down or discharge process. Why are those things so important?
Well, the step down process is important because you can’t just say, “all right, you’re cured now go out in the streets” cold turkey. It is better you have the step down to ease yourself, and that’s why I’m a big believer in a lower level, longer term continuum of care. A lot of these rehabs are based on an actuarial model created by the insurance companies where it’s intensive, where it’s acute, and it’s short term, and it’s built for failure because you relapse over and over again. And I think the better system is to have a less expensive, longer term, lower level continuum of care over 12 months instead of this intensive 21 days and then you’re out to do it over, and over, and over again.
Mm-hmm. How many facilities are there like that though? I mean, that’s a big thing to have send your loved one away for 12 months?
It wouldn’t be… No, it’s a lower level continuum of care, so it would not be sending them away for 12 months. Instead of being in a facility for 30 days and then released, you would actually be in the facility and then you’d have a counselor who you’d have to check in and it would be over 12 months.
Okay.
And instead of just keep relapsing, you have someone there. You can do it from home, you can do it from a legitimate sober home, but it’s not the intensity and it’s not as acute. I think there’s a lot of models out there proposed that will help and there’s proven studies that show that that will work, but the insurance companies don’t fund that as much as their current model, which they think is less expensive because instead of 12 months, it’s 30 days, but we’re not talking about warehousing people for 12 months. We’re just talking about having someone with you as a counselor to call you, to show up, to check in with you over that extended period of time.
Finally, these are some simple things, because most people do Google everything or do an internet search of everything, make sure the facility has an easily identifiable physical address and contact information, that the website has photos of real people, real staff and facilities, and that they’re accredited, that they possess a good sign, it’s good if they have the Joint Commission accreditation for addiction treatment. You’ve been talking about that, the gold seal as you call it.
Yeah. Yes. You see a lot of these facilities that use stock photos of models and then, I mean, that can be a red flag right there. I mean, not always. There’s some that don’t want to expose their people to the internet, but look, you want to talk to people who’ve gone through it. That’s important. If they can’t show you any success stories, if they don’t let you talk to former patients, yeah, maybe that’s a red flag too. But all this is back in just doing the due diligence, Elizabeth, there are a lot of facilities out there and a lot of good facilities, but you got to find them. They’re not going to be the ones that are going to pay to play. They’re not going to be the ones to pay to put a head in the bed. Those who do are the ones you’ve got to run away from.
What is the 1-800 number people can call?
The 1-800 number is 1-844-324-5463. 844-324-5463.
Call that with what questions?
Oh, yeah. That’s the sober home hotline. That’s our task force. It doesn’t matter where you are in the country if you have an issue. Now, we’re not going to be able to say, “Hey, is this rehab good in Illinois?” We wouldn’t know that, but if there’s something in Florida, please let us know. Or if you have a general question like, “Hey, this rehab just offered me this, what should I do?”, we can help.
Okay.
And it’s a hotline. If no one is answering at the time, leave the message. We do get back to everyone.
Okay. Dave Aronberg, always great to talk to you. Thank you so much for all the work you do making sure that when people get help, they get the help they need and they don’t get scammed.
Thank you. Elizabeth, thank you. I really appreciate this interview and keep up the great work. You speak for so many out there and I’m grateful to you.
Ah, thanks, Dave.