Rehab: An American Scandal

Rehab: An American Scandal

by Shoshona Walter

Simon & Schuster, 2025

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Book Cover

In Rehab: An American Scandal, Shoshana Walter surveys today’s addiction treatment landscape, to show what works, what does not work, and why. This volume is eye-opening, and emotionally compelling, as Walters demonstrates the promises as well as the flaws of our current treatment systems for addiction to drugs and alcohol. Walter identifies addiction treatment as a $53 billion per year industry, that operates as a “rehab-industrial complex,” to borrow from President Eisenhower’s lexicon.¹ Walters finds treatment outcomes contingent upon the commonalities that promote successful recovery—money, family support, structure, and resources—while identifying the inhibitors as the lack of financial resources, absence of family support, harmful governmental regulations, lack of understanding, and sabotage of recovery efforts by individuals and institutions.

This exposition is grounded in four persons’ recovery journeys: Chris Kahn from Louisiana, April Lee from Pennsylvania, Larry Ley from Indiana, and Wendy McIntyre from California. Through their triumphs and travails, Walters illustrates the systemic failures, predatory practices, and profound inequities that characterize the American approach to addiction treatment.

Chris Kahn’s story is familiar, as he finds himself addicted to opiates initially legitimately prescribed for his ankle fracture. Chris found these pills to be both analgesics as well as euphorics. Chris also discovered that his social and emotional voids were filled by inclusion, then into his community’s “drug culture.” His story highlights the strong power of favorable demographics, as a white man whose father worked in law enforcement, as well as the three-way collusion between social drivers of addiction, the pharmaceutical industry’s marketing machinery, and aggressive and opportunistic rehabilitation programs. ^2,3

April Lee’s story invokes structural racism as a barrier to both her life trajectory and her recovery. Where Chris Kahn had family financial support, a lawyer, education, and job prospects, April Lee had access only to recovery houses amidst the militaristic, utilitarian approach to rehab that characterizes low-income treatment options. April’s experience highlights the difficulties with health insurance, the challenge of finding programs, and the critical importance of speed in entering a program as a significant factor in rehab success and lasting sobriety. April’s story also reveals that 12-step programs and the variety of options available are not equally accessible to all people.

Larry Ley saw a dire need for effective medication-assisted recovery care in rural Indiana communities and started an initially much-touted program to achieve this. As a private practitioner prescribing Suboxone™, his story illustrates ‘two invisible hands arm wrestling’—free market forces versus regulatory intervention. These strong market forces—the bucking bronco of the pharmaceutical-industrial complex—could not be lassoed or corralled by what Walters describes as a haphazard regulatory system.

The pharmaceutical marketing mechanism is well-described in Ley’s story, with doctors being “roped in” with meals. Doctors, like armies, goes the argument, are sustained by food: We march on our stomachs. The senior reviewer finds pathetic, funny, and true this contention that doctors, like armies, are sustained by food – that we march on our stomachs. And no surprise, then, that I recall, from my residency years, a pharmaceutical representative who was notorious for providing expensive meals for sleep-deprived, cash-flow-poor residents, interns, and students. The pharmaceutical representative’s hope was that these current and future prescribers would then go out and start prescribing his rarely indicated, highly expensive medication routinely, feeding a nefarious cycle of overprescribing an unindicated medication.

The experience of Dr. Ley having to take a training course and be certified to prescribe this expensive and profitable medication parallels what medical drug and device companies are alleged to do, engendering, upon device introduction, an aura of expertise and exclusivity to those doctors who train under the company’s “certification” to use their new, pricey, and perhaps not fully validated pills and gadgets.

And for those of us who need yet another reminder of the dangers of hubris, Ley’s story is unfortunately more than allegorical. Ley taunted regulators and authorities and essentially asked them to come after him, stating, “Nobody’s gonna tell me how to run my business.” Sensationalist journalism and political opportunism are evident here, with the town’s mayor rallying around hearsay implicating this physician, in what felt like a witch hunt. Ley then “poked the skunk” by taunting government and bureaucracy, when he boasted that he had “…put more dealers out of business than a cop.” Ley in this way threw down the gauntlet, to a system that indeed demonstrated its willingness and ability, to arrest this bold and vocal prescriber who, for their purposes, was a drug dealer. Broader enforcement led eventually to the US Department of Justice’s pursuit of Purdue Pharma, the makers of the narcotic OxyContin™, and Suboxone’s™ makers, the Reckitt Benckiser Group (RB Group), and Indivior.^4,5 Some vindication for Ley came when a recently minted physician started addiction care in a rural community based upon the “proof of concept” provided by Ley’s recovery program.

A loose and inconsistent regulatory approach, antithetical to what “regulation” means, is demonstrated by Wendy McIntyre’s tragic story, centered around the death of her son Donovan. Rather than consistent application of rules and regulations, she found her son victim to poorly formulated guidelines, and lack of regulatory oversight and investigatory timeliness. Walter here demonstrates the ease with which owners circumvented regulations in a seemingly conspiratorial and self-serving rehab-pharma-regulatory matrix, operating counter to the needs of patients with addiction.

It is through these four stories that Walter shows how our addiction recovery system weaves a rope that hangs itself, and many in addiction. The regulatory framework, she argues, needs to be reassessed, as it is both excessively strict in some areas, and too lax in others. Overly complex and burdensome regulations, for example, led many Suboxone prescribers to abandon this therapy for narcotic addiction. In addition, the distinction between licensed addiction rehabilitation facilities and unregulated sober living homes created a regulatory blind spot, where vulnerable populations received care from potentially unqualified providers. And facility regulations were sometimes easily circumvented through structural changes, such as ownership transfers, and reclassification of facilities from long-term care to sober-living homes. Finally, the stark inequities in treatment access and outcomes documented in the book raise questions about whether medical regulation can or should address structural barriers to addiction care in individual addicts’ “recovery capital, the combination of internal and external resources that people draw on to successfully recover from addiction,” such as those necessary financial, social, demographic and community pillars to successful recovery.

Walter’s book makes explicit a fundamental inequity: “…anyone can get addicted. But in America, only certain people get the chance to recover.” This book gives us an idea of why, and where we may be able to look to fix this.