State-level actions targeting unethical substance use disorder treatment practices: A qualitative study

Introduction: There has been increasing recognition of unethical practices occurring in substance use disorder (SUD) treatment, such as patient brokering and deceptive marketing. We conducted a qualitative study with key informants to characterize state actions that have been undertaken to target unethical practices and the context surrounding state-level actions, including barriers and facilitators to their implementation. Methods: We recruited key informants at the state-level, as well as those from national organizations engaged in improving SUD treatment quality, who could provide perspectives on the scope of unethical practices in the field and ways in which states have sought to prevent unethical practices and improve the quality of SUD treatment. We conducted semi-structured interviews via videoconference with 15 key informants from 11 organizations, including four national advocacy organizations, four state-level advocacy organizations, one local advocacy organization, and two SUD task forces, with both civilian and law enforcement perspectives represented. Results: Key informants described the scope of unethical substance use disorder treatment practices as encompassing patient brokering, deceptive marketing, unethical billing and insurance fraud, and harmful practices in recovery housing. They discussed state-level legislative and non-legislative activities (e.g., licensing and certification efforts, task forces) that have been undertaken to target unethical practices, but they emphasized the need for improved regulation and enforcement. Adequate funding and clear authority were seen as key to success, but without the ability to coordinate across state boundaries, key informants also felt state-level actions alone would be insufficient in combatting unethical actors and practices in substance use disorder treatment and recovery housing spaces. Conclusions: Lessons from states that have enacted legislation and other activities targeting unethical SUD treatment practices may help other states decide which policy approaches are most appropriate for their circumstances. However, our results also suggest that without additional resources or the ability to coordinate across state boundaries, state-level actions intended to combat unethical SUD treatment practices may be unlikely to have the desired effect.