Four years ago, when Casey O'Brien went from Massachusetts to Florida for treatment, she thought she was entering a system that would help her manage her substance use and mental health issues.

The reality, she says, was far different.

"My experience in Florida, I ended up going from flophouse to flophouse, homeless, strung out ... given all of these promises of the luxurious life," said O'Brien, who's 27 now. "But it's really, it's seedy, it's dark and not something you would ever imagine when you hear the word treatment."

Casey O'Brien (Deborah Becker/WBUR)

O'Brien spent more than two years in Florida, most of the time at what she calls "flophouses," but what are known as sober houses -- where patients go after rehab, presumably to live in a drug-free environment while they get their lives together.

But O'Brien says in these houses she continued to use drugs openly, and the operators of the homes encouraged her to stay.

"It doesn't matter if you're clean or sober, your rent gets paid, you're given cigarettes, and can use drugs freely so long as you take a drug test for them and go to these quote-unquote 'intensive outpatient programs,' " she said.

Intensive outpatient programs, also known as IOPs, are where patients go for a few hours three to five days a week for group and individual counseling. They're essentially stepdown programs after residential treatment.

Typically, O'Brien says, the Florida IOPs would collude with sober houses and drug testing labs to bill insurance as much as possible.

"It's all fraud," she claimed. "You go to these places under the impression there is going to be treatment, and really you go sit in a room and talk and watch movies and your insurance gets charged hundreds of thousands of dollars."

Another person who went to Florida and doesn't want to be identified told WBUR that he was part of the fraud. He said he was paid about $500 a person to find patients with what's considered good health insurance and send them to specific programs. In exchange, he said he could live in those programs' sober houses rent-free and still actively use drugs. At one home he was given a job as "admissions coordinator," where he would run errands for the home operator and continue to troll — typically at 12-step meetings — for the highest-paying patients.

O'Brien says the practice was well known in Florida, which she says it teeming with people from all over the country — most in their early 20s, so still covered by their parents' health insurance until age 26.

O'Brien says she didn't engage in the scams, but it's not hard to figure out why people do.

"If someone says, 'I can give you money, just tell your friend to come here,' nine people out of 10 are going to take that deal because it benefits them," O'Brien said. "They don't realize [the] negative impact."

The Oversight In Massachusetts

In this July 6 photo, Timothy Schnellenberger, rear right, speaks with recovering addicts at his substance abuse treatment center, Recovery Boot Camp, in Delray Beach, Fla. Schnellenberger has operated treatment centers since 2002, and says that the influx of criminal operators has cast a dark shadow over an industry with deep roots in South Florida. (Lynne Sladky/AP)

South Florida is known as one of the addiction recovery capitals of the country, with thousands of treatment centers and sober houses. The main reasons that many people go there is to get away from drug habits, and because many of the Florida programs promise long-term care, such as sober housing after rehab.

Florida officials have set up task forces to try to clean up the industry and in the past 10 months they've arrested dozens of program operators on charges related to improper treatment.

Andy Amoroso, who sits on the Palm Beach County League of Cities, told NPR that because some 75 percent of those coming to Florida for treatment are not from the state, loved ones should beware.

"My message would be, stop sending your children and your loved ones to South Florida because we're sending them back in body bags," Amoroso said.

These reports have caught the attention of the hundreds of police departments that help people get treatment. The Police Assisted Addiction and Recovery Initiative (PAARI), which started in Gloucester two years ago, says it is closely vetting programs and steering people away from Florida unless it's a well-known program.

"Now that we're aware of what's going on in Florida, we are very reluctant to send anyone there unless we absolutely have a relationship with them," said Jon Rosenthal, co-founder of PAARI.

Rosenthal says of the more than 500 people who went to Gloucester police seeking treatment, just 13 were sent to programs in Florida, and PAARI did not receive any complaints about the quality of treatment.

In Massachusetts, addiction treatment is licensed by the state Department of Public Health. In response to the opioid epidemic, the department started tracking deaths at treatment facilities just this year and started tracking complaints against treatment programs just three years ago.

Documents obtained by WBUR show that as of last week, the state has received reports of nine deaths at treatment facilities since January. And in 2016 -- the last full reporting year -- the department received 307 complaints about treatment programs, and 55 were substantiated, meaning the provider had to take corrective action.

Allison Bauer is director of the department's Bureau of Substance Addiction Services, which oversees treatment in Massachusetts. She says that number of complaints is relatively small, considering that each year more than 80,000 people are treated in programs that are overseen and in some way funded by the state.

"You never want a complaint, you want to bat a thousand, but that feels like a strong system in terms of the number of complaints being received," Bauer said.

Just last week, Bauer's bureau announced that it was suspending admissions at Recovery Centers of America in Danvers after two patient deaths there this year.

"We can as an interim, if we feel there is an imminent risk of harm to either current or future clients, we can suspend admissions to a program while deficiencies are being corrected," Bauer said.

Bauer says it's not likely that rampant treatment fraud like what's happening in Florida could happen in Massachusetts — largely, she says, because of the state's oversight and regulations. She says her office has a complaint hotline that providers are required to disclose to patients. Also, she says there are two full-time complaint investigators in her bureau, as well as licensing investigators, and treatment programs must renew their licenses every two years.

Additionally, addiction treatment programs can voluntarily get accredited by some private groups. It's estimated about half of all programs are accredited.

'We Don't Know Truly What Is Working'

But many addiction specialists, such as Dr. John Kelly, the director of the Recovery Research Institute at Massachusetts General Hospital, say the main issue is that there is still disagreement — even among providers — about what constitutes appropriate treatment for which patients.

"The problem is that what we think works is not what is really working," Kelly said. "We don't know truly what is working — is 35 days better than 20 days, and for whom? At what point do you step down? There is no empirical basis for that."

Kelly says one national treatment accrediting group — The Joint Commission — is putting new standards in place starting in January. Those will require accredited treatment providers to track patients' progress and provide data about what's working and what is not. Kelly says it's a step that will help set standards for addiction treatment — something that does not currently exist.

"It's 30 years too late, but better late than never. We should have been doing this decades ago," Kelly said.

Those who advocate for improvements in substance use disorder treatment agree — and say the opioid epidemic is shining a light on what has always been a troubled treatment system.

"We have the stupidest treatment system in the world, basically," said Maia Szalavitz, an author and neuroscience journalist. She says the troubles continue because in most states there is little oversight and a lot of stigma associated with addiction.

"What we really need is for loved ones to get angry and stop saying, 'we need more money for treatment,' and start going to the government and saying, 'we need this stuff investigated,' and 'we need money for treatment that treats our loved ones with dignity, respect and evidence,' " Szalavitz said.

So what should patients do if they're looking for addiction treatment? Dr. Kelly recommends doing a lot of research.

Casey O'Brien, who is now back in Massachusetts after her saga in treatment in Florida, says problems with treatment are in every state — including here. She says the best way to learn about a program is to ask the people who've been there.

"All I can say is, continue to reach out, ask for help, don't get information from someone related to a treatment center," she said. "As a patient, you are a consumer. It's a business; you have a right to ask questions."

O'Brien says she left Florida after her insurance ran out and she was kicked out of the program, where she was living with the father of her baby. Five months pregnant and on the streets of Florida, she returned to Massachusetts and entered treatment here. She's been drug-free ever since.

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