A new study finds many organizations that provide residential drug- and alcohol-use services in North Carolina have mandated labor requirements. Organizations with labor requirements are less likely to provide recommended evidence-based treatment for opioid-use disorders and are more likely to operate without a state license for adult substance-use services.
"More than a third of residential substance-use service providers in the state require patients seeking treatment to engage in some form of labor," says Jennifer Carroll, lead author of the study and an associate professor of anthropology at North Carolina State University. "Unpaid labor is not a legitimate form of treatment or recovery support in any setting. And we observed almost a third of the service providers mandated labor in a commercial enterprise that is owned and/or operated by the service provider.
"That's problematic, in part, because there is no evidence that mandated labor is part of an effective treatment for substance-use disorders," Carroll says. "What's more, the safest, most effective, evidence-based treatment for opioid-use disorder is opioid agonist treatment - and the vast majority of the providers that require participants to perform labor also do not allow patients to access opioid agonist treatment."
These research findings stem from a statewide study that assesses the services provided by residential substance-use disorder treatment providers in North Carolina.
For the study, researchers conducted a statewide inventory of residential substance-use service providers in North Carolina. The researchers then had "secret shoppers" pose as people seeking help for heroin addiction and call every organization that claimed to provide residential services for opioid-use disorder, with the goal of learning more about how the different programs operate. The researchers identified 94 providers. Twenty-eight providers could not be reached or declined to answer questions when contacted. The remaining 66 answered some or all of the questions from the researchers.
Of the 66 providers surveyed, 28 (42.4%) mandated unpaid labor, usually associated with low-wage employment (mowing lawns, working in retail stores, etc.). And 20 of those 28 organizations mandated labor in an agency-owned or -operated commercial enterprise. Providers imposing labor requirements were more likely to offer residential services at low or no cost, which improves access to services.
"However, these providers were also less likely to provide patients with access to the gold standard in evidence-based treatment for opioid use," Carroll says. "And providers that required patients to work in agency-owned and -operated commercial enterprises were more likely to restrict eligibility to people who were physically able to perform manual labor, which limits access to services. Work without pay is exploitation regardless of the circumstances."
State regulations do allow service providers that are licensed as "therapeutic communities" to mandate labor in agency-owned or agency-operated enterprises. However, the study found that the majority of providers who imposed labor mandates were faith-based and operating under an exemption in state law that allows faith-based residential service providers to operate without a state license for adult substance-use services.
"There is no evidence that work is a form of treatment," Carroll says. "And our findings suggest many residential substance-use treatment providers in N.C. are not providing patients with evidence-based treatment and are instead having patients engage in unpaid labor. That's not healthcare, and there is no evidence that it helps patients on the road to recovery. The fact that many of these providers don't give patients access to opioid agonist treatment also increases their risk of overdose.
"These providers are often presented as places where people can go for help with substance-use disorders," Carroll says. "And it is troubling that there is no evidence the services they are providing can actually help people."
The paper, "'If you're willing to work…we can work with you': Obligatory labor at residential substance use services providers in North Carolina," is published open access in the journal Substance Use & Misuse. The paper was co-authored by Brandon Morrissey, a Ph.D. student at NC State; Sarah Dixon, a recent master's graduate from NC State; Alejandra Salemi of Duke University; Bayla Ostrach of Boston University; Taleed El-Sabawi of Wayne State University; and Roxanne Saucier of Open Society Foundations.
