An addiction treatment facility, highly regarded by North Carolina lawmakers, sits in a residential neighborhood here and operates like a village in itself. Triangle Residential Options for Substance Abusers, better known as TROSA, hosts roughly 400 people a day on a campus with rows of housing units, cafeterias, a full gym and a barbershop.
The program, which began in 1994, is uniquely designed: Treatment, housing and meals are free to participants. And TROSA doesn鈥檛 bill insurance. Instead, residents work for about two years in 罢搁翱厂础鈥檚 many businesses, including a moving company, thrift store and lawn care service. Program leaders say the work helps residents overcome addiction and train for future jobs. Of those who graduate, 96 percent of individuals remain sober and 91 percent are employed a year later, .
Impressed with such statistics, state lawmakers recently allotted $11 million for TROSA to expand its model to Winston-Salem. It鈥檚 the largest amount in the state budget targeted to a single treatment provider and comes on the heels of $6 million North Carolina previously provided for its expansion, as well as $3.2 million TROSA has received in state and federal funds annually for several years.
This latest influx of taxpayer dollars 鈥� coming at a time when and each dollar spent on treatment is crucial 鈥� is . Advocates, researchers, and some former employees and participants of TROSA say the program takes advantage of participants by making them work without pay and puts their lives at risk by restricting the use of certain medications for opioid use disorder. Although those who graduate may do well, only 25 percent of participants complete the program 鈥� a figure TROSA leaders confirmed.
鈥淚f I had known about this funding, I would have been the first person on the mic to [tell lawmakers], 鈥業 don鈥檛 think you all should do this,鈥欌�� said K.C. Freeman, who interned at TROSA in 2018 and later spent two months on staff in the medical department. 鈥淵ou can鈥檛 look at the small number of people who had success and say this works. It鈥檚 not the majority.鈥�
The dispute over 罢搁翱厂础鈥檚 funding comes amid national conversations about billions of dollars available after landmark opioid settlements with drug companies. Two flashpoints in the North Carolina debate may provide a window into heated conversations to come. First: Are work-based rehabs legal or ethical? And second: Should every facility that receives public funding allow participants to use all medications for opioid use disorder?
Work as treatment
Work-based rehabs are widespread across the country. The investigative news outlet Reveal such facilities, including some that place participants in dangerous jobs at oil refineries or dairy farms with no training and exploit workers to bolster profits.
Many of these programs use a portion of their revenue to sustain the rehab and offer residents free housing or meals. That can make them attractive to state legislators, said , a UCLA law professor who specializes in employment and labor law.
鈥淏ecause essentially they鈥檙e running businesses off of people鈥檚 uncompensated labor, there is a built-in funding mechanism,鈥� he said. 鈥淚f the state doesn鈥檛 have to pay full freight to run a program ... that might be a reason to like it.鈥�
罢搁翱厂础鈥檚 indicate more than half of its multimillion-dollar budget is funded through its businesses at which residents work, as well as goods and services that are donated to the program. About 30 percent of its funding comes from government grants and contracts.
Although TROSA and its leaders report no significant campaign donations, they spend upward of $75,000 a year on lobbying. In presentations, they often share 鈥� conducted by an independent research institute at 罢搁翱厂础鈥檚 request 鈥� which found TROSA saves the state nearly $7.5 million annually in criminal justice and emergency care costs.
The program鈥檚 self-financing aspect is part of its appeal for North Carolina Sen. Joyce Krawiec, a Republican who represents part of Forsyth County, where TROSA is building its new site.
鈥淭he good thing about TROSA: They raised most of their own funds,鈥� she said in a phone interview.
It鈥檚 reasonable that residents don鈥檛 get paid for their work, she added, since they鈥檙e already receiving free treatment and housing. Other rehabs can be prohibitively expensive for many families, so TROSA provides a much-needed option.
鈥淏ecause essentially they鈥檙e running businesses off of people鈥檚 uncompensated labor, there is a built-in funding mechanism."Noah Zatz, UCLA Law Professor
But being a bargain doesn鈥檛 necessarily make it legal, Zatz and other labor experts said. A previous suggests nonprofits that run businesses without paying employees could violate the .
But TROSA administrators say they are not an employer; they are a therapeutic community. Clear policies guard against the exploitation of anyone, said Keith Artin, president and CEO. The jobs provide residents with structure and an opportunity to change their behaviors.
鈥淭he work-based element is essential to recovery,鈥� Artin said. 鈥淲e鈥檙e teaching people how to live.鈥�
Toward the end of residents鈥� two-year stays, TROSA assists them in job-hunting and allows them to live on campus for several months while they work at a newfound job and build savings.
Diverging work experiences
罢搁翱厂础鈥檚 model has widespread support among lawmakers and families affected by addiction. Benjamin Weston said it was 鈥渁 blessing.鈥�
Weston said he started using cocaine as a teenager and struggled with addiction for years. At 22, he entered TROSA. He said he was grateful for two years of free treatment.
After brief assignments in 罢搁翱厂础鈥檚 thrift store and moving company, Weston transitioned to the development office, where he solicited donations from local businesses. 鈥淚t was meaningful work that also taught me a lot of good job skills,鈥� he said.
Since graduating in 2016, Weston has worked in development for , a nonprofit his mother started to support survivors of abuse and addiction.
Other graduates interviewed for this article talked about using the moving skills or commercial driving licenses they gained to obtain full-time jobs. Some said they鈥檙e buying houses and starting families 鈥� successes they credit to their experience in the program.
But not every resident finds the work model therapeutic. Several described working 10 to 16 hours a day, six days a week, in physically demanding moving or lawn care businesses. Several said there was little time for therapy and, with only a handful of counselors for hundreds of residents, wait times for a session could span weeks.
Freeman, the former TROSA employee who has a master鈥檚 in social work, said he thought residents rarely had an opportunity to process the trauma that made them use drugs in the first place. Although Freeman did not counsel clients 鈥� his role at TROSA focused on ordering and stocking medications 鈥� he said he noticed many graduates returned repeatedly to the program, struggling to stay away from substances once they left campus.
Richard Osborne first heard of TROSA while incarcerated on drug and theft-related charges. Like 38 percent of TROSA residents, he chose to attend the program as a condition of his probation.
One day in 2017, Osborne and other residents working with the moving company were unloading large boards of plywood from a trailer, when a board fell and smashed him against the trailer, he said. His vision became blurry and he worried about having a concussion, he said.
As he remembers it, no one suggested medical care. 鈥淭he next day, they told me I had to get back to work,鈥� he claimed.
That鈥檚 when Osborne said he decided to leave.
Today, Osborne, 31, said he has not used drugs in about four years, holds a steady job, and has a loving family. But 颈迟鈥檚 no thanks to TROSA, he said.
鈥淭hey鈥檙e taking advantage of people at their low points in life,鈥� he said. The moving company a year, yet residents who work for it are not even allowed to keep tips, he added.
TROSA leaders confirmed the tips policy but said they could not comment on an individual residents鈥� experience. In general, CEO Artin wrote in an email, 鈥渨hen a resident is injured we ensure that they receive immediate medical attention and would never knowingly put a resident at risk.鈥�
As a nonprofit, TROSA funnels revenue from its businesses back into the treatment program, he added.
The program鈥檚 2020 show its top five employees combined earned over $750,000 in salary and benefits.
Medication hesitancy
TROSA provides psychiatric care through a contract with Duke Health and offers group or individual counseling to residents who request it. The program employs four full-time counselors and partners with local providers who donate physical therapy, dental care, and other medical services.
But TROSA does not provide access to some of the treatments for opioid use disorder: and. Both medications activate opioid receptors in the brain and reduce opioid withdrawal and cravings. It鈥檚 been that these medications the risk of opioid overdose death, and the FDA-approved drugs are considered the 鈥溾�� for treatment.
Right now, TROSA leaders say the only medication for opioid use disorder the program offers is naltrexone, an injectable medication that works differently than the other two because it requires patients to fully detox to be effective. Because of this, are hesitant to use it, saying it puts people at higher risk of overdose death.
About one-third of TROSA participants report opioids are their primary drug of choice.
TROSA leaders said they鈥檝e discussed adding the other addiction treatment medications but face logistical barriers. All medications at TROSA are self-administered, and leaders worry about diversion of oral methadone and buprenorphine, which are classified as controlled substances. They say they鈥檇 consider injectable buprenorphine, but 颈迟鈥檚 costly for their mostly uninsured participants.
鈥淧eople choose to come here because it is a behavior modification program,鈥� said Lisa Finlay, lead clinical counselor at TROSA. 鈥淭hey know that we don鈥檛 offer buprenorphine or those medications. We have people who have tried those medications in the past and believe that they actually led them back to using.鈥�
that people using medications for opioid use disorder have the best outcomes when they have access to other recovery support services, such as housing, employment, counseling and a community. But while clinicians across the country have embraced these medications, leaders of residential treatment programs founded in the more traditional 12-step, abstinence-based recovery model have pushed back.
Some old-school recovery leaders claim the use of medications is simply , which has created stigma around this form of treatment.
A found that about 40 percent of residential programs surveyed in the U.S. didn鈥檛 offer opioid use disorder medications and 20 percent actively discouraged people from using them. In North Carolina, there are 62 licensed long-term residential treatment facilities, according to the , and fewer than half accept patients who take these medications. Only 12 facilities are licensed to prescribe buprenorphine.
This has resulted in tough conversations with patients for, a clinical social worker on a UNC Health team that treats people with severe IV drug-related infections. Once patients are stabilized, many start buprenorphine, she said. Some say they want to go to a residential program for structure, job training and to learn coping skills. Roberts recalled one patient saying to her: 鈥淚 need to go to residential treatment and I need this medication because I fear I鈥檒l die.鈥�
鈥淭hat's really heartbreaking to hear a patient clearly articulate what it is that they need 鈥� which is in line with the [research] literature,鈥� she said. 鈥淎nd that you know there are very few places in the state that offer that.鈥�
Doctors and public health experts nationwide are to fund rehab facilities that allow these medications, saying they鈥檙e the best way to combat the opioid crisis.
鈥淚 also have concerns from what I learned about 罢搁翱厂础鈥檚 approach to treating opioid addiction in particular."Rep. Graig Meyer (D-Durham)
颈迟鈥檚 of the Americans with Disabilities Act to deny recovery services such as housing to people using medications for opioid use disorder. Health experts say that funding abstinence-based addiction programs could also if people leave the program and return to using drugs with a much lower tolerance, especially as in the street drug supply.
These conversations will become only as opioid settlement funds arrive, said , director of the national Rand Opioid Policy Center.
鈥淭he goal isn鈥檛 just to get people into treatment; 颈迟鈥檚 to get people doing better,鈥� he said. 鈥淵ou want to make sure that you鈥檙e using the money effectively.鈥�
The conversations have begun in North Carolina. When Rep. Graig Meyer (D-Durham) for TROSA late last year, clinicians reached out to him explaining their concerns about the program not allowing participants to use methadone or buprenorphine.
Although Meyer still believes 颈迟鈥檚 an effective program, he said, 鈥淚 also have concerns from what I learned about 罢搁翱厂础鈥檚 approach to treating opioid addiction in particular. I鈥檇 like to see TROSA consider what their current practices are.鈥�
is an independent, nonpartisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina.
(Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
