"If You're Willing to Work…We Can Work With You": Obligatory Labor at Residential Substance Use Services Providers in...

"Work therapy" is not an evidence-based treatment for substance use disorders. Nevertheless, many substance use service providers impose labor obligations. The purpose of this study was to describe the prevalence and correlates of obligatory labor at providers of residential substance use services in North Carolina.

This audit study surveyed residential substance use service providers in North Carolina, systematically collecting program characteristics including obligatory labor. We used Fisher's exact tests to assess associations between program characteristics and two conditions of interest: obligatory labor and obligatory labor in agency-owned and -operated commercial enterprises. We qualitatively described the nature of labor mandates as summarized by program staff.

Of 66 providers surveyed, 28 (42.4%) mandated labor, and 20 (30.3%) mandated labor in an agency-owned or -operated commercial enterprises. Providers who imposed either of these mandates were more likely to be faith-based and operating without a state license for adult substance use services. Providers imposing labor requirements were more likely to offer residential services at low or no cost. Providers mandating labor in agency-owned and -operated commercial enterprises were more likely to restrict eligibility to persons meeting health and "able-bodiedness" requirements. Many providers described these labor obligations as therapeutic and mandatory.

More providers require residents to work in an agency-owned and operated commercial enterprise than allow access to opioid agonist treatment, the gold standard treatment for opioid use disorder. Adjustments to state regulations may help improve the availability of evidence-based services and increase regulatory supervision of these service providers.