NEW YORK — At drug treatment centers on Staten Island, the calls disturb the daily routine. The solicitations interrupt meals, counseling sessions and support groups.
Sometimes, staff members say, the callers make explicit offers: thousands of dollars to refer a person with a heroin or pain-pill addiction and good insurance. Other offers are more subtle — a recurring donation or a contract.
The callers are recruiters working for treatment centers as far away as Arizona, California or Florida, or as close as Long Island or upstate New York, all angling to fill their beds with patients from Staten Island.
"They are opportunistic people or organizations who are preying on people of vulnerability at a time of high stress," said Luke Nasta, the director of the addiction treatment center Camelot of Staten Island, which has been there for 45 years. "It's unethical. It's borderline criminal."
The calls began years ago, Nasta said, but they have become far more frequent as Staten Island's opioid addiction rate has soared and brought the borough some notoriety. An episode of the National Geographic series "Drugs, Inc." last year described it as "Heroin Island."
"If you're in the business you say, 'Oh, well this is a fertile ground,'" Nasta said. "So they come here and they solicit."
Even if the solicitations do not cross a legal line, people in the treatment community say they do cross an ethical line.
"There are enough people doing it who seem to think it's OK, or know that it's not and don't care," said Marvin Ventrell, the executive director of the National Association of Addiction Treatment Providers, which has about 550 members.
Some people end up in drug treatment by court order; others at the urging of family or friends. In New York, some treatment programs are for-profit. Most, like Camelot's 45-bed residential center for men, are nonprofit.
"If a person comes to this door, the last thing I want to talk to him about is what kind of insurance he's got," John Coleman, the director of operations at Camelot, said. "I'm not saying that's not important or doesn't play a part in getting help, but I don't care. I want them in the doors and off the street."
In 2015, Staten Island recorded the highest rate of overdose deaths involving prescription painkillers in New York City and had the second highest rate of overdose deaths involving heroin, after the Bronx, according to the city's Department of Mental Health and Hygiene.
The Staten Island district attorney's office is investigating 59 suspected overdoses this year. In February, the office started an initiative to treat every overdose like a crime scene.
Nationwide, more money has been flowing into addiction treatment over the last several years, due in part to two laws, one passed in 2008 — the Mental Health Parity and Addiction Equity Act — that ensured equal coverage of mental health care; and in 2010, the Affordable Care Act. The money has drawn new entrants to the treatment industry, often private, for-profit providers.
"It began to change the game significantly," Ventrell said. "The money is now there."
Particularly when profit is part of the equation, he said, pressure to fill beds could lead to unethical efforts to recruit patients. That possibility prompted the treatment providers association to create an ethics code two years ago.
"The addiction industry was no longer a small collegial group that was carefully working together and trying to do the best thing for clients," Ventrell said. "Rather, it had become a very competitive business."
The code specifically addresses remuneration: "No financial rewards or substantive gifts are offered for patient referrals."
In February, Ventrell put in place a system for filing complaints about member organizations.
The system is too new and the data too sparse to draw conclusions yet, he said; so far, of the 10 complaints filed, four related to payments for patient referrals.
In New York City, 346 treatment programs — including residential and outpatient — are certified by the New York State Office of Alcoholism and Substance Abuse Services; 22 of them are on Staten Island.
Rob Kent, the general counsel for the agency, said he was concerned about paying for referrals.
"If you are referring a patient to somebody that is paying you, is it because they are paying you or because you believe the program is the best option for the patient?" Kent said.
Addiction treatment providers across the city also said they had been offered money for referrals.
Donna Mae DePola, the president of the Resource Counseling Center, which offers outpatient treatment in Brooklyn and is opening a recovery center on Staten Island this year, said the subtle nature of the approaches made them hard to document and report to the authorities.
"A lot of it is hearsay," DePola said, adding that a solicitor could easily deny making any offers. "So what I try to do is tell my friends in the field. We talk, send emails, say stay away — stuff like that."
And the approach is often obscured.
"They ask you in a way that doesn't sound illegal," she said. "'Well, we can do a contract and the contract can say this.'"
Before heroin became the drug of choice, there were prescription pain pills.
"Once the pills came around Staten Island, it just, it exploded," said Kevin Oshea, 33, a recovering addict from Annadale, Staten Island, in treatment at Camelot.
A crackdown on prescription painkillers on Staten Island in the past five years led addicts to chase the cheaper high of heroin, and the toll from overdoses has been staggering, according to Michael E. McMahon, a Democrat who is the borough's district attorney.
"People started dying like crazy," Oshea said. "Once I got introduced to it, the ship sailed."
McMahon said heroin had reached deep into many communities where it once was taboo. "What's shocking to me is that heroin has gone from accessible to acceptable," he said in an interview.
McMahon said no one had brought the issue of payments for patient referrals to his attention. "Second only to the drug dealers who purvey this problem is someone who would try to take advantage of anyone who is ill," he said.
Dealing with recruiters is part of the reality for drug treatment centers on the island, Jacqueline Filis, the director of the Staten Island YMCA Counseling Services, said.
"There are people that are coming into our community with their marketing materials," she said. "It's hard to figure out the good from the not so good."
'A Quick Buck'
Dennis Jay, executive director of the Coalition Against Insurance Fraud, a nonprofit based in Washington, said the money surging into drug treatment had made patient brokering hard to stop.
"In four years, not just the treatment centers, a whole industry has been created," Jay said. "It's a little bit scary to just see how much money is available in this. You just wonder how many are in it to make a quick buck."
A federal law prohibits paying for referrals for treatment covered by Medicaid. But patient referrals for care covered by private insurance or paid for out of pocket would most likely be regulated by the individual state, Jay said. Some, like Texas, have regulations prohibiting paid referrals in the mental health and addiction treatment field. New York regulators can penalize addiction treatment organizations if they are found to be "soliciting or receiving, or agreeing to receive, any fee" to or from a third party for the referral of a patient.".
Rep. Daniel M. Donovan Jr., a Republican who represents Staten Island and southern Brooklyn, said that he first heard about the payment offers from treatment providers a few months ago, and that he had been exploring stricter regulations.
"The issue is disturbing," said Donovan, who preceded McMahon as district attorney. "People may not be directed to the right resources for their ailments because someone is receiving compensation."
In fact, Donovan sent a letter Monday to the federal Department of Health and Human Services asking whether "the existing federal legal framework is adequate to protect addicts and their families from unscrupulous patient brokering."
While some industries, including law to real estate, have disclosure requirements for paid referrals, the drug treatment industry does not, he said.
"The victims of most con games are people who are the most vulnerable," Donovan said. "The parents of an addicted child, I am telling you from my 12 years as a DA, those parents are desperate for an answer."
In the throes of his addiction, Marco DiDonna always carried what he considered the essentials: cellphone, wallet, keys and a bottle filled with prescription pills.
DiDonna, who said he has not used drugs in more than two years, still receives one-on-one counseling every week. An addict is never cured, he said.
Now a volunteer at Carl's House, a community center on Staten Island that works with addicts and their families, DiDonna said he wants to use his own experience to help others.
When he was in treatment, DiDonna said he heard of "quick get-rich schemes" where treatment centers would pay addicts to refer their friends. Often they were 28-day for-profit programs in sunny locations, he said.
"There are these centers with 10-star amenities and zero-star care," DiDonna said.
DiDonna said he has been contacted by recruiters while volunteering, though he said he could not name them for legal reasons.
" 'I know you guys need money,' " he said, recalling what a recruiter said in a recent call. " 'If you guys need funding, we can help you out. We can put you on a $5,000 donation a month, just call me whenever you get a private-insurance person.' "
He said such pitches repel him.
"Get these marketers out of here. Get them away from Staten Island."