Estimating the Number of Substance Use Disorder Recovery Homes in the United States

"And Now that I Feel Safe…I'm Coming Out of Fight or Flight": A Qualitative Exploration of Challenges and Opportunities for Residents' Mental Health in Substance Use Recovery Housing

Co-occurring mental health concerns are prevalent among substance use recovery housing residents. We sought to explore how residents with co-occurring mental health and substance use needs experience recovery housing. We conducted semi-structured interviews with residents (N = 92) in recovery homes across Texas and developed themes through thematic analysis. Residents note that living in a group home can exacerbate anxiety and paranoia, especially during periods of high turnover. Overwhelmingly, however, residents believe recovery housing improves their mental health. Residents use their shared lived experiences to support one another. Residents also express appreciation for the transition period offered by recovery housing, allowing them to solidify their recoveries before fully re-entering society. Participants describe recovery homes as a critical support for their co-occurring mental health and substance use concerns. These results provide key insights on how to better support mental health in recovery housing.

Establishing Quality and Outcome Measures for Recovery Housing: A Tiered Approach Supporting Service Evolution

With over one-hundred thousand drug overdose deaths in 2021, substance use disorder (SUD) is a public health crisis in the United States. Medical stabilization has been the predominant focus of SUD interventions despite low levels of retention. Consequently, national quality measures for SUD care outside the clinical continuity of care are limited. The expansion of recovery support services addressing social drivers of health outside clinical settings is needed. The current SUD quality measures are not applicable nor feasible for recovery support service providers with limited resource capacities, like the estimated 17,900 recovery housing providers nationwide. Despite widespread support for recovery housing and its documented effectiveness, no universal set of measures has been developed for widespread adoption. In this brief, a matrix of quality measures are proposed to meet the needs of recovery housing providers with various capacities to support service evolution and improve equitable SUD treatment and recovery care.

Justifying the need for a recovery related surveillance system: Exploratory focused interviews

Background and Aims

No recovery related surveillance system exists but given the evidence of effectiveness and growing supply, a house- and resident- level recovery house (RH) surveillance system could be beneficial for data collection on recovery support service (RSS) engagement, and retention; for improved standardization of RH programs and services; and for identification of outcomes associated with long-term recovery.

Methods

This study aimed to explore current data collection practices at the resident- and house- level through qualitative focus interviews of RH representatives. The 13 RH interviews were scheduled with 16 RH representative respondents.

Results

The most frequently collected resident data was at entry (92%) and departure (85%) and included demographics (n = 5), substance use history (n = 6), treatment and recovery history (n = 5), legal and correctional history (n = 6) and mental health information (n = 7). Recovery support data was collected by 85% of houses. Post-stay data was only collected by four RHs (31%).

Conclusion

These results indicate that there is a lack of standardized systematic collection, analysis, and reporting of recovery related data in the RH field. A recovery related surveillance system has the potential to fill this gap and inform and improve standard of resident care to support long-term recovery from substance use disorder.

Spiritual Awakening in 12-Step Recovery: Impact Among Residential Aftercare Residents

Spiritually-based interventions in the form of 12-step programs are frequently offered as a part of substance use treatment programs in the United States. Programs based in the 12 steps guarantee that by working their program, an individual will undergo a process of transformation labeled a spiritual awakening. However, the impact of this experience on recovery factors and treatment adherence is unclear. The current study investigated adult residents (n = 115) who experienced a spiritual awakening attributed to 12-step group affiliation during their stay at residential aftercare facilities for substance use disorder. Self-efficacy and hope were greater for individuals who experienced a spiritual awakening versus those persons who did not experience awakening. Awakening was associated with greater affiliation to AA and decreased negative exit from the facility. Results revealed the potential for an awakening to improve treatment behavior and outcomes in a residential environment, as well as benefit an individual's personal recovery resources. Further theoretical and clinical implications are discussed.

State-Level Support for Recovery Housing: Results from a National Collaborative Study of U.S. Single State Agencies

Single State Agencies (SSAs) are responsible for managing the publicly funded alcohol and other drug prevention, treatment, and recovery service system. Recovery housing (RH) is an important recovery support service (RSS) for individuals experiencing substance use disorder (SUD). Despite its effectiveness, information on state utilization and support is limited. To assess state-level support for RH and its incorporation within the SSA-managed SUD service systems, we administered a survey with SSAs in the 50 United States and the District of Columbia. In total, 48 out of the 51 SSAs responded, yielding a 94% response rate. Findings indicate strong state-level support for RH in terms of it being an integral RSS (98%), part of state-level strategic plans (73%) and prioritized for funding (87.5%). States are making progress to formalize RH with 68% reporting RH had been defined formally or within their agency. However, activities around understanding the capacity and need for RH are limited, with 44% indicating a needs assessment had not been conducted. At the same time, states perceive RH as a priority RSS, with growing recognition of its positive impact on long-term SUD recovery. This research identifies the opportunities for stakeholders to further evolve and expand RH at the federal, state, and local levels.

Complex Contexts within Oxford Houses: Psychiatrically Comorbid Social Networks

This study aimed to explore whether there are differences between Oxford House recovery home residents with psychiatric comorbidity in their ability to form, maintain, and dissolve loaning ties and seek advice, when compared to Oxford House residents without comorbidity, and if differences do exist, are those ties mono- or bi-directional. Findings indicated unique interdependencies among individuals with psychiatric comorbidity for advice seeking, loaning, and recovery factor scores. The results of this investigation are consistent with the dynamic systems theory conceptions of community-based recovery. Recovery homes provide access to social capital, via the residents' social network, by facilitating recovery-oriented social exchanges, which can lead to changes to the recovery home social dynamics. Upon interpreting the results of this study, components from a dynamic systems theory emerged (e.g., explaining the processes that preserve or undermine the development, maintenance, and dissolution of a network); and provided a framework for interpreting the loaning, advice-seeking, and the latent recovery factor networks and their relationship with psychiatric comorbidity. A deeper understanding of the interplay among these dynamics is described providing an understanding of how Oxford House recovery homes promote long-term recovery in a shared community setting for those with high psychiatric comorbidity.

Social Model Recovery and Recovery Housing

Recovery housing is an important resource for many in their recovery from alcohol and other drug use disorders. Yet providers of recovery housing face a number of challenges. Many of these challenges are rooted in stigma and bias about recovery housing. The ability to describe the service and purported mechanisms of action vis-a-vis an overarching framework, approach, or orientation could also go a long way in adding credence to recovery housing as a service delivery mechanism. Several aspects of social model recovery are often explicitly built or organically reflected in how recovery housing operates, yet describing recovery housing in these terms often does little to demystify key features of recovery housing. To more fully cement social model recovery as the organizing framework for recovery housing this article aims to: review the history, current status, and evidence base for social model recovery; comment on challenges to implementing the social model in recovery housing; and delineate steps to overcome these challenges and establish an evidence base for social model recovery housing.

House Level Latent Classes as Predictors of Recovery and Evictions

The current study explored whether substance abuse recovery houses could be categorized into meaningful classes, which might be associated with house evictions as well as changes in individual-level recovery capital. A total of 602 individuals from 42 recovery homes were followed for up to 6 data collection periods over 2 years. House level latent class analyses were based on house-level data. A 3-class model fit very well (entropy 0.94) and better than a 2-class model. Class profiles examined concurrent (averaged across waves 1 and 2) house and resident-level variables (e.g., gender, race, age, employment, education). Class was then used to prospectively predict outcomes of the hazard of eviction and improvement in a recovery index over waves 3-6. One latent class representing 45% of the recovery houses had the highest density of members willing to loan, able to pay their rent, active involvement in outside chapter activities-this group of houses had the best outcomes including the lowest eviction rate and highest mean recovery factor. The two other classes had higher eviction rates, with one having the lowest density of friendship, selectivity of residents, and ability to pay rent. The other of the higher eviction-rate classes surprisingly had the highest density of friendship and advice seeking, but the lowest density of willingness to loan. These findings suggest that there are meaningful differences in types of recovery homes, and that house characteristics appear to influence recovery changes and eviction outcomes.

Benefits of Continuing Linkages to Recovery Homes Following Departure

There is a need to better understand social mechanisms that increase or decrease successful departures from recovery homes. A prior study found that involuntary departure as well as one’s personal social capital were important to sustaining recovery following the departure from recovery homes. Little is known about what house contextual or interpersonal factors explain who successfully exits these recovery settings. In the present study, we examined continued linkages to Oxford House recovery homes following departure, using questions concerning 1. Continuing to visit their previous recovery home, 2. Maintaining contact with the Oxford House Organization, 3. Continuing to see people they saw as residents following departure, and 4. Continuing to attend the same AA/NA meetings that had been attended as an Oxford House resident. Residents with continued linkages to the recovery home were found to evidence significant increases in self-efficacy as well as abstinence following departure. For those that remained most linked by answering all four questions positively, 95% remained abstinent following leaving the recovery homes. The implications of these findings are discussed in terms of possible changes in constructing a new social identity.

Financial landscape of recovery housing in the United States

Recovery housing provides substance-free living environments that use peer-support to empower individuals in recovery from substance use disorder. This study estimated the total revenue of the recovery housing industry from recovery houses, nationwide.

Using survey data collected in June and July of 2020, we calculate the total revenue of the recovery housing industry and determine the share of revenue that comes from different sources for rural and nonrural houses.

We find that individual recovery houses operate with an annual revenue of $250,000 and the whole industry accounts for $4.5 billion annually. COVID-19 has reduced industry revenue by 4%. Rural and nonrural houses differ significantly in their sources of revenue.

Our results suggest that COVID-19 reduced the size of the recovery housing industry. Houses in nonrural regions may need more federal support due to the relatively high reliance on resident fees, which may be unreliable during COVID-19.

The role of recovery housing during outpatient substance use treatment

BACKGROUND

Recovery housing generally refers to alcohol- and drug-free living environments that provide peer support for those wanting to initiate and sustain recovery from alcohol and other drug (AOD) disorders. Despite a growing evidence base for recovery housing, relatively little research has focused on how recovery housing may benefit individuals accessing outpatient substance use treatment.

METHODS

Using administrative and qualitative data from individuals attending an outpatient substance use treatment program in the Midwestern United States that provides recovery housing in a structured sober living environment, this mixed methods study sought to: (1) determine whether individuals who opted to live in structured sober living during outpatient treatment (N = 138) differed from those who did not (N = 842) on demographic, clinical, or service use characteristics; (2) examine whether living in structured sober living was associated with greater likelihood of satisfactory discharge and longer lengths of stay in outpatient treatment; and (3) explore what individuals (N = 7) who used the structured sober living during outpatient treatment were hoping to gain from the experience.

RESULTS

Factors associated with the use of recovery housing during outpatient treatment in multivariate models included gender, age, and receiving more services across episodes of care. Living in structured sober housing was associated with greater likelihood of satisfactory discharge and longer length of stays in outpatient treatment. Focus group participants reported needing additional structure and recovery support, with many noting that structure and accountability, learning and practicing life, coping, and other recovery skills, as well as receiving social and emotional support from others were particularly beneficial aspects of the sober living environment.

CONCLUSIONS

Findings underscore the importance of safe and supportive housing during outpatient substance use treatment as well as the need for future research on how housing environments may affect engagement, retention, and outcomes among individuals accessing outpatient substance use treatment.

Individual and Contextual Protective and Risk Characteristics for Residents of Recovery Homes

Some recovery homes have facilitating relationships and organizational characteristics, and there are also social capital differences among residents of these recovery homes. It is important to better understand the impact of protective and risk individual and house factors on recovery issues among residents of these community-based settings. Individuals from 42 recovery homes were followed for up to six data collection periods over two years. House level latent class analyses tapped relationship and organizational domains and individual level latent class analyses were from derived from elements of recovery capital. Houses that manifested protective factors provided most residents positive outcomes, except those with elevated self-esteem. Houses that were less facilitating had more negative exits, except for those residents who were the highest functioning. Both individual and house characteristics are of importance in helping to understand risk factors associated with eviction outcomes for residents in recovery homes.

Latent profile analysis in recovery homes: A single quantitative dimension captures most but not all of the important details of the recovery process

Background: Our study explored whether latent classes adequately represented the social capital recovery indicators at the resident level and whether latent class membership predicted subsequent exits from the recovery homes. Method: Our sample included about 600 residents in 42 recovery homes. Over a 2-year period of time, every 4 months, data were collected on eight elements of recovery capital. Results: We found 5 latent classes were optimal for representing 8 elements of recovery capital. Representing 79% of the sample, 3 of the 5 latent class profiles of the means of the 8 recovery indicators were roughly parallel and differed only in level, but the remaining 2 latent class profiles, representing 21% of the sample, were not parallel to the first 3, suggesting that a single quantitative dimension of perceived recovery may capture most but not all of the important details of the recovery process. Next, using longitudinal data from homes, the distal outcomes of resident eviction and voluntary exit were found to be related to latent class membership. Resident level pre-existing predictors (e.g., employment status, educational attainment, gender, Latinx ethnicity) and house level pre-existing predictors (e.g., financial health, poverty level of typical population served, new resident acceptance rate) significantly discriminated the classes. In a model that combined both pre-existing predictors and distal outcomes, latent class membership was still the strongest predictor of evictions controlling for the pre-existing predictors. Conclusions: These classes help to clarify the different aspects of the recovery latent score, and point to classes that have different ethnic and gender characteristics as well as outcomes in the recovery homes. For example, the high levels of self-confidence found in class 3 suggest that Latinx might be at higher risk for having some difficulties within these recovery communities.

An examination of abstinence social support among recovery home residents with psychiatric comorbidity

BACKGROUND

Although social support is a resource that helps persons in their recovery from substance use disorders, it is not clear whether specific types buffer the effects of stress and optimize outcomes for those with psychiatric comorbidity. This investigation examined two types of social support in relation to lengths of stay to identify mechanisms related to retention among individuals with psychiatric comorbidity living in community-based settings.

METHODS

Baseline rates of social support (abstinence specific and general types) and stress were examined in relation to follow-up lengths of stay (at four-months and beyond) among individuals (N = 368) with psychiatric comorbidity (n = 90) and no psychiatric comorbidity (n = 278) living in community-based settings (Oxford Houses) in the U.S. The psychiatric severity index of the Addiction Severity Index was used as a proxy measure of psychiatric comorbidity. Moderated mediation analyses were conducted to test the potential mediating effects of abstinence social support and general social support on the relationship between stress and lengths of stay, and whether these were influenced by psychiatric comorbidity.

RESULTS

A full mediating effect was observed for abstinence social support for residents with psychiatric comorbidity, whereas a partial mediating effect for general social support was observed for all residents.

CONCLUSIONS

Findings demonstrate qualities of social support have differential effects, substantiating the notion that specific components of social support optimize outcomes for those with psychiatric comorbidity living in recovery homes.

Willingness to Lend Resources is Associated with Increases in Recovery and Participation in Community Activities

Recovery homes may facilitate individuals with substance use disorders re-integration back into community settings by providing friendship, resources, and advice. Participants of the current study were over 600 residents of 42 Oxford House recovery homes. Findings indicated that willingness to share resources in the form of loans was associated with higher levels of house involvement in recovery home chapters. Active involvement in house and community affairs may influence more recovery within homes or may be an indicator of houses with residents with more capacities and skills for positive long-term health outcomes. Such findings suggest that recovery is a dynamic process with multiple ecological layers embedding individuals, their immediate social networks, and the wider community.

Dynamic Interdependence of Advice Seeking, Loaning, and Recovery Characteristics in Recovery Homes

Recovery homes in the US provide stable housing for over 200,000 individuals with past histories of homelessness, psychiatric co-morbidity and criminal justice involvement. We need to know more about how these settings help those remain in recovery. Our study measured advice seeking and willingness-to-loan relationships and operationalized them as a dynamic multiplex social network-multiple, simultaneous interdependent relationships--that exist within 42 Oxford House recovery homes over time. By pooling relationship dynamics across recovery houses, a Stochastic Actor-Oriented Modeling (SAOM) framework (Snijders et al., 2010) was used to estimate a set of parameters governing the evolution of the network and the recovery attributes of the nodes simultaneously. Findings indicated that advice and loan relationships and recovery-related attitudes were endogenously interdependent, and these results were affected exogenously by gender, ethnicity, and reason for leaving the recovery houses. Prior findings had indicated that higher advice seeking in recovery houses was related to higher levels of stress with more negative outcomes. However, the current study found that recovery is enhanced over time if advice was sought from residents with higher recovery scores. Our study shows that social embedding, i.e. one's position in relationship networks, affects recovery prospects. More specifically, the formation of ties with relatively more recovered residents as an important predictor of better outcomes.

Recovery homes coping with COVID-19

Recovery homes are a widespread community resource that might be utilized by some individuals with substance use disorders (SUD) and COVID-19. A growing collection of empirical literature suggests that housing can act as a low-cost recovery support system which could be effective in helping those with SUD sustain their recovery. Such settings could be already housing many residents affected by COVID-19. Many of these residents are at high risk for COVID-19 given their histories of SUD, homelessness, criminal justice involvement, and psychiatric comorbidity. Stable housing after treatment may decrease the risk of relapse to active addiction, and these types of settings may have important implications for those with housing insecurity who are at risk for being infected with COVID-19. Given the extensive network of community-based recovery homes, there is a need to better understand individual- and organizational-level responses to the COVID-19 pandemic among people in recovery homes as well as those managing and making referrals to the houses. At the present time, it is unclear what the effects of COVID-19 are on recovery home membership retention or dropout rates. This article attempts to provide a better understanding of the possible impact of COVID-19 on the infected and on recovery resources in general.

Medication assisted therapy and recovery homes

There is a need to better understand improved recovery supportive services for those on Medication Assisted Treatment (MAT) for opioid use disorder (OUD) and, at the same time, enhance the available treatment interventions and positive long-term outcomes for this vulnerable population. A growing empirical literature supports the assertion that improved access to housing and recovery support is a low-cost, high-potential opportunity that could help former substance users who are utilizing MAT to sustain their recovery. Recovery home support could serve the populations that need them most, namely servicing a significant number of the enrolled in MAT programs. The two largest networks of recovery homes are staff run Traditional Recovery Homes (TRH) and self-run Oxford House Recovery Homes (OH). There is a need to better understand how substance users on MAT respond to recovery homes, as well as how those in recovery homes feel toward those on MAT and how any barriers to those utilizing MAT may be reduced. Recovery may be an outcome of the transactional process between the recovering individual and his/her social environment. In particular, how recovery houses can help people on MAT attain long-term recovery.

Context Matters: Home-level But Not Individual-Level Recovery Social Capital Predicts Residents' Relapse

The purpose of this study is to contribute to the literature on the prediction of substance use relapse, using sophisticated systems' approaches to individuals and their contexts. In the current study of 42 recovery homes, we investigated the construct of social capital from the perspective of both recovery home residents and the house level. A confirmatory factor analysis found a latent recovery factor (including elements of recovery capital, comprising resources such as wages, self-efficacy, stress, self-esteem, quality of life, hope, sense of community, and social support) at both the individual and the recovery house level. Next, using longitudinal data from homes, an individual's probability of relapse was found to be related to house rather than individual-level latent recovery scores. In other words, an individual's probability of relapse was primarily related to the average of the "recoveries" of his or her recovery home peers, and not of his or her own personal "recovery" status. The finding that resident relapse is based primarily upon the total recovery capital available in the homes highlights the importance of the social environment for recovery.

The Emergence, Role, and Impact of Recovery Support Services

Various community recovery support services help sustain positive behavior change for individuals with alcohol and drug use disorders. This article reviews the rationale, origins, emergence, prevalence, and empirical research on a variety of recovery support services in U.S. communities that may influence the likelihood of sustained recovery. The community recovery support services reviewed include recovery high schools, collegiate recovery programs, recovery homes, recovery coaches, and recovery community centers. Many individuals are not provided with the types of environmental supports needed to solidify and support their recovery, so there is a need for more research on who may be best suited for these services as well as when, why, and how they confer benefit.

Reducing health disparities among black individuals in the post-treatment environment

An important step in reducing health disparities among racial and ethnic minorities with substance use disorders involves identifying interventions that lead to successful recovery outcomes for this population. The current study evaluated outcomes of a community-based recovery support program for those with substance use disorders. Participants included 632 residents of recovery homes in three states in the US. A multi-item recovery factor was found to increase over time for these residents. However, rates of improvement among Black individuals were higher than for other racial/ethnic groups. Black Americans perhaps place a higher value on communal relationships relative to all other racial/ethnic groups, and by adopting such a communitarian perspective, they might be even more receptive to living in a house that values participation and involvement. The implications of these findings for health disparities research are discussed.

Sheltering in place and social distancing when the services provided are housing and social support: The COVID-19 health crisis and recovery housing

Recovery housing is a vital service for individuals with substance use disorders who need both recovery support and safe housing. Recovery housing is a residential service, and it relies heavily on social support provided by peers both within the residence and in outside mutual help groups. As such, efforts to keep residents safe from SARS CoV-2, the virus that causes the illness COVID-19, pose a number of challenges to social distancing. Further, residents are some of the more vulnerable individuals in recovery. They are more likely to have co-occurring health conditions that place them at risk for COVID-19, and they often have risk factors such as employment in low-wage jobs that increase their potential for negative economic impacts of the pandemic. Since most recovery housing operates outside formal substance use treatment, residents who pay out-of-pocket for services largely support these residences. Comprehensive support for those using, as well as those providing and ensuring the quality of recovery housing, is needed to ensure the viability of recovery housing.

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Recovery housing provides recovery support in a residential setting, serving highly-vulnerable individuals with substance use disorders.

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Efforts are underway to develop best practices for protecting residents and the peer-support community from COVID-19.

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Most recovery residences are not part of the formal substance use treatment system.

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Without adequate support for recovery housing, those who provide this service will be hampered in their ability to respond to increased resident needs.