Supply and Demand

Supply

The recovery residence marketplace is highly fragmented and has long been “hidden in plain sight,” meaning few outsides of the addiction treatment and recovery community have known about them despite being in existence for well over a century.

The supply of recovery residences is largely unknown; however, recent efforts give us a clearer picture of the marketplace.

• In 2020, a study estimating the number of substance use disorder recovery homes in the United States (Jason, 2020) projected at least 17,900.
• Oxford House™, the largest recovery housing provider in the US, publishes an annual report and census. In 2020, Oxford House reported 2,754 homes in the US.
• NARR state affiliates report the total number of recovery residences certified. Moreover, each state affiliate publishes a director of certified recovery residences to empower consumers, referral agents, and funder choices. A list of NARR state affiliates can be found at NARRonline.org.
• A growing number of states have begun to conduct recovery housing environmental scans to inform state strategic plans. Examples include Ohio and Oklahoma.
• In 2020, the National Institute of Health (NIH) funded the Alcohol Research Group to launch the National Study of Treatment and Addiction Recovery Residences (NSTARR) project. NSTARR will: 1) Examine the availability of recovery housing in the US and describe the environments where recovery residences are located; 2) Characterize the national recovery housing landscape in terms of organizational and residence characteristics, policies, practices, programming, and service delivery orientation. NSTARR will also explore whether these characteristics vary depending on where residences are located; 3) Identify underlying patterns among recovery residences and examine the association between these patterns and existing categorizations of treatment and recovery housing; and 4) Explore organizational, residence, policy, practice, programming, and delivery orientation characteristics associated with recovery housing practices that have studies that back them up. This is referred to as evidence-based practices.

Demand

There is a critical shortage of recovery housing for Americans in or pursuing recovery (White House, 2019). “How much of a shortage, where and for whom” are questions that remain unanswered. Anecdotally, we know that the gap is most significant amongst populations with higher, more complex needs and lower financial resources and underserved communities. Nonetheless, the interest in recovery housing continues to grow due to:

• Cost-Effective Outcomes
• Shift Towards Chronic Care
• Shift Towards Public Health
• Preventing and Ending Homelessness

Cost-Effective Outcomes

Benefits associated with staying in a recovery residence include decreases in alcohol and drug use, psychiatric symptoms, and arrests, as well as increases in employment. Recovery residences can play a critical role for individuals in outpatient treatment, those exiting residential treatment, homeless individuals in early recovery, those involved in drug courts, those returning to the community from incarceration, and those who may not require residential treatment if they have a living environment that is supportive of recovery, outpatient treatment and/or mutual aid groups. Many who cannot return to a home with active drug use or a community where they used drugs find a haven in a recovery residence. Significantly, like peer RSS generally, recovery residences can help maximize the public and private investments in treatment by ensuring better long-term outcomes, by sometimes making a lower, less costly level of care possible, and in some instances, by making treatment unnecessary. (White House, 2019)

Consider that most substance use issues return from treatment or institutions to living environments that enable addictive lifestyles. While not every person seeking recovery will need or choose recovery housing, research shows many benefit from living in recovery residences. These benefits were outlined in The Role of Recovery Residences in Promoting Long-term Addiction Recovery (Jason, 2013).

Shift Towards Chronic Care

Despite addiction being a chronic illness, the US healthcare system has historically treated it with acute, episodic services. More recently, there has been a shift towards a chronic care approach that includes a continuum of care, including recovery housing.

A study conducted by the NIDA determined that 30-day treatment centers were approximately 30-35% successful in treating addictions. The same study found that if clients transitioned from residential care into some form of aftercare for six months or more, then the success rates increased to 65-70%.

• Recovery-Oriented System of Care (ROSC) – ROSC is a comprehensive, chronic care approach to mental health and substance use recovery promoted by SAMHSA. Through widespread input, SAMHSA drafted a definition of “recovery,” which includes four supportive domains: Health, Home, Purpose, and Community. Recovery housing supports recovery through all four of these domains, and in turn, recovery housing should be considered a vital resource within recovery-oriented systems of care.
• Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) – Federal legislation requires insurance companies to offer mental health and substance use benefits equal to major medical, with a few exceptions. This means that insurance companies are faced with covering multiple addiction treatment exposures. As a result, third-party payers began looking for more cost-effective approaches.
• Recovery Supports Valued – A growing body of research and interest around recovery support services (including recovery housing) as a cost-effective means of increasing recovery outcomes: improved abstinence, mental health, increased income and employment, and decreased criminal justice involvement.
• Insurance companies’ interests – To lower costs and increase outcomes, insurance companies increasingly explore housing as health care and recovery housing as part of the reimbursable continuum of care.

Shift Towards Public Health

Addiction has long been viewed as a public safety issue, but there is a growing shift to viewing it as a public health issue. Several things are driving this shift:

• Criminal Justice Reform – Overcrowding of jails and prisons with people with SUDs – All you have to do is Google the cost of jail bed days in your local or state areas to see that diverting individuals engaged in the criminal justice system who have a substance use disorder to recovery-oriented services makes economic sense.
• Opiate crisis and the broader recognition of harm reduction strategies: MAT and Naloxone. Opioid Crisis – From 1999 to 2010, opioid prescriptions quadrupled in the US, and deaths from prescription opioids have correspondingly quadrupled since 1999. A record 42,000+ people died of an opioid overdose in 2016, of which 40% involve a prescription opioid. The average cost of hospital admission for opioid overdoses increased from $58,500 to $92,400 between 2009 and 2015. This far outpaced medical inflation and is attributed to opioid overdose patients arriving in worse shape, requiring more extended stays and a higher level of treatment.
• Community-based services – Increased focus on home and community-based services. Recovery occurs in the community, not in institutions.

Preventing and Ending Homelessness

Safe and stable housing is one of the four pillars of recovery support (SAMHSA 2012), but there is a shortage of affordable housing, contributing to homelessness. People with mental and/or substance use disorders can be particularly vulnerable to homeless or precariously housed. Approximately 1 in 5 people experiencing homelessness have a chronic substance use disorder. Studies have found that leaving a person to remain chronically homeless costs taxpayers as much as $30,000 to $50,000 per year, compared to $20,000 per year to provide them with supportive housing. Depending on the level of support required, recovery housing may only cost $9,000 per year.

While HUD has identified recovery housing as an essential option for persons who choose an abstinence pathway to recovery (HUD 2015), funding policies favor housing first permanent supportive housing models, living environments that do not require abstinence. As such, they may not be safe or stabilizing places to live for individuals with a substance use disorder or families with children. While housing first models have proven effective in promoting housing retention, especially among individuals with a primary diagnosis of mental illness, evidence to support positive outcomes related to people with a primary or co-occurring substance use disorder are mixed and questionable.

If we believe there are many pathways to recovery and that recovery is a person-centered process, why would we not support someone’s choice to live in recovery housing to support their abstinence pathway? Funding policies must promote choice, including recovery housing.

Resources:

• Jason, L.A., Mericle, A.A., Polcin, D.L., & White, W.L. (in press, 2013). The Role of Recovery Residences in Promoting Long-term Addiction Recovery. American Journal of Community Psychology. Posted at www.williamwhitepapers.com
• Leonard A. Jason, Elzbieta Wiedbusch, Ted J. Bobak & David Taullahu (2020): Estimating the Number of Substance Use Disorder Recovery Homes in the United States, Alcoholism Treatment Quarterly, DOI: 10.1080/07347324.2020.1760756
• National Study of Treatment and Addiction Recovery Residences (NSTARR)
• Recovery Housing Brief, HUD, 2015
• The President’s Commission on Combating Drug Addiction and The Opioid Crisis, Final Report, White House, 2019.