A Nationwide Survey Study of Recovery Community Centers Supporting People in Recovery from Substance Use Disorder

Abstract

Objective:

The medical community has become aware of its role in contributing to the opioid epidemic and must be part of its resolution. Recovery community centers represent a new, under-utilized component of recovery support.

Methods:

Online national survey of all RCCs identified in the United States with use of US Census ZIP code tabulation area data to describe the communities they serve.

Results:

Residents of areas with RCCs were more likely to be Black (16.5% vs. 12.6% nationally, p=0.005), and less likely to be Asian (4.7% vs. 5.7%, p=0.005), American Indian, or Alaskan Native (0.6% vs. 0.8%, p=0.03), or live rurally (8.5% vs. 14.0%, p<.0001). More than half of RCCs began operations within the past five years. RCCs were operated, on average, by 8.8 paid and 10.2 volunteer staff; each RCC served a median of 125 individuals per month (4–1,500). RCCs successfully engaged racial/ethnic minority groups (20.8% Hispanic; 22.5% Black) and young adults (23.5% < 25 years of age). RCCs provide addiction-specific support (e.g., mutual help, recovery coaching), and assistance with basic needs, social services, technology access, and health behaviors. Regarding medications for opioid use disorder (MOUDs), RCC staff engaged members in conversations about MOUDs (85.2%) and provided direct support for taking MOUD (77.0%). One third (36.1%) of RCCs reported seeking closer collaboration with prescribers.

Conclusion:

RCCs are welcoming environments for people who take MOUDs. Closer collaboration between the medical community and community-based, peer-led RCCs may lead to significantly improved reach of efforts to end the opioid epidemic.

Introduction

The opioid epidemic is an ongoing national public health emergency in the U.S., claiming over 80,816 lives in 2021 alone (75% of the overall 107,622 drug overdose deaths that year), the deadliest year yet measured in this epidemic.¹ The COVID-19 pandemic has substantially worsened the opioid epidemic,^2,3 and has further widened health disparities, with greatest increases in opioid-related overdose deaths occurring among Black Americans.⁴ Increasing access to treatment and recovery support services is a top priority of the U.S. Department of Health and Human Services.⁵

The medical community has become aware of its role in contributing to the opioid epidemic,⁶ and must be part of its resolution. Currently, the gold-standard treatment for opioid use disorder (OUD) is long-term treatment using Food and Drug Administration (FDA)-approved medications (i.e., methadone, buprenorphine, and naltrexone). Yet, lack of engagement with, and early discontinuation of, medications for opioid use disorder (MOUDs), represent critical barriers to the effectiveness of MOUDs.^7–13 A cascade of care model has been proposed that highlights the need to intervene at multiple levels: prevention, identification, treatment, and recovery.¹⁴ To date, research and medical thinking have focused largely on one level (i.e., treatment).¹⁵ This lens needs to be widened if we are to end the opioid epidemic.

In this paper, we focus on recovery. Recovery is multi-faceted concept describing both the process and outcome of overcoming problematic substance use. Numerous organizations and agencies have undergone the process of defining recovery, emerging with highly similar definitions.¹⁶ The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as: “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential,” and notes that there are “four major dimensions that support a life in recovery: health, home, purpose, and community.”¹⁷ This conceptualization is markedly different from the formal medical view, where remission from substance use disorder is conceptualized in the DSM-5 as living without experiencing substance use disorder criteria (except craving, which can persist long into remission) for specific lengths of time (i.e., ≥3 to <12 months for ‘early remission’, and ≥12 months for ‘sustained remission’).¹⁸ This definition lacks the focus on wellness evident in definitions of recovery.

The U.S. National Drug Control Strategy highlights the importance of recovery support services in engaging and supporting people throughout all stages of addiction recovery.¹⁹ Millions of Americans have successfully recovered from substance use disorder (SUD), only a fraction of whom (28%) participate in formal treatment.²⁰ The U.S. National Drug Control Strategy specifically highlighted recovery community centers (RCCs) as an emerging and important new component of recovery-oriented systems of care²¹ that, until recently, were comprised solely of professional treatment and mutual-help organizations.²² RCCs were originally conceptualized as “recovery-oriented sanctuaries anchored in the hearts of communities”.²³ The actual location of RCCs varies from community to community due to a number of factors, including real-estate costs, openness of communities to allow RCCs to operate in specific settings, and rurality of setting. RCCs provide services directly addressing substance use alongside services that address basic material, instrumental, and social needs for housing, income, healthcare, transportation, childcare, and social support. Beyond being a service-oriented place, RCCs also connect people for social-leisure activities, and play an active role in dismantling stigma, a critical barrier to engaging people in OUD care,²⁴ by putting a visible, de-stigmatizing face on recovery, and engaging in community outreach activities.²⁵

RCCs could be invaluable partners to the medical community in supporting people with OUDs. Historically, however, there has been an ideological misfit between MOUDs and recovery support services. Some peer-led organizations have upheld a firm stance against the use of opioid agonist medications to achieve abstinence from substance use. To this day, Narcotics Anonymous (NA), for example, advises MOUD prescribers their patients “may be met […] sometimes by members who express strong opinions about medically assisted treatment.”²⁶ Despite findings that demonstrate potentially additive, salutary effects of using medications and attending NA, research has highlighted that in many settings NA participants who choose to take opioid agonist medications cannot count their days taking them as days of sobriety and cannot hold service positions in the fellowship.²⁷ Negative attitudes towards MOUDs were also observed in other recovery support services, which have grown out of the 12-Step tradition, such as Oxford Houses.²⁸ These diverging philosophies have led to a divided effort, where peer-led groups are only rarely connected with medication treatment.²⁹

Recovery community centers take a different stance on MOUDs. RCCs have grown out of the recovery movement, and thereby are guided by a different guideline: “There are many pathways of long-term recovery, and all are cause for celebration.” The Association of Recovery Community Organizations (ARCO), which connects recovery community centers nationwide, states on its official website that “medication-assisted recovery, combined with counseling and behavioral therapies, is an effective pathway to treat substance use disorders and to prevent opioid overdose.” This stance provides fertile ground for RCCs and medical settings to collaborate.

To provide insight into the scope and services of RCCs, we conducted the first nationwide survey of all known RCCs. Within this survey, we specifically addressed attitudes and practices regarding MOUDs.

Methods

Sample

RCCs are funded by various agencies and through philanthropy,³⁰; thus, there is no central, all-encompassing structure for them. The largest organization providing accountability, visibility, standardization, and quality control is the “Association of Recovery Community Organizations” (ARCO). To join ARCO, RCCs must go through a certification process. This process ensures that ARCO RCCs are non-profit organizations; are led and governed by the recovery community; have a primary focus on recovery from SUDs; use grassroots community engagement strategies; use a participatory process in the running of their center; provide primarily peer as opposed to professional-delivered recovery support services; welcome all pathways to recovery (including non-abstinence pathways); use diverse, equitable, and inclusive policies, practices and services; use recovery friendly language; adhere to a code of ethics for paid and volunteer staff.³¹ For this study, we included all RCCs that fit the following definition: “Brick and mortar places located within the heart of a community that serve as a central recovery hub by providing a variety of support services for people in or seeking recovery.”

To identify all RCCs nationwide (see Supplementary Figure 1), we started with all RCCs known to our team: 113 RCCs who were ARCO members during the study period (9/1/2021 – 8/9/2022); 25 RCCs funded by the Commonwealth of Massachusetts during the study period; and 14 RCCs in the northeastern region of the U.S. that we were familiar with through our prior research.^30,32,33 We then used our NIDA-funded network to identify more RCCs, yielding an additional 94 RCCs.

Of the identified 246 RCCs, we excluded RCCs with no web presence or phone number (n=12), RCCs that had closed (n=3), and organizations that did not meet our definition of RCCs (n=33), as indicated by RCC staff via survey (n=8), email and/or phone (n=12), or by information displayed on the organization’s website (n=13). Of the remaining 198 verified RCCs, 122 (62%) completed our survey. For all 198 RCCs, we used their publicly available physical address in combination with 2021 U.S. Census data³⁴ to describe their setting in terms of rurality, race, and ethnicity.

Procedure

Study staff sent email invitations to directors of RCCs, followed up via phone calls on three or more different days. To engage in the survey, RCC directors (n=101) or their delegates (n=21; e.g., center manager, associate director, founder, director of program) had to click “yes” to an item presenting our definition of RCCs, followed by the question “Does this describe your center well?”. The Mass General Brigham IRB reviewed and approved all study procedures. RCC leadership were offered $50 to complete the survey; 41 (34%) opted out of remuneration.

Measures

Area-level US Census data.

Using the publicly listed addresses of the identified RCCs, we retrieved ZIP code tabulation area (ZCTA) data from the U.S. Census database regarding three variables: rurality, race, and ethnicity. These data provide the number of residents within a ZCTA who belong to distinct categories. These categories were as follows: rurality (urban, rural), race (White, Black, American Indian or Alaskan Native, Asian, Native Hawaiian, and Other Pacific Islander, some other race, two or more races); and ethnicity (Hispanic/Latino, not). From these data, we calculated the percentage of residents belonging to each group in each ZCTA. The 198 RCCs were located in 193 different ZIP codes.

Survey.

The survey served two goals: (1) to gain insight into the types of RCCs that exist, and the communities which they serve; (2) to gain feedback from RCC leadership about potential outcome measures that could be used to capture the positive impact RCCs make on the individuals and communities they serve. This paper focuses exclusively on Part 1.

RCC logistics, footprints, model of care, and demographics (Table 1) were assessed with multiple choice items and text entry fields. For demographics, RCC directors estimated the percentage of RCC members per given category for age, gender, race, and ethnicity. The online survey alerted them if these percentages did not add up to 100%. For RCC services (Table 2), RCC directors used a checklist to indicate the services their RCC provided. This list of services was created in our prior collaboration with RCCs in the northeastern region of the US.^30,32,33 Next, RCC directors used a checklist to indicate the type of organizations and systems they connect with in fulfilling their mission; a follow-up question then presented the same list and asked, “Do you wish that your RCC had more and/or better direct linkages to any of the following?” (Table 3). Finally, RCC directors were asked to provide feedback on their RCC’s approach to SUD medication treatment in general (“How open is your RCC to medication-assisted treatment?”, rated on a 1–5 scale (1 = ”not open at all”, 5 = ”extremely open”), and medications for opioid use disorder (MOUD) specifically (“How does your RCC handle medications for opioid use disorder? Select ALL that apply”; response options shown in Table 4).

Table 1 -.

RCC Logistics, Footprints, Model of Care, and Demographics

	Total		ARCO		Other RCCs		Group
	n=122		n=57		n=65		Difference
	M / %	(SD/n)	M / %	(SD/n)	M / %	(SD/n)	p
RCC Logistics
Number of years in operation	7.7	(7.3)	9.8	(7.4)	5.8	(6.8)	<0.003
Number of paid staff	8.8	(10.5)	12.2	(13.0)	5.8	(6.3)	<0.001
Number of volunteer staff at your RCC:	10.2	(11.5)	12.3	(14.3)	8.4	(7.9)	0.06
Provides support for (% of RCCs)
Alcohol problems	100.0	(122)	100.0	(57)	100.0	(65)
Drug problems	100.0	(122)	100.0	(57)	100.0	(65)
Other addictions	69.7	(85)	66.7	(38)	72.3	(47)	0.50
Mental health problems	67.2	(82)	75.4	(43)	58.5	(39)	0.07
RCC Footprints (in medians, due to skew)
Number of RCC members last year	500		675		500		0.76
Number of active RCC members last month	125		128		100		0.56
RCC Model of Care (in %)
A social place where people go to meet and spend time with peers	77.0	(94)	79.0	(45)	76.9	(49)	0.64
A service-oriented place where people use services hosted by the RCC	87.7	(107)	93.0	(53)	84.6	(54)	0.10
An information-oriented place where people are connected with resources and learn more about recovery	91.0	(111)	89.5	(51)	92.3	(60)	0.59
RCC Demographics (estimated by RCC director)
Age (% of RCC members in each age group)
<25 years:	23.5	(17.1)	26.6	(18.9)	20.9	(15.0)	0.07
25–59 years:	63.3	(17.7)	62.5	(18.9)	63.9	(16.8)	0.68
60+ years:	13.0	(10.9)	11.3	(7.0)	14.4	(13.2)	0.13
Gender (% of RCC members in each group)
Female:	42.7	(12.7)	44.8	(13.7)	40.9	(11.5)	0.10
Male:	55.3	(12.9)	53.2	(13.8)	57.1	(11.9)	0.11
Other:	2.1	(3.7)	2.0	(3.6)	2.1	(3.8)	0.90
Race (% of RCC members in each group)
American Indian or Alaskan Native:	2.4	(4.1)	2.7	(4.3)	2.3	(4.0)	0.62
Asian:	1.6	(2.8)	1.5	(2.1)	1.7	(3.3)	0.65
Black / African American:	22.5	(20.8)	24.4	(21.8)	20.7	(19.9)	0.35
Native Hawaiian or Pacific Islander:	1.2	(6.0)	0.7	(1.5)	1.7	(8.1)	0.40
White:	62.8	(24.2)	59.7	(24.1)	65.6	(24.1)	0.19
More than one race:	10.5	(10.9)	11.6	(12.7)	9.6	(9.1)	0.34
Ethnicity (% Hispanic)	20.8	(20.9)	17.8	(17.8)	23.5	(23.1)	0.15

Table 2 -.

RCC Services

	Total		ARCO		Other RCCs		Group
	n=122		n=57		n=65		Difference
	%	(n)	%	(n)	%	(n)	p
Support group meetings
”All Recovery” meetings	72.1	(88)	75.4	(43)	69.2	(45)	0.45
Peer-facilitated recovery support groups (e.g., relapse prevention groups)	89.3	(109)	91.2	(52)	87.7	(57)	0.53
Mutual-help groups (e.g., Alcoholics Anonymous)	70.5	(86)	68.4	(39)	72.3	(47)	0.64
Mental health support (e.g., dual diagnosis support groups)	54.1	(66)	59.6	(34)	49.2	(32)	0.25
Recovery Coaching	82.8	(101)	89.5	(51)	76.9	(50)	0.07
Opioid and/or harm reduction services
Medication-assisted treatment (MAT) support (e.g., Pathway Guide, MARS group)	42.6	(52)	49.1	(28)	36.9	(24)	0.17
NARCAN training and/or distribution	84.4	(103)	80.7	(46)	87.7	(57)	0.29
Technology/internet access (e.g., use of center computers, printers, fax)	73.0	(89)	63.2	(36)	81.5	(53)	0.02
Assistance with basic needs and social services
Employment assistance (e.g., job or computer skills, resume writing, CORI support)	72.1	(88)	70.2	(40)	73.8	(48)	0.65
Basic needs assistance (e.g., access to food, clothing, transportation)	72.1	(88)	66.7	(38)	76.9	(50)	0.21
Family support services (e.g., family/parent education or support groups)	66.4	(81)	63.2	(36)	69.2	(45)	0.48
Housing assistance	63.9	(78)	63.2	(36)	64.6	(42)	0.87
Education assistance	53.3	(65)	50.9	(29)	55.4	(36)	0.62
Financial services	36.9	(45)	36.8	(21)	36.9	(24)	0.99
Health insurance education	36.1	(44)	33.3	(19)	38.5	(25)	0.56
Legal assistance	24.6	(30)	19.3	(11)	29.2	(19)	0.20
Childcare services	8.2	(10)	5.3	(3)	10.8	(7)	0.27
Assistance with health behaviors
Health, exercise, and nutrition programs (e.g., fitness classes)	61.5	(75)	59.6	(34)	63.1	(41)	0.70
Smoking cessation support	17.2	(21)	14.0	(8)	20.0	(13)	0.38
Facilitation of substance-free recreational activities
Recreational/social activities (e.g., substance free social events)	82.0	(100)	78.9	(45)	84.6	(55)	0.42
Expressive arts (e.g., arts/craft groups, music, poetry)	65.6	(80)	49.1	(28)	80.0	(52)	0.00
Opportunity to volunteer / “give back” to the center	89.3	(109)	89.5	(51)	89.2	(58)	0.97
Recovery advocacy outreach and opportunities (e.g., community, regional, statewide events)	84.4	(103)	87.7	(50)	81.5	(53)	0.35

Table 3 -.

Organizations and systems RCCs connect with in fulfilling their mission

	Total		ARCO		Other RCCs		Group
	n=122		n=57		n=65		Difference
	M / %	(SD/n)	M / %	(SD/n)	M / %	(SD/n)	p
Does your RCC currently have linkages to any of the following?
Medical centers	80.3	(98)	78.9	(45)	81.5	(53)	0.72
Substance use disorder clinics	88.5	(108)	87.7	(50)	89.2	(58)	0.79
Clinics/prescribers who prescribe medication for substance use disorder	86.1	(105)	84.2	(48)	87.7	(57)	0.58
Behavioral treatment (individual/group therapy)	84.4	(103)	86.0	(49)	83.1	(54)	0.66
Emergency departments	72.1	(88)	73.7	(42)	70.8	(46)	0.72
Churches or other religious centers	72.1	(88)	73.7	(42)	70.8	(46)	0.72
Sober Homes	85.2	(104)	89.5	(51)	81.5	(53)	0.22
Criminal legal system (originally called “justice system” in survey)	78.7	(96)	80.7	(46)	76.9	(50)	0.61
Other non-RCC service/organization	31.1	(38)	29.8	(17)	32.3	(21)	0.77
Do you wish that your RCC had more and/or better direct linkages to any of the following? Select ALL that apply.
Medical centers	33.6	(41)	36.8	(21)	30.8	(20)	0.48
Substance use disorder clinics	29.5	(36)	28.1	(16)	30.8	(20)	0.74
Clinics/prescribers who prescribe medication for substance use disorder	36.1	(44)	33.3	(19)	38.5	(25)	0.56
Behavioral treatment (individual/group therapy)	27.9	(34)	29.8	(17)	26.2	(17)	0.65
Emergency departments	33.6	(41)	28.1	(16)	38.5	(25)	0.23
Churches or other religious centers	18.9	(23)	21.1	(12)	16.9	(11)	0.56
Sober Homes	29.5	(36)	35.1	(20)	24.6	(16)	0.21
Justice system	24.6	(30)	17.5	(10)	30.8	(20)	0.09
Other non-RCC service/organization	10.7	(13)	7.0	(4)	13.8	(9)	0.22

Table 4 -.

RCC attitudes towards medication assisted recovery

	Total		ARCO		Other RCCs		Group
	n=122		n=57		n=65		Difference
	M / %	(SD/n)	M / %	(SD/n)	M / %	(SD/n)	p
Openness of RCC to medication-assisted treatment (scale 1–5)
Average score (on 1–5 scale)	4.6	(0.7)	4.6	(0.8)	4.6	(0.7)	0.78
Percent of RCCs indicating “extremely open”	68.0	(83)	64.9	(37)	70.8	(46)	0.59
RCC’s handling of medications for opioid use disorder (MOUDs)
Provides direct support for MOUDs (e.g., providing information)	77.0	(94)	75.4	(43)	78.5	(51)	0.69
Staff engage members in conversations about MOUDs	85.2	(104)	86.0	(49)	84.6	(55)	0.83
RCC works directly with clinical sites providing MOUDs	63.9	(78)	66.7	(38)	61.5	(40)	0.56
RCC does proactive outreach to persons using MOUDs	57.4	(70)	54.4	(31)	60.0	(39)	0.53
RCC advocates that people use MOUDs	45.9	(56)	45.6	(26)	46.2	(30)	0.95
RCC tolerates use of MOUDs, but does not actively encourage it	1.6	(2)	1.8	(1)	1.5	(1)	0.93
RCC discourages people from starting MOUDs	0.0	(0)	0.0	(0)	0.0	(0)	n/a
RCC advises people to stop using MOUDs	0.0	(0)	0.0	(0)	0.0	(0)	n/a
Does not apply - RCC does not have members with opioid use disorder	0.0	(0)	0.0	(0)	0.0	(0)	n/a

Analysis

To describe the setting of the identified RCCs (n=198), we averaged ZCTA percentages across RCCs (including the five pairs of RCCs in the same ZIP code) to provide an estimate of the communities served by these RCCs regarding rurality, race, and ethnicity. To test if residents from areas with RCCs differed from the US population, we conducted one-way t-tests (one per category, not corrected for multiple comparisons, because these were exploratory analyses), using the US population statistics as the known population values.

To describe participating RCCs (n=122), we calculated descriptive statistics (i.e., means with standard deviations; percentages with sample sizes; medians for continuous variables with substantial skew) for survey items. We then conducted group comparison tests (t-tests for continuous variables, chi-square tests for categorical variables, quantile regressions to compare medians) to compare RCCs that were ARCO members (i.e., listed as a member on the ARCO website at study onset and/or study end) vs. not to test if there were any systematic differences between RCCs operating within the guidance of ARCO versus outside of it.

Results

Communities that have RCCs

The 198 identified RCCs were in 39 states with 1–26 RCCs per state, and a median of 4 (see Figure 1). Two RCCs were located in the District of Columbia.

Figure 1.

Number of recovery community centers (RCCs) per state.

Residents of ZCTAs with an RCC (Supplementary Table 1) were less likely to live in a rural setting than the US population in general, with an average of 8.5% (SD=16.5%) of residents of ZCTAs with an RCC living in a rural setting, compared to 14.0% of the US population (p<0.0001).

The ethnic-racial demographics of ZCTAs with an RCC mirrored US demographics more closely. Regarding ethnicity, 17.4% (SD=19.0%) of ZCTAs with an RCC were Hispanic, compared to 18.4% nationwide (p=0.55). Regarding race, similar percentages were observed for residents of ZCTAs with an RCC compared to the US population for the census categories white (65.2% vs. 68.2%, p=0.07), Native Hawaiian and Other Pacific Islander (0.2% vs. 0.2%, p=0.11), some other race (5.8% vs. 5.6%, p=0.69), and two or more races (7.0% vs. 7.0%, p=0.91). ZCTAs with an RCC had more Black residents (16.5% vs. 12.6%, p=0.005), and fewer American Indian or Alaskan Native (0.6% vs. 0.8%, p=0.03) or Asian (4.7% vs. 5.7%, p=0.005) residents.

Survey participation was unrelated to RCCs’ setting, as tested via logistic regression models using these ZCTAs variables as predictors of survey participation (p ≤ 0.14).

RCC logistics, footprints, model of care, and demographics

Survey responses indicated that the RCCs affiliated with ARCO vs. not were largely similar in terms of the RCCs’ footprints, model of care, and demographics (Table 1). Differences were found regarding the length of time an RCC had been operating, with more non-ARCO than ARCO RCCs having been in operation for less than five years (70.8% vs. 33.3%), and staffing, with ARCO RCCs reporting having more paid staff members (12.2 vs. 5.8 on average, respectively). All RCCs provided support for problems with alcohol and drugs; many (>67%) also provided support for other addictions and mental health issues. The number of individuals seeking recovery support at an RCC ranged widely between RCCs, with a median of 125 individuals served in a given month (4–1,500), and 500 in a year. Importantly, surveys indicated that RCCs serve not just a service-delivery role (endorsed by 87.7% of RCCs), but also as an information-oriented place where people learn more about recovery (91%), and a social place where people go to meet and spend time with peers (77%). Estimated demographics of people supported by RCCs suggest substantial reach of younger age groups (23.5% less than 25 years of age), and racial and ethnic minority groups (20.8% Hispanic; 22.5% Black). Compared to ZCTA demographic data, RCCs reported greater engagement of Black (paired t-test p=0.004), American Indian (p=<0.001), multi-racial (p=0.004) and Hispanic people (p=0.01), and less engagement of Asian(p=<0.001) people.

RCC services

ARCO and non-ARCO RCCs were largely similar in the services they provided (Table 2). These services include addiction-specific services, such as mutual-help group meetings of different varieties (e.g., 12-step, SMART, All Recovery), recovery coaching, and opioid and harm reduction services. They also include, though less uniformly across RCCs, assistance with basic needs and social services, technology access, and assistance with health behaviors. For example, the majority of RCCs provided basic needs assistance (72.1%) and employment assistance (72.1%); fewer provided housing (63.9%) and education assistance (53.3%). In line with dominant definitions of recovery,^17,35 RCCs also offered opportunities to provide civic service (e.g., volunteer, 89.3%), and involvement in advocacy and outreach (84.4%). The social role of RCCs was also emphasized, with the majority of RCCs providing recreational activities (82.0%) and opportunities for expressive arts (65.6%).

Organizations and systems RCCs connect with in fulfilling their mission

ARCO and non-ARCO RCCs did not differ in their interconnectivity with organizations and systems they connect with to fulfill their mission of supporting people in recovery (Table 3). The majority of RCCs interface with a wide variety of organizations, including substance use treatment settings, healthcare settings, the criminal legal system, and faith-based organizations. Here, the most wished for improvements in system linkage were with prescribers of SUD medications (36.1%), medical centers (33.6%) and emergency departments (33.6%).

RCC attitudes towards medication assisted recovery

ARCO and non-ARCO RCCs did not differ in their attitudes towards SUD medication treatment (Table 4). Just over two-thirds of RCCs reported being “extremely open” (68.0%) to medication treatment. Regarding MOUDs specifically, RCC staff actively engaged members in conversations about MOUDs (85.2%), provided direct support for taking MOUD (77.0%), and worked directly with clinical sites providing MOUDs (63.9%). None of the RCCs discouraged people from taking MOUDs or advise people to stop taking them.

Discussion

Our nationwide survey of RCCs captured remarkable growth and investment in RCCs nationwide, with more than half of RCCs having begun operations within the past five years. Yet even at ~200 RCCs nationwide, the number of RCCs is a fraction of the number of SAMHSA certified opioid treatment programs (~1,800), and even a smaller fraction of substance use treatment settings more generally (14,000), including outpatient (~11,000), residential (~3,000) and hospital inpatient (~1,000) settings, with multiple of these facilities providing several of these services.³⁶ RCCs are not regulated in the way formal treatment settings are. ARCO provides some structure around accountability and standardization, which may have positive impacts on staffing and RCCs’ capacity to provide support for mental health issues, which were higher in ARCO RCCs. Given the surge of mental health issues since the onset of the COVID-19 pandemic,³⁷ particularly among those with SUD,³⁷ this additional capacity is noteworthy. Beyond this issue, however, ARCO and non-ARCO RCCs follow a very similar model of care that provides recovery support in a welcoming, accessible, and long-lasting way. Their strong emphasis on mutual help groups is in line with emerging research recommendations to engage people with OUD in mutual help activities.^38,39 RCCs meet this need in a variety of ways, ranging from traditional 12-step meetings to more inclusive “all recovery” meetings, which are not substance specific, and embrace all recovery pathways. Within the same setting, RCCs address basic needs and social services, and function as social places that offer substance free recreational events and meaningful ways to give back to the community. At present, no clinical trial has been conducted to explicitly test the clinical and public health utility of RCCs, yet their growth, continuation, widespread utilization, and preliminary research evidence provide consistency and coherence converging on the notion of helpfulness.

Our data highlight a particularly noteworthy strength of RCCs: their ability to reach populations historically underserved by formal treatment settings. We found that RCCs are particularly successful in engaging Black Americans and young adults. Given that Black Americans are disproportionally experiencing opioid-related overdose deaths,⁴ and that young adults have the highest rates of untreated SUD,³⁷ the ability of RCCs to reach these target groups provides tremendous opportunity. These opportunities are, at present, not capitalized on. A third of RCCs report wishing for closer collaboration between their centers and medical settings, particularly with prescribers of SUD medications. How exactly such closer collaborations can be accomplished is a tractable problem. To encourage and support such creative thinking, in this paper we have presented data to increase awareness of the resources RCCs offer.

In our survey, we also asked about a potential barrier that may hinder MOUD prescribers and medical settings working more closely with RCCs. Our data, in line with prior research,⁴⁰ show that RCCs are a welcoming environment for persons taking MOUDs. In these RCCs, taking MOUDs was not just met with acceptance but with support. RCC staff have a very different relationship with people in recovery than MOUD prescribers. Rather than prescribe, monitor and advise people to take MOUDs, RCC staff provide ongoing opportunities to engage in conversations about MOUDs and can share personal experiences in an ongoing, less formal context.

Limitations

While this is the most far-reaching study of RCCs in the United States to date, we may not have identified all currently existing RCCs. First, we excluded RCCs with no web presence or phone number, limiting our sample. Our rationale for excluding these centers was that without a working website or phone number we would be unable to verify if these centers fit our definition of an RCCs and if they were still operational. Second, new RCCs may have opened since we completed data collection, and others may have ceased operation. Moreover, our data are further limited by our response rate (62%). While there were no demographic predictors of survey completion, there may be other unmeasured systematic factors that may have influenced the decision to participate in the survey and consequently may affect our reported estimates here in unknown ways.

Conclusions

Closer collaboration between the medical community and RCCs could significantly improve the reach of efforts to end the opioid epidemic. RCCs are welcoming towards MOUDs, and are able to reach populations historically underserved by formal treatment settings.