“Now that we’ve opened the door”: challenges recovery home directors face when housing residents receiving medication for opioid use disorder

Abstract

Medications for opioid use disorder (MOUDs) are a well-established treatment strategy. Supported by evidence of their effectiveness to reduce opioid misuse, they promote stabilization, prevent overdose deaths, and promote long-term recovery. Unfortunately, many individuals prescribed MOUDs face stigma inaccessing other recovery support resources. Recovery homes (RH), also known as recovery residences or sober living homes, are residential environments designed to support and provide structure to individuals working to achieve sobriety. However, some RHs have historically been unsupportive, with some explicitly denying entry to those prescribed MOUDs. The purpose of this study is to better understand obstacles hindering successful RH placement and support for those receiving MOUDs, as perceived by three groups participating in a housing navigation pilot: recovery home directors, individuals referred to a housing navigation helpline, and recovery coach navigators employed by a behavioral health organization that connects referred clients to recovery homes. Data from these three groups were collected as part of a larger evaluation of a housing linkage pilot. Semi-structured interviews were conducted with each group to ascertain barriers to supporting recovery home residents receiving MOUDs. Findings show the logistical barriers recovery homes face providing access and support for residents receiving MOUDs. Part of this challenge stems from the strict abstinence focus of RHs supported by many, but not all staff. While some directors employ strategies to support residents receiving MOUDs, they unintentionally employ stigma-driven practices that can undermine medication uptake and destabilize the recovery trajectory for residents living in recovery housing. To best support this population, RH staff need more education around evidence-based medication and support to address logistical challenges serving this population, such as providing timely and consistent medication access, especially for those arriving from carceral settings. Finally, to implement effective strategies to destigmatize medications and integrate residents receiving MOUDs, training is needed to help staff understand laws and policies that inform their work.

Introduction

The opioid epidemic highlights the urgent need for better access to person-centered harm reduction, treatment, and recovery support services [1]. As the gold standard treatment for opioid use disorder, medications for opioid use disorder (MOUDs) promote stabilization, reduce opioid misuse, prevent overdose deaths, and promote long-term recovery [2, 3]. Despite their established effectiveness, individuals using MOUDs continue to face stigma. [4, 5] Recovery residences traditionally emphasized non-medication-based abstinence and are one notable environment where stigma can occur, serving as a barrier to recovery-supportive housing for individuals receiving MOUDs.

MOUDs and stigma

MOUDs are pharmacological treatments prescribed to mitigate symptoms associated with discontinuing illicit opioid use [6]. MOUDs help stabilize individuals by reducing cravings, alleviating withdrawal symptoms, and normalizing physiological functioning [7, 8]. Methadone, buprenorphine (often referred to by the widely used brand-name formulation Suboxone™), and long-acting injectable naltrexone vary in mechanism of action, with methadone and buprenorphine acting as full and partial opioid receptor agonists, respectively, and naltrexone acting as an opioid receptor antagonist [3]. These medications are frequently complemented with additional treatment modalities (e.g., substance use rehabilitation, counseling) and risk-mitigating resources (e.g., employment, stable housing) helping individuals stabilize their environment while avoiding the physiological response of abrupt discontinuation [9].

The influence of 12-step, mutual aid groups (e.g., Alcoholics Anonymous) has established medication-free abstinence as the bedrock of recovery and may perpetuate attitudes that individuals prescribed MOUDs are not truly abstinent or in recovery [4, 10]. Mistrust toward MOUDs seems to derive, in part, from a mismatch between the “medical model” of the pharmacological community and the “social model” of recovery communities. Biological approaches are seemingly pitted against lived experience and psychosocial support-based approaches, resulting in a philosophical clash [11]. In a study of 300+ recovery service providers which also included RH, researchers found 25% of service providers would not accept individuals using MOUDs [12].

Recovery homes

Recovery homes (RH), also known as recovery residences or sober living homes, are residential environments designed to support and provide structure to individuals working to achieve sobriety [13]. Evidence supports their ability to promote a variety of positive recovery outcomes, including engaging with treatment, employment, and reducing substance use [14–16], and they have recently been included in the American Society of Addiction Medicine’s continuum of care levels [17]. The National Association of Recovery Residences (NARR) classifies these homes on four levels based on their degree of support, with Level I being peer-led to Level IV being clinically supervised and administered [18]. RHs emerged from the social model of 12-step communities, and most continue to encourage or require 12-step meeting attendance which promote complete cessation of mood-altering substances as a foundational principle for recovery [19–21]. This influence may promote anti-MOUD stigma, despite 12-step groups having no official stance on MOUDs and not preventing membership based on their use [22, 23]

Research suggests these homes can be both environments of stigma and support for people using MOUDs. They have historically been hostile environments for people using MOUDs, with some homes explicitly denying these individuals entry [24, 25]. Stigma seems especially directed at clients receiving methadone, as it has greater misuse potential than buprenorphine. In recent years, however, RH organizations have made deliberate efforts to be more inclusive toward people using MOUDs through workshops and disseminating educational materials to dispel MOUD myths [26, 27]. A shift toward acceptance of MOUDs is evidenced by somerecent studies ofthe Level I RH network Oxford House [24]. More favorable attitudes toward individuals taking MOUDs were noted in the later study, partially reflecting a greater proportion of residents using MOUDs [25, 26]. To help address these tensions, the concept of “medication-assisted recovery” (MAR), defined as the use of medications in combination with abstinence-based goals, has emerged as a bridging framework [24]). MAR blends progressive recovery goals and services and offers a pathway for recovery residences and mutual aid groups to become more inclusive of individuals using MOUD. This philosophical shift allows some homes historically grounded in abstinence-only approaches to better support residents pursuing recovery pathways. Staff can play a role in promoting MAR-based recovery by connecting residents receiving MOUD to appropriate providers and MOUD-supportive community organizations, such as MAR Anonymous meetings. [28]. Conversely, RH staff may unintentionally reflect stigma by encouraging residents taking MOUDs to taper off their medication [29]. In addition to perpetuating stigma, these suggestions may alienate residents from the social benefits of RHs.

Current study

The purpose of this study is to gain insights into obstacles hindering successful RH placement and support for those receiving MOUDs, as perceived by three groups participating in a housing navigation pilot: RH directors, individuals referred to a housing navigation helpline, and recovery coach navigators employed by a behavioral health organization that connects referred clients to recovery support services. Data on these three groups were collected as part of a larger evaluation of a housing linkage pilot executed by The Cook County Recovery Home Coordinated Capacity Pilot Program, a three-year collaborative effort to enhance treatment and recovery service engagement among criminal legal system (CLS)-involved individuals receiving MOUD. This pilot harnessed the expertise of recovery housing navigators to connect individuals who contacted the helpline to one of eight Chicago-based RHs. Although the focus of the pilot was to specifically serve (CLS)-involved individuals receiving MOUDs, navigators connected anyone requiring housing and/or other social services. The RHs chosen for the pilot either were already accepting residents receiving MOUD or agreed to do so as requirement of participation.

The data presented in this paper derives mostly from semi-structured interviews with 8 RH operators. A few quotes are included from one navigator and one client to illuminate particular points. Despite the paper’s specific focus on RH directors’ experiences, it fills important gaps by investigating treatment processes with a type of resident often not accepted within recovery housing (e.g., those receiving MOUD) and within housing management structures (i.e., Other NARR classifications, Oxford houses, therapeutic communities, etc.) that are often understudied.

Approach

The study team employed both grounded theory and discourse analysis to underpin the methodological orientation of the study design. Grounded theory is a framework for qualitative inquiry, data collection, and analysis. It is an iterative process that seeks to understand how individuals make sense of and contribute to particular processes and is well-suited for exploring nuances across health-related experiences [30]. To this end, semi-structured interviews were conducted across three groups of individuals. We interviewed RH directors and housing navigators to understand their role and experiences supporting CLS-involved people living in recovery housing. Referred clients were also interviewed to learn about their substance use history, CLS involvement, and experiences working with the housing navigator. Interview schedules differed for participant groups. While the same questions were asked of everyone within each of the three groups, semi-structured interview questions are broad and open-ended, leading to the emergence of unexpected topics. Discourse analysis was used to enhance the investigation by focusing on unique decision-making within the specific context. Discourse analysis examines how knowledge about a topic is generated across different accounts and how these different interpretations can provide a deeper understanding of the overall process [31]. Discourse analysis examines the range of situational factors (e.g., social context, political context, personal belief system) across diverse groups who hold separate roles or positions within the same process. Interviews with RH directors, housing navigators, and referred clients provide three different perspectives on challenges this population face accessing housing as well as any challenges they face living in recovery housing while receiving MOUDs.

Participants and recruitment

The lead author contacted each director and navigator by email to explain the data collection methodology, provide additional information about the interview, and answer questions. After directors and navigators gave verbal consent to participate in the study, the lead researcher scheduled interviews via email. Eight RH directors and four housing navigators participated in interviews. RHs had been operating for an average of 29 years and were spread across various Chicago-area communities, mainly in the south suburbs. The average home had 53 beds, ranging from 7 to 150. Five homes housed only men, two were co-ed, and one served only women.

To recruit housing clients, recovery coach navigators asked each referred client if they were interested in being contacted to discuss their experiences using the navigation program. Navigators completed a consent-to-contact (CTC) form for each client who expressed interest in participating or learning more. Completed CTCs were uploaded to a password-protected system which allowed researchers to contact individuals. Of the 205 individuals referred to the program, 117 completed CTC forms, 33 were successfully contacted and 32 interviewed. Only one client participant refused to participate in the study.

Data collection

The lead author—a PhD-level research scientist with over 20 years of experience interviewing in the criminal legal and health fields—collected data between August 2022 and January 2024 using a semi-structured interview guide. During the navigation pilot, the eight RH directors and four housing navigators were interviewed at two data collection points, one year apart. One director from each of the eight RHs was interviewed in the first year (noted in text later as Y-1) and again in the second year (noted as Y-2), resulting in a total of 16 interviews. At least one of two RH interviews took place in-person and on-site; facility tours were common. Interviews were also conducted with housing navigators during both years of the pilot. Two navigators were interviewed in the first year (Y-1). In the second year, one of the same navigators was interviewed a second time along with a newly hired navigator, resulting in two interviews (Y-2) with three different navigators. A single interview was conducted with a total of 32 housing clients referred to the program. All interviews lasted roughly one hour, were audio-recorded and transcribed, and identifiers were removed during transcription. The same interview questions were used at both data collection points. The goal of client interviews was to learn about their experiences using the navigation process to find recovery housing. The goal of RH director interviews was to gather information about the process used to place clients, as well as challenges and approaches in housing CLS-involved residents receiving MOUDs. The goal of RH director and navigator interviews was to better understand how the navigation process worked from their perspective as well as the barriers and facilitators in linking and supporting clients receiving MOUDs. Only client participants were compensated and were provided $25 for their time. This paper draws mostly from RH director (RH-D) interviews and adds a few housing navigator (H-NV), and navigation referral client (NR-C) quotes to further illuminate the themes presented.

Data analysis

The first author coded, categorized, and analyzed interviews using MAXQDA [32], a qualitative analytic program. Coding was performed in three stages. First, structural coding was applied by using a priori codes from the qualitative interview research questions. This “grand tour” style of coding provides a basic comparative overview across interviewees’ experiences around a similar topic [31]. Then, interview transcripts undergo a round of inductive coding where data are analyzed, drawing out processes undertaken by participants as they relate to the research inquiry. Next, the researcher used MAXQDA functions to extract a deeper understanding of the processes under investigation by isolating subtleties across participants’ experiences and how these experiences intersect based on their properties and dimensions. Simultaneous coding and data collection generated insights from the first interviews, allowing the lead author to shape interviews through deeper probing around each questions. As is recommended for interpretive qualitative research, only one analyst coded the data [30]. Using her expertise around RHs, the lead author then transformed process codes to conceptual codes, finalizing codes to fit within the existing literature on RHs while being mindful of research gaps. Project stakeholders (e.g., project leaders, recovery directors, and housing navigators) were invited to provide feedback throughout the research process. Researchers elicited feedback for finalization of the interview questions and presented preliminary and developing data findings and analysis at three different points in time for member checking. Stakeholder feedback refined patterns and established the critical lens presented in this paper.

Findings

The RH directors included three women, all identifying as African American/Black, and five males, one identifying as African American/Black, one Latinx, and three as white. Client participants mostly identified as male (82%). The average age was 42 years with a range of 24–59 years. Clients identified as Black (50%), White (36%), and Latino (14%). All three navigators were women with an average of 10 years’ experience at the healthcare organization. One held a master’s in social work, another in counseling, and two were Certified Alcohol and Drug Counselors. One navigator had lived experience with substance use and recovery.

“Nowadays, it’s much more acceptable”: recovery homes’ shift to accept residents receiving MOUDs

Traditionally, RHs have endorsed abstinence for all psychoactive substances, whether illicit or legally prescribed, (e.g., benzodiazepines for anxiety disorder or MOUD). The housing navigation pilot was created to link individuals receiving MOUDs to recovery housing. While all eight pilot RHs were required to accept clients receiving MOUDs (e.g., methadone, buprenorphine), housing navigators continued to face inconsistencies regarding whether non-participating RHs would accept MOUD clients and/or the pressures clients might face once they arrived. One housing navigator explains:

I think MOUD is super helpful. We know there are eight homes that today, or tomorrow, or next week, or next month, will take patients on MOUDs. Other homes are kind of like a crap shoot. There was a lot of places [where] we hear from patients that say, like, “The homes say I need to go down on my dose,” and it’s, like, “What are you talking about? That’s crazy!” And at first, we were, like, “Are you sure?” And we kept hearing that. And then, we’re like, “This is not cool.” (HN 2, Y-2)

However, even within the RH participants in this study, directors recall the slow shift thinking about the place for medication within traditional abstinence-based recovery models. Referring to taking more residents engaged in MOUD, one director explains the difficulty some staff faced:

I don’t know if you remember [but] it was a fear, you know? Like, “What does this mean? What is this harm reduction approach? We’re abstinence [based].” People [had feelings] about methadone and all that stuff in the past, but I came from a methadone clinic. So, I was able to explain to the team what it meant, and I was able to encourage [our home] to start taking people on methadone. So, now we have clients on Suboxone [an oral formulation of buprenorphine] and methadone. But that started to happen [just] this year. (RH-D 5, Y-2)

This RH director illuminates the views some staff held about MOUD as type of harm reduction strategy, rather than a medical treatment and therefore perceiving MOUD as at odds with abstinence or recovery. Another director echoes a similar view:

We don’t disallow any [MOUD]. Twenty years ago, no recovery home, would have allowed any type of MAR [medication-assisted recovery] or MAT. Nowadays it’s much more acceptable and they understand that you could very well, in the long term, be utilizing MAR or MAT in order to help you recover. So, we have people in the building right now on methadone and Suboxone. (RH-D 6, Y-1)

These quotes reflect the nuances in how directors perceive MOUD within abstinence, harm reduction, and medical frameworks (i.e., MAR, MAT), and whether individuals prescribed MOUD are in recovery or not. Another director attributes recent MOUD acceptance to a much larger treatment movement which perceives substance use as the result of significant life trauma:

I think that it used to be zero tolerance and people felt like they needed to be stern: zero tolerance, scared straight, creating the fear. But understanding that clients may have a traumatic background, we don’t want to retraumatize them and we don’t want to create barriers to their treatment or their treatment needs. Having that mindset seems to be the best approach. (RH-D 4, Y-2)

From this perspective, it appears the drive to accept MOUD stems from the desire to promote a positive social recovery, specifically by not causing further harm. From this perspective, recognizing different paths to recovery is the best approach toward easing the trauma that perhaps led to substance use. Perceiving MOUD as part of 1’s medical recovery helps some directors frame MOUD as medication for a legitimate medical condition and as a pathway to mitigate the harms of illicit drugs, rather than a source of dependency:

We got to think about methadone as a medication that is blocking an urge to go use something else. If you use it as a medication, then the participant’s mentality and thought process changes. (RH-D 2, Y-2)

Often, methadone is perceived as a ‘crutch’ or just another drug, leaving people to assume those taking it are not ‘really’ in recovery. However, this director perceives methadone as a treatment for withdrawal symptoms that drive clients to use opioids, pointing to the utility of methadone as a solution to a medical problem, and suggesting clients must similarly recognize its use in the same way. From his perspective, framing methadone as a logical and healthy approach to a medical issue (i.e. withdrawal) can help those prescribed MOUD to take on a more positive outlook about including MOUD as a part of their recovery. Paradoxically, however, this keen, yet subtle, comment also allows space for the continued stigma of MOUDs by calling on others to determine the client’s intent for using methadone. Therefore, it is important to investigate the role both RHs and residents play in this process.

“That’s just another dope”: MOUD stigmas in recovery housing

Perceptions about MOUDs rely on how RH staff handle MOUD stigmas that emerge among residents living at the RH. One RH director shared the challenges when MOUDs are stigmatized among residents in recovery housing:

We want to make sure the other participants don’t stigmatize the medication either, because the stigma that comes with methadone can be detrimental to participants taking methadone. They might feel like, “Oh, man, that’s just another dope,” or something like that, which we don’t want them to think. (RH-D 2, Y-2)

This director understands the importance of managing stigmas—especially around methadone—to prevent undermining one’s recovery. When asked about MOUD stigma, RH residents spoke mostly about methadone. When asked why he believed people stigmatize methadone, one resident explained:

I feel like there’s stigma around methadone. Like, you get high off it. Well, honestly, you don’t. It kills your cravings and, yeah, you might get a little tired when you first get on it and you’re not used to it, but you don’t get high; Like, you don’t get no euphoric feeling. It ain’t like popping Oxys or doing a line of heroin. (NR-C, 24)

To distinguish methadone from heroin, one director explains how he educates residents to think about MOUDs as just another medication:

We educate our participants. We let them know, “Hey, listen, some of the participants here might use this medication. Some of you are lucky enough that you haven’t gone through those extremes that you might need this medication, but if you were to need this medication, well, guess what? We got plenty of linkage agreements with other methadone, or Suboxone, or Vivitrol [a name brand of naltrexone] providers, they can provide something that will alleviate whatever it is that you’re going through. Because, at the end of the day, if it’s methadone, Vivitrol, or Suboxone, or metformin, it’s still a medication.” (RH-D 2, Y-2)

Note this director groups MOUDs with metformin (a medication to treat type 2 diabetes) in an attempt to destigmatize and normalize MOUDs. Like a resident needing metformin to regulate glucose, this director describes MOUDs as something people may need to alleviate symptoms experienced when one discontinues opioid use. Although attempting to destigmatize MOUD by aligning them with other medications, this director may also unwittingly undermine the effort by describing residents who do not take MOUDs as “lucky enough” to have not “gone through these extremes.” This phrase appears to tether individuals who choose to use MOUDs in their recovery as being on the worst end of an imaginary spectrum of opioid use.

“Now that we’ve opened the door …”: challenges supporting residents receiving MOUDs

Accepting clients receiving MOUDs is relatively new and therefore directors must face new challenges to best support this population. RH directors discuss the difficulties they face insecuring and managing medications for new residents.

Accessing medication

One of the challenges for RHs that accept individuals prescribed MOUD is that residents may arrive without having enough medication to last them until the home can arrange their first doctor appointment:

We had to remove some clients from the (RH) because they were in an irate state of mind because they were not [stabilized] properly with their medication (before they arrived) or they weren’t given their medication when they were at (in-patient) treatment and then they come here (RH) [and] they want their medication (now). That should have been balanced out [before they left treatment] so we could just pick up where they left off, because we know that medication, taking it and monitoring it, is key for them to be sustainable with their recovery. (RH-D 7, Y-1)

As mentioned by this director, accessing MOUD medication is more than just getting a prescription. It includes a less defined area of mental health and medication stability, something required for one’s long-term recovery. Directors recognize the fear and frustration residents experience about accessing their medication:

I would say for the methadone clients, now that we’ve opened the door [started accepting MOUDs], I think there’s that fear of, “I’m not going to be able to get my medication.” I think that’s their fear of RHs. And it’s more psychological and we can talk to them, counsel them, but in their mind, it’s like, “I’d rather not go to the facility. I want to be out in the community because I want to be able to go get my medication.” (RH-D 5, Y-1)

From this director’s experience, the fear of not accessing medication once placed at a RH may undermine an individual’s decision to seek recovery housing or damper their commitment to treatment engagement. This director continues:

When the clients come in, they feel like, “Oh, I didn’t get my prescription filled, so I won’t have it, and I’m going start going through withdrawals.” So, if they come to us and they don’t have their Suboxone 30 days or they don’t have a Suboxone doctor, we send them over to [a clinic] and they get it. (RH-D 5, Y-1)

While community primary care doctors can prescribe buprenorphine, methadone cannot be prescribed in a general healthcare setting. Methadone for OUD must be dispensed from federally and state licensed opioid treatment programs. Therefore, to ease new residents fear of not receiving their medication, RHs develop relationships with local providers:

They’ll let you know, “Hey, I was taking methadone,” and then we reach out to a couple of programs we have contacts with. (RH-D 4, Y-1)

One of the challenges RHs encounter in forging connections with methadone programs is that few may be available due to community-level stigmas:

Having run a methadone clinic myself, previous to this position, some places don’t want methadone in their area, so it wasn’t easily accessible. Because it’s one thing to say, “Oh, we can get it,” but if it’s a 30-minute drive and they don’t have a car and we’ve only got the two vans … it could have been a barrier for some clients. And that’s something we always think about. (RH-D 5, Y-1)

Community-held stigmas around MOUDs may mean fewer clinics will open in neighborhoods where people need them, making it difficult for residents to access MOUD treatment, especially when homes cannot provide transportation. This is especially challenging for individuals just starting methadone. As one director states, “Well, in the beginning, they have to go dose every day at the clinic, so transportation might be an issue.” (RH-D 2, Y-1). For homes situated near clinics administering medication, directors recognize walking through neighborhoods to reach the clinics can be triggering for some residents. The director states, “Some individuals said walking [to the clinic] they could find bags, people selling drugs to them. That’s a trigger.” (RH-D 7, Y-1)

Medication compliance and management

NARR Level 3 RHs do not employ clinical or medical staff and these RH directors shared both challenges and strategies for monitoring and dispensing MOUD medications to residents. All homes adhered to similar medication policies for storing, monitoring, and reporting medication. The majority of directors described securing medications in a locked office, safe and/or medication boxes and distributing MOUDs to residents:

[Residents] come down where the House Monitor is, and they’ll unlock [the safe], and give [medication] to them to take. And we kind of monitor but. no, we don’t administer. (RH-D 4, Y-2)

Another director explains a similar management system for methadone:

It depends on the individual, but typically they bring back a certain number of doses and then we keep those doses in a locked environment in the security center of the building here. And then they come to take those medications on camera. So, we keep control of them, we make sure that they’re being administered as appropriate. We just review the medication though, we don’t actually administer medication. We’re not a nursing facility or anything like that. So, we do supervised medication, but we aren’t necessarily taking control of that entire portion of it. (RH-D 8, Y-2)

These quotes describe RHs as supervising medication disbursement to ensure clients receive what is prescribed without physically handing the medication to the resident. Like the above two directors, this director also explains their role in monitoring, not administering, medication:

We do medication monitoring. We don’t dispense medication, right? So, every resident has a lock box in the locked medication cabinet in the office. And they have to come in and they get their own box. And then they take out the medication that they need for the day. (RH-D 1, Y-2)

All but one of the homes held residents’ medication in a centralized location. One site allowed residents to hold their own medication and then conducted a weekly count to ensure residents were not over-medicating or diverting the medication. In describing their process, this director also highlights the importance between “monitoring” and “administering” medication:

We’re documenting every single medication that a client is on and they are storing their medications securely in their own individual lockbox in a closet in their bedroom. Periodically throughout the month, we’ll do med count where our clients will bring their medications down to the office and we do a count of them. We’re not a nurse’s office and we don’t dispense medications to our clients. That is on them. But our number one way of managing the process is knowing what’s coming in, looking frequently at the medications, and if the individual is taking them at the appropriate levels. (RH-D 3, Y-2)

RH directors present medication monitoring as a seamless process. Although rare, only a few experienced compliance issues. One director shares:

I would say we haven’t had notable problems at all with it. Every now and then we’ll have a problem with compliance. If somebody is supposed to take three different Suboxone strips a day, sometimes they get lazy and they wanna just take all three at once, which is not how Suboxone is intended to be administered. So then, we have to have a talking to them and say that’s not how this is supposed to be used and maybe we can have their doctor talk to them about why it’s important to use it as prescribed, things like that. (RH-D 8, Y-1)

While this director was seemingly unaware that buprenorphine dosing can be conducted once daily with proper technique (e.g. [33], ), they are clear that the RHs interaction with medication is simply monitoring and not administering it. Perhaps directors clarify between these two terms because, by law, only a Substance Abuse and Mental Health Services Administration (SAMHSA) certified Opioid Treatment Program can dispense MOUDs [34]. Although no director specifically cited this law, one director did speak to the liability of not dispensing medication correctly.

“As long as nobody can tell that you are on it”: defining and regulating the recovery space

Directors find a small number of residents receiving MOUDs, specifically those experiencing sedation from methadone, pose challenges to RH programming and other residents in the home. Directors find these residents are unable to fully participate in programming, a requirement to remain in recovery housing. Some directors also perceive sedation as comparable to intoxication and, therefore, disruptive or triggering to other residents. In response, some directors seek to mask methadone use from other residents. Finally, some directors seek to control residents’ methadone use and often want to reduce their prescribed dosage.

Sedation and sharing MOUD status as programmatic disruption

Although RHs accept residents receiving MOUDs, directors perceive sedation, a side effect of the medication, as disruptive to required RH programming and the other residents. One director explains:

The only thing we’re concerned about is that you’re fully able to participate in the program. I don’t care how much [medication] you’re taking, ‘cause everybody is different, right? We’ve had residents on a really high dose and you would never in a million years know that they were taking any kind of medication. And so, the one thing that we tell them is, you have to appear alert and fully able to participate. You can’t be sleepy, look sleepy … you can’t look like you’re high. (RH-D 1, Y-1)

This viewpoint equates appearing alert for full participation as akin to sober while appearing sleepy as akin to intoxication, rather than a potential side effect of medication. Another director finds residents appearing to be “high” as triggering for others:

I don’t want there to be a red flag or a trigger for the other [residents] that lived that life and want to grow. And seeing [residents on MOUDs appear to be “high”] just takes them back there. I’m helping them pursue a happy new lifestyle of recovery. (RH-D 7, Y-1)

Some directors associate sleepiness or “nodding off,” a stigmatized term perpetuating stereotypes [35], with being prescribed too high a dose:

We’re okay with [MOUD usage] as long as long as nobody can tell that you’re on it. If you start getting drowsy and nodding off, it usually means you have the wrong dosage. So, if it’s actually giving you a high, then you probably have the wrong dosage and we need to adjust that. (RH-D 7, Y-1)

Another director shares a similar perspective:

[If a resident is] really groggy, methadone is the biggest issue. So, we will give them some guidance and advocate on their behalf if they’re nodding off in meetings. They’re clearly mis-medicated on methadone and one of our requirements of staying here is that, if you’re on MAT, as long as nobody can tell that you’re on it, it’s fine. If you’re nodding off like crazy, that’s triggering to other people, and it shows that you’re on the wrong dosage. It’s not helpful for anybody. So, we will advocate on your behalf to change the medication dosing so that, you know, people can use more appropriate levels of medication. (RH-D 6, T-3)

Despite declaring a desire to destigmatize methadone, few directors articulated an approach to this end. In one attempt to destigmatize MOUDs, one director explained why their home refused to let residents speak about using MOUDs as a part of their recovery:

I think it’s part of the drug culture and that’s the culture that they’re coming out of, right? And they’re learning a new culture. The drug culture is a lot about how much you had, how much you did, how much you did in a day. It feels very natural to come into recovery, and be on medication, and talk freely about your dose. And it’s just reeducating them. Normal people, you know, “normies,” don’t do that. Let’s not do that, okay? We’re trying to re-enter society. That’s not something most people do, run around, talk about how many milligrams of insulin or what level of medication they’re on for heart disease. We don’t talk about those things. (RH-D 1, Y-2)

For this director, talking about medication and medication-assisted recovery is akin to problematic “drug culture” behavior, something they are trying to change by regulating how those taking MOUDs can speak about their recovery in the recovery space. Reframing MOUDs as just another medication, this director situates MOUD within the realm of protected health information and justifies controlling residents’ conversations about MOUD usage because it is confidential and should not be divulged to others.

Managing the MOUD-assisted recovery process

Directors attempt to manage recovery by controlling residents’ MOUD use, often wanting to reduce prescribed doses and regulate how long MOUDs are used. Although agreeing that MOUDs should not be stigmatized because OUD is a “chemical imbalance,” this director shares the conditions under which he accepts the use of MOUDs at his facility:

It’s not a stigma. It’s a chemical imbalance. As long as they have a step-down plan, I’m okay with it. I remember when fentanyl hit the street and when the term “harm reduction” became relatively popular. But back then, it wasn’t used as it is today. Back then, you know, Jimmy got high eight times last month, and he only got high six times this month, so that’s harm reduction. That’s not what it means anymore. Not even close. So, as long as there’s a step-down plan. I [don’t] want to be on methadone the rest of my life. Yeah, that’s not the way it works. There [has to be] a slow, gradual, step-down plan so they can be free from everything. (RH-D 8, Y-1)

Although perceiving substance use as a chemical imbalance and willing to accept residents prescribed MOUDs, this director requires residents receiving MOUDs to have a plan to reduce their usage. For him, harm reduction is not just using less but being “free from everything.” This perspective is at odds with the American Society of Addiction Medicine’s (ASAM) National Practice Guideline for the Treatment of Opioid Use Disorder [36] which recommends pharmacological treatment has no time limit. Another director shares a similar perspective:

If somebody were on a certain dose and that was like a maintenance dose initially and then that dose should have gone down, but did not go down, then they start to show signs of nodding off and things like that. If we start to see those signs, then we ask them to adjust their dosage. We generally encourage people to wean off their dosage at some point. (RH-D 6, Y-2)

One RH director shares their home’s policy to avoid potential dosing problems in the future, stating “we [try to] take anyone 60 milligrams or less.” (RH-D 7, Y-1)

Although directors did not agree on using MOUD dosage levels to decide eligibility for recovery housing, many did perceive doses higher than 60 could be indicative of misuse or overuse and clients on higher levels could pose potential management challenges, especially for smaller homes with fewer staff. However, not all directors share this view even if residents desire to wean off:

We tell them, like, “Hold on, don’t rush [weaning off MOUDs]. If it’s working for you, talk with your doctor. We don’t have an opinion on that but talk with your doctor.” Because we’ve seen people try to come down too quickly and then there’s side effects. Like with any other medication, once you start coming off of it, there’s things that happen and they don’t really understand what’s happening physically, emotionally, right? And so, really getting them to develop that relationship [with their doctor]. This isn’t just somebody who writes you a prescription. You should have a relationship with them and feel comfortable being able to talk to them about what’s going on. (RH-D 1, Y-2)

Discussion

Fulfilling their goal to support and provide structure to individuals on a journey to achieve sobriety [13], RHs in this study accept residents receiving MOUDs and agree that it can be an important part ofrecovery. This study adds to existing research that MOUD acceptance is growing in recovery housing [25, 26] and is one of only a few articles specifically focusing on NARR Level 3 housing. First, the data presented here shows the continued barriers to providing MOUDs to those who need them. In some cases, especially for those referred from carceral settings, residents may not have a prescription or connection to a dispensing clinic to continue their medication. Fearing withdrawal symptoms, incoming RH residents may feel they will be unable to secure their medication, a fear that could undermine their decision to live at a RH or damper their commitment to the process once placed in a home. Even with a prescription or linkage, additional challenges emerge such as lack of timely and safe transportation to access medication or the triggering effects of walking through neighborhoods to MOUD clinics. The success of these medications depends on removing logistical barriers to access and providing the support individuals need to stabilize while using them [9].

The data shows how RHdirectors are grappling with how to incorporate MOUDs within their RHs focus on abstinence, reducing dependency and generating self-determination. Perceiving MOUDs’ acceptance as a somewhat recent shift, directors compare MOUDs to any other medication prescribed for a medical condition. Perceiving MOUDs as a part of 1’s medical recovery helps some directors reframe MOUDs from what some may still view as an illicit drug to a medication used for a legitimate medical condition. Others describe MOUDs as a part of a harm reduction approach to minimize possible trauma one might expect with strict abstinence from any substance, illicit or prescribed. Although they attempt to normalize and destigmatize MOUDs by speaking about their acceptance of it, some also perceive MOUDs as a crutch and a barrier to full recovery, thereby opening the space to further stigmatize MOUDs. How staff interpret residents’ motivation for using MOUD informs their strategies for regulating those who use it.

To destigmatize MOUDs, some RH directors speak to their efforts to educate residents and foster a MOUD-positive environment. Despite this effort, RH directors’ attempts to manage medications show their reluctance to fully accept MOUDs. This reflects what Miles et al. [11] call the philosophical clash between the “social model” of recovery communities and the “medical model” of pharmacological treatments. To manage this philosophical clash, RHs employ in various strategies to manage residents, ensuring they do not disrupt programming. Residents who appear sleepy or “nodding off” are assumed to be “high” and, therefore, disruptive to fellow residents and incapable of fully participating in required programming, a condition of remaining in the RH. Rather than being considered a potential side effect of medication, sedation is perceived akin to being intoxicated, further stigmatizing MOUDs. Several directors indicated residents should not appear to be using MOUDs, with one admitting those receiving MOUDs are not allowed to speak about their usage with other residents. This director sought to mask methadone use from other residents by invoking healthcare privacy. Although beyond the scope of this article, one might surmise NA and AA would encourage, rather than discourage, participants to speak about their MOUD-assisted recovery during meetings, which are required for all residents living at the RHs participating in this study. However, it is not uncommon for people to be discouraged from speaking about their MOUD in these meetings [4]

Finally, linking the effects of sedation to the assumption that one is over-medicated, directors seek to control residents’ medication use and desire to reduce their prescribed doses. While some directors perceive “nodding off” as a sign that doses are too high, another director interprets this as an indication of “readiness” to reduce dosage. Several directors spoke about encouraging residents to “step-down” medication (also known as a “subtle detox”) or, as one director described, making residents “free from everything.” Directors may view the use of MOUDs as a dependency or a crutch preventing residents from “fully recovering,” implying MOUD is a barrier to recovery growth. These responses demonstrate the need to further investigate nuances in how directors define both harm reduction and abstinence and the practices they employ to integrate residents receiving MOUDs. The responses reveal existing beliefs around MOUDs, as well as the possibility of inadvertently stigmatizing MOUDs and those who receive them, despite the goal to reduce stigmatization. Data also shows directors are inconsistent in their understanding of MOUDs and how medication side effects may be addressed. One home openly discussed refusing to accept residents whom they perceived to be receiving too high of a methadone dose and this restriction potentially violates the Fair Housing Act. Practices that undermine evidence-based medication uptake and destabilize the recovery trajectory for those receiving MOUDs can undermine the full potential of this life-saving medication [2].

These findings point to the need for several policy recommendations. MOUD is one of the most effective treatments for OUD. In an era of fentanyl and its analogs, MOUD prevents fatal misuse of illicit opioids and thus supports the urgent contemporary public health objective to save lives. During an overdose crisis, public funds must prioritize those treatments and supports with the most evidence and/or most promise. As an example, the navigation program upon which this study is based required participating RHs to provide all three forms of MOUD. Similarly, payors of NARR Level 3 RHs should incentivize if not require homes to accept these life-saving treatments.

Second, more training is required for RH leaders and staff. There remain several misconceptions about MOUDs, and these misconceptions can lead to residents being encouraged to lower to a subtherapeutic dose, discontinue treatment, and/or leave the RH and its significant benefits. Greater education on the pharmacology and dosing logic of medications can empower staff to better shape the relationships they currently have with medical providers and MOUD program staff and improve their efforts to address MOUD stigma within their RH. Only recently have researchers explored trainings such as this in the recovery home space [37, 38]. Similar training for RH residents may bolster their ability to advocate on behalf of residents who appear ‘groggy’, educating both staff and other residents about MOUD and its potential effects on individuals attempting to regulate their medication levels as a part of their recovery. As such, the perpetuation of stigma against MOUDs increases the likelihood that one of the most effective tools for recovery would be unduly denied to people who need them.

Lastly, access barriers to MOUDs have been lowered through the elimination of the DEA X-waiver, permitting more prescribers to offer buprenorphine in routine clinical care, and recent changes to 42 CFR Part 8 permit greater flexibility with take-home methadone doses. However, more needs to be done to improve coordination between prescribers and RHs. For example, these data show the need for improvement in the transition process for new residents receiving medication. Timely and supportive medication access is key to establishing the stability needed for RH success. This transition can also be enhanced through improved coordination between the homes and MOUD dispensing programs. While RH staff spend time fostering relationships with various clinics, a more coordinated connection could reduce the time required and challenges of accessing medication for residents.

Limitations

Despite limitations related to the small sample size, geographic concentration (all homes were located in a Midwestern urban area), the exclusive focus on Level 3 RHs, this study contributes meaningfully to the growing body of literature on the capacity of RHS to support individuals in recovery and to address stigmas related to MOUD [4, 5]. Although it remains uncommon for RHs to accept individuals prescribed MOUD, this study provides important insights into both the benefits and challenges associated with serving this population. A further limitation is the exclusive reliance on RH directors’ perspectives; while all homes included in the study were required to admit residents prescribed MOUD, the views of RH staff who interact directly with residents were not explored.

Conclusion

The data presented here does illuminate strategies employed by RH directors who are committed to supporting this population. The data also reveals gaps and areas in which directors need additional assistance for working with this clientele, namely more education around evidence-based medication. This study also points to the financial and staff support RHs require to address logistical challenges serving this population, including providing medication access, particularly for those arriving from carceral settings. Finally, training is needed to help staff understand laws and policies that inform their work, to help them better implement effective strategies for destigmatizing medications and integrating residents receiving MOUDs.

Abbreviations

CLS

Criminal Legal System

H-NV

Housing navigator

MOUD

Medication for opioid use disorder

NARR

National Association of Recovery Residences

NR-C

Navigation referral client

RH-D

Recovery home director

Author contributions

J.D.: Methodology, Software, Investigation, Formal analysis, Data curation, Writing - Original draft, Writing - Review & Editing; J.B.: Writing - Original draft, Writing - Review & Editing, Formal Analysis; D.W.: Conceptualization, Methodology, Resources, Writing - Review & Editing; J. N. & K. H.: Conceptualization, Resources, Writing - Review & Editing.

Funding

This research was funded by the U.S. Department of Justice and the National Institute of Drug Abuse. Opinions are those of the authors and do not necessarily reflect those of the funder.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics, consent to participate, and consent to publish

This project was approved by the Chestnut Health Systems’ Institutional Review Board. IRB Study No. 1161-0122. Consent to participate and to publish was obtained from each person interviewed for this paper.

Grant number

#2020-AR-BX-0074, 15PBJA-22-GG-04397-COAP, additional FAIN R24DA051974

Competing interests

The authors declare no competing interests.