“If he did it, I can do it, too. I can change my life around”: The social model of recovery within the context of recovery homes accepting residents prescribed medications for opioid use disorder

Abstract

Introduction:

This paper provides an in-depth examination of examines four recovery residences, that serve individuals prescribed medications for opioid use disorder (MOUD). The study has two primary aims: first, to deepen understanding of how recovery residences adopt and operationalize Social Model of Recovery principles; and second, to identify gaps in staff integration of residents receiving MOUD—gaps that may either support or undermine the integrity of the social model within these settings.

Methods:

We conducted semi-structured interviews with 17 residents receiving MOUD living in four participating recovery homes. The interviews were conducted between August 2022 and January 2024 using a semi-structured interview guide designed to explore residents’ experiences upon entering and living in the recovery home. Qualitative software was used to organize and qualitatively analyze transcripts through multiple rounds of coding. Themes were discussed across the research team and grouped across each of the various principles of the Social Model of Recovery.

Results:

Residents reported feeling supported in safe, structured environments that promoted accountability and community, while staff with lived experience played a central role in fostering trust and modeling long-term recovery. Structured programming, peer coaching, and access to essential resources further reinforced recovery-supportive conditions. However, inconsistent staff attitudes toward MOUD revealed underlying stigma, which some residents found intrusive or isolating.

Conclusion:

This study addresses key gaps in recovery science by offering qualitative insights into Level 3 recovery residences, emphasizing the perspectives of residents navigating staff relationships, organizational policies, and recovery programming. Despite increasing MOUD acceptance, recovery homes rarely address MOUD-related stigma formally, creating tension between medical and social models of recovery and contributing to judgment or marginalization of MOUD recipients. These findings highlight the urgent need for evidence-based MOUD integration strategies, staff education, and stigma reduction efforts to ensure that recovery homes fully support all residents’ recovery pathways.

1. Introduction

Recovery housing provides structured support for individuals with substance use disorders, promoting long-term recovery. The National Alliance for Recovery Residences (NARR) sets quality standards, with Level 3 homes offering peer support, life skills development, and clinical services. Rooted in 12-step traditions, NARR’s Social Model of Recovery emphasizes community, mutual support, and peer-led engagement, with standards aligned to the six domains of the Social Model Philosophy Scale (NARR, 2018; Kaskutas et al., 1998). This paper explores how these elements are applied in four NARR Level 3 residences and how they support—or fall short for—residents prescribed medication for opioid use disorder (MOUD), offering insights to guide best practices.

1.1. The social model of recovery

Recovery homes (RH), also referred to as recovery residences or sober living homes, are structured residential environments designed to support individuals in their pursuit of sobriety (Mericle, Miles, & Cacciola, 2015). Reviews of research on these homes show that these homes facilitate positive recovery outcomes, including engagement with treatment, employment, and reduced substance use (Mericle et al., 2023; Mericle, Hemberg, et al., 2019; Reif et al., 2014). Recently, RHs were incorporated into the continuum of care by the American Society of Addiction Medicine (Public Policy Statement on Housing’s Role in Addressing Substance Use and Facilitating Recovery, 2025). All homes are categorized by NARR into four levels of support, along a continuum with Level 1 being peer-led (e.g., Oxford homes) and Level 4 being clinically supervised (NARR, 2018). NARR Level 2 includes managed environments with increased governance found in Level 3 which includes supervised activities, non-clinical staff and offer life skills programming. NARR endorses the Social Model of Recovery, grounded in 12-step communities and emphasizes healthy, sustained living in recovery. Many residences require or encourage participation in 12-step meetings. Homes seeking NARR affiliation must comply with its standards, which include staff’s ability to apply the Social Model, as outlined in NARR Standard 3.0. (https://narronline.org/wp-content/uploads/2024/05/NARR-Standard-3.0.pdf) (Jason & Ferrari, 2010; Polcin et al., 2021; Wittman et al., 2017).

The Social Model of Recovery, which emerged from the philosophy of Alcoholics Anonymous and the 12-step tradition, emphasizes the importance of peer support and shared experiences in the recovery process (Polcin et al., 2014). This approach prioritizes social and interpersonal elements of recovery over individualistic methods, emphasizing peer-to-peer relationships over traditional practitioner-client dynamics and replacing treatment plans with “recovery plans” (Borkman et al., 1998). Central to the social model are recovery programs where residents support one another, drawing on personal experiences in a sober, safe environment that fosters community and the rebuilding of self-identity (Wright, 1990).

1.2. Implementation of social model recovery in recovery housing

The Social Model Philosophy Scale (SMPS), developed by Kaskutas et al. (1998) assesses how programs implement the social model of recovery across six key domains: physical environment, staff role, authority base, view of substance use, governance, and community orientation (Borkman et al., 1998). These domains are reflected in the NARR Standards and in recent work by Mericle et al. (2023), which highlights how social model recovery housing views recovery as a lifelong process, managed by staff with lived experience, and emphasizes peer-supported governance and community relationships. Social model residences, like sober living houses in California, promote recovery through peer networks and enforce strict rules to sustain this culture (Mericle et al., 2023; Polcin et al., 2014, 2021). However, research on adherence to social model elements reveals substantial variation across domains, and we do not know enough about what implementation of the SMR looks like at each of these levels (Mericle, Miles, & Way, 2015; Mericle et al., 2017; Miles et al., 2022). Additionally, existing studies on RHs focus on program managers’ and directors’ perspectives (Dewey et al., 2024; Dewey et al., 2025; Mericle et al., 2017; Mericle, Miles, & Cacciola, 2015), leaving a critical gap in understanding how residents perceive their homes’ alignment with social model principles—an issue this paper addresses.

1.3. MOUDs and MOUD stigma

MOUDs are pharmacological treatments prescribed to alleviate the symptoms associated with discontinuing illicit opioid use. These medications help stabilize individuals by reducing cravings, relieving withdrawal symptoms, and normalizing physiological functioning (SAMHSA, n.d.). MOUDs are often used in conjunction with other treatment modalities, such as substance use rehabilitation and counseling, as well as risk-mitigating resources, including employment and stable housing. These complementary interventions help individuals stabilize their environment and avoid the physiological consequences of abrupt opioid discontinuation (Damian et al., 2017).

The influence of 12-step groups (e.g., Alcoholics Anonymous), which emphasize abstinence as the foundation of recovery, has led some to the perception that individuals prescribed MOUDs are not in recovery (Andraka-Christou et al., 2021; Madden, 2019). These views are further fueled by the belief that MOUDs are ‘just another drug’ used in place of heroin rather than as a medical solution on one’s recovery pathway (Mackey et al., 2020; Cioe et al., 2020; Ostrach & Leiner, 2019; Cooper et al., 2020). This mistrust toward MOUDs appears to stem, in part, from a mismatch between the “medical model” of the pharmacological community and the “social model” of recovery communities. This tension between biological and psychosocial approaches has created a philosophical divide (Miles et al., 2020; Pasman et al., 2022), resulting in stigmas against individuals who use substances and those who seek treatment through MOUD prescriptions (Madden, 2019). Studies show that stigma toward MOUD can occur across the healthcare system, including first responders, treatment professionals, and pharmacists (Cioe et al., 2020; Cooper et al., 2020; Mackey et al., 2020; Ostrach & Leiner, 2019). This ‘intervention stigma’ stems from providers’ abstinence-based views of recovery, limited training and lack of knowledge on MOUDS. Intervention stigma could also exist at the policy level through restrictive regulation policies, especially with methadone which can promote diversion and return to use, further fueling intervention stigmas (Dewey et al., 2025; Madden, 2019). Intervention stigma continues through to recovery service providers. In a study of over 300 recovery service providers, 25 % indicated they would not accept individuals using MOUDs (Kepple et al., 2019), including providers of recovery-supportive housing, or recovery homes.

1.4. Recovery housing and MOUD

Despite the growing body of literature on recovery housing, a significant gap remains concerning the integration of residents prescribed MOUD and how their inclusion aligns with—or challenges—the principles of the social model of recovery. Research shows that RHs can serve as both supportive and stigmatizing environments for individuals using MOUD. Stigma—defined as negative stereotypes and behaviors toward those perceived as different—is especially pronounced for individuals in recovery, often resulting in rejection and isolation (Abu-Ba’are et al., 2024). In recovery housing, it may manifest as labeling, discrimination, and internalized shame, discouraging residents—especially those with histories of illicit drug use—from disclosing their status or seeking support. These dynamics are compounded by treatment systems that may unintentionally reinforce stigma, prompting residents to adopt coping strategies such as secrecy and social withdrawal (Abu-Ba’are et al., 2024).

Historically, RHs have often excluded individuals using MOUDs, especially those on methadone, due to stigma and misconceptions (Jason, 2021; Majer et al., 2020). However, many RHs are now working to become more inclusive by providing peer education and training to shift attitudes (NARR, 2019; SAMHSA, 2023; Wilkerson et al., 2024). Studies of the Oxford House network, a Level I RH system, show growing acceptance of MOUDs, partly due to increased resident use. This shift has led to more supportive environments for MOUD users, with staff and peers offering greater acceptance and understanding. (Bobak et al., 2023; Gallardo, Wilkerson, et al., 2024; Gallardo, Zoschke, et al., 2024; Majer et al., 2020).

While the social model of recovery adopted by RHs that relies on peer interaction can diffuse the tension and stigma associated with substance use, it is unknown how homes handle stigmas around MOUD use when historically their views have been rooted in stigma and prejudice (Abu-Ba’are et al., 2024; Mericle et al., 2023). Despite technical assistance and guidance on MOUD in recovery housing, some RH staff may inadvertently perpetuate stigma by encouraging subtherapeutic dosing, asking residents on MOUDs to taper off their medication (Dewey et al., n.d.; Dewey et al., 2024, 2025; Wood et al., 2022). Such suggestions not only reinforce stigma but may also alienate residents from the social benefits that RHs offer and compromise their recovery as MOUD treatment discontinuation is associated with increased risk of recurrence (Ronquest et al., 2018).

2. Materials and methods

2.1. Current study

The data presented here come from a larger qualitative study exploring challenges and effective strategies in supporting recovery across four Chicago-based recovery homes serving justice-involved residents receiving MOUD (Dewey et al., 2025). This larger study consisted of focus groups with 19 staff members and semi-structured interviews with 17 total residents. This paper focuses on residents’ experiences while living in the RHs, experiences the research team then mapped onto Social Model of Recovery principles, paying particular attention to resident experiences with MOUD and stigma while living in the home.

2.2. Approach

We conducted semi-structured interviews with 17 residents living in one of four participating NARR Level 3 RHs. Qualitative interviewing offers in-depth insight into participants’ perspectives, particularly how they experience elements of recovery residences aligned with each social model domain (Gerson & Damaske, 2021). The semi-structured format, with broad, open-ended questions, gave participants flexibility to guide the conversation, facilitating the emergence of unanticipated topics. The methodological framework followed thematic and process coding to capture residents’ idiosyncratic experiences by inductively building conceptual categories from descriptive and process-based narratives (Amanfi, 2019; Braun & Clarke, 2006; Saldana, 2021).

2.3. Participants and recruitment

Participating recovery home (RH) were selected using a purposive sampling method, as RH inclusion required that homes accept residents who are both justice-involved and prescribed MOUD. Justice involvement was defined as having any past contact with the criminal justice system, including time spent in carceral settings, or interactions with the courts, or police. The research team invited four RHs that had previously participated in a three-year independent housing intervention evaluation focused on this population. These four homes were selected to ensure a diverse sample. Two homes served women and predominantly African-American populations, one home primarily served Latino men, and the remaining home served mostly Caucasian men. All directors agreed to participate. All homes were licensed by the Illinois Department of Human Services Division of Substance Use Prevention and Recovery. The homes are also categorized as NARR Level 3 homes while only two homes were certified by the Illinois Association of Extended Care, a state-governing body that provides standards for recovery homes and other recovery-based residential living environments. Located in different Chicago communities with one located in a surrounding suburb, the homes had been in operation for an average of 14 years, with an average capacity of 35 beds. Bed capacity ranged from 10 to 150. RH staff indicated that about 80 % of their residents had some type of justice involvement while the number receiving MOUD was roughly 10 %. RHs employed full-time, non-clinical staff who provided on-site life skills programming. All homes followed similar dosing practices by holding residents’ MOUD in a locked box on-site, providing access to medications 2× per day (morning and evening). RH staff monitored residents taking their medication but did not administer it as they were not clinical staff.

The research team met with each RH director to explain the study and provided flyers to share with eligible residents—justice-involved individuals currently prescribed MOUD. Directors facilitated recruitment, providing contact information to each eligible resident interested in participating. The research team contacted each resident, answered any questions, and obtained written consent. Interviews were conducted privately, either onsite or by phone. As the study progressed, the research team realized it was difficult to identify enough participants receiving MOUD, especially in the smaller homes and therefore, eliminated this requirement to meet the required number of interviewees. Eleven out of the seventeen interviewees received MOUD at the time of recruitment. All interviewees contacted by the research team agreed to be interviewed, and no one refused to participate.

2.4. Data collection

Between August 2022 and January 2024, the lead author, a PhD-level qualitative researcher with over 20 years of experience, conducted semi-structured interviews with RH residents (n = 17), exploring arrival experiences, house rules, staff dynamics, and recovery processes. Questions covered substance use, criminal-legal involvement, and home placement. Conversations often deepened beyond the guide, with emerging themes shaping later interviews. All interviews were one hour, audio-recorded with consent, transcribed, and anonymized. Participants received a $35 Visa gift card. The study had IRB approval and informed consent. Despite the small sample, theoretical saturation was achieved as data gathered provided adequate categorical similarities and key themes were duplicated over the last four interviews (Saunders et al., 2018). Moreover, the sample size is similar to and, in many cases, exceeds other studies in this area (See Majer et al., 2014; Timpo et al., 2014; Ellis et al., 2024).

2.5. Data analysis

The first author used MAXQDA, a qualitative analysis software (VERBI Software, 2022) to code interview transcripts thematically. The initial round of coding aimed to elucidate residents’ experiences living in recovery housing, extracting both explicit and implicit meanings (Saldana, 2021; Charmaz, 2014). Initial coding focused on understanding residents’ experiences in recovery housing, using a priori codes based on interview questions to organize data and extract key quotes quotations (Maietta et al., 2021; Saldana, 2021). This round facilitated cross-case comparison and the identification of broad patterns. In the second round, process coding was used to identify strategies supporting residents prescribed MOUD which we then categorized using principles of the social model of recovery. Intersecting codes in MAXQDA revealed dimensions of each category, leading to higher-order themes. To ensure the findings aligned with a broad understanding of recovery home operations, the lead author consulted with co-authors experienced in the field and shared the data with RH partners. This member-checking process refined the thematic analysis and informed the final codebook, which organized key challenges and strategies used to support individuals involved receiving MOUD (Candela, 2019).

3. Results

Table 1 displays resident demographics. Participant demographics included seven women and ten men, with an average age of 42 years and an age range of 25 to 63 years. On average, participants had been residing in the RH for six months. Table 1 also shows that residents had a diverse range of time on MOUDs with the majority receiving Methadone.

Table 1.

Resident demographics.

Residents (n = 17)
Age Average	42 years
Age Range	25–63 years
Gender
Male	59 % (10)
Female	41 % (7)
Race
African-American/Black	47 % (8)
White	29 % (5)
Latino/Hispanic	24 % (4)
Average Time in RH	7 months
Time Range on MOUD	1 month-16 years
MOUD Type (n = 11)
Methadone	67 % (7)
Buprenorphine	33 % (4)

3.1. Physical environment

Residents emphasized a safe and structured environment was essential to sustaining their recovery. One resident stated, “They said that this program had a lot of structure. And that was something that I really needed. I needed that, and a safe environment was the most important thing.” (RESIDENT #7) Residents described a safe home as a drug-free environment with properly monitored medications, as expressed by one resident:

There’s no smoking in the building. There’s no drug paraphernalia in the facility. Those are real simple rules that an individual can follow if they want to do right. Have we had some people that break the rules? Sure. But they’re no longer here. (RESIDENT #2)

Residents described the steps RHs took to ensure a substance-free, safe environment which included conducting periodic room checks and requiring residents to open any packages they receive in front of staff to ensure residents are not using or receiving any illicit substances.

In addition to room and bodily searches upon entering, residents also described RHs use of both random and scheduled drug testing practices: For example, one resident shared:

Sundays… We have a new resident pick a number between 1–28. This is in the rules. They read it out loud (and they) pick a different one each week. That is when we do drops (urinalysis testing). (RESIDENT #8)

Residents pointed to RHs’ rigid rules around movement as evidenced in their programmatic structure, with one resident having shared, “For the first 30 days, you need to be here (on-site), be in by 6:00 pm curfew. You got to attend 90 in 90, your 90 meetings in 90 days for your first 90 days.” (RESIDENT #20) Another resident shared that:

Some of the rules would be to have your room in compliance, being on time for medication, be on time for groups. The kitchen duties, choir duties, what’s expected of you. And your recovery planner, it’s a weekly log of how many meetings we make, you have to make four AA meetings (each week). (RESIDENT #7)

To promote structure and adherence to program rules, the RHs eliminated the sustainability fee (monthly rent). This reduced financial stress and the need to work outside the facility, enabling residents to focus on recovery and fostering greater engagement and accountability, as one resident described:

The first sixty days there’s no charge on rent. Which was nice because I took advantage of the first 60 days. I felt out my medication and just took it slow. Part of me was scared. I didn’t want to use anymore, but it was a new place, so I just didn’t want to overwhelm myself. (RESIDENT #4)

Clients also mentioned RHs rigid protocols for managing prescribed medications to prevent medication sharing or diversion. Medications, such as MOUD, were not allowed in residents’ rooms and had to be signed in with staff upon arrival. One resident stated, “All medication must be sent to the office. You have to stop at the office before you, you can’t pass the office with your medication. It’s got to be in its (original) packaging” (RESIDENT #7). These sorts of procedures were common across the four facilities residents were recruited from. As a resident from another home explained:

The staff are present, and they see us take our medications. We then are checked in our mouth, whether we took our medications. They don’t want any problems. So, make sure that they know, as well as we know, that we took our medication properly. (RESIDENT #11)

Residents perceived homes’ high expectations as motivating for one’s commitment to recovery:

Because not only do we have a safe environment, a clean environment, an environment with high standards, and sometimes you’re going to be in places in your life, you’re going to be, like, oh my God, they expect too much of me. But I’ve also been in a position where people didn’t expect nothing of me and that didn’t really feel too good. (RESIDENT #12)

3.2. Staff role

Under the social model of recovery, staff serve as active community members, engaging residents through collaboration and shared responsibility. In all RHs studied, staff offices were located within or near communal areas, and staff were regularly seen interacting with residents. Residents described their connection to staff beginning from the moment they arrive at the facility:

They’ll (staff) help you and they talk to you, one-on-one. My counselor will come and sit down with you. He’ll ask you what’s going on, what’s on your mind. (He will ask me) what do you want for your goal, and I tell him, this and that (RESIDENT #17).

Residents often described staff as partners in their recovery and appreciated the staff’s interest in keeping them on track:

(Staff are) very hands-on. I wouldn’t say they worked harder than you for you, but they’ll definitely show their effort. They’ll remind you, did you follow up with this, did you make that appointment? So, I feel like they are a motivating force in being sober and elevating your situation. (RESIDENT #20)

Residents found staff available and willing to listen to them as they face many struggles during the first few days and weeks in recovery housing:

Just being a shoulder to lean on, basically. Like, it’s hard being out there by yourself, not knowing next time you’re going to eat, not having somebody you could vent to and trust them not to just throw it in your face or have listened to you. That’s a big part of it, just them actually caring. (RESIDENT #20)

3.3. Authority base (lived experience)

A key component of the social model of recovery is recognizing real-life experience as valuable knowledge. In the homes where residents were recruited, all but two staff members had direct experience with substance use, recovery, or the criminal legal system. Residents emphasized the value of this lived experience, noting that it builds trust, fosters mutual understanding, and demonstrates the possibility of long-term recovery through commitment to the program. One resident stated, “Another thing I like about this place is that this staff are, most of them are clients, so they’ve been in our shoes. They know what we need.” (RESIDENT #7).

Having common experiences helped residents feel safe sharing information about their substance use:

If you need a shoulder or an ear, you can come and talk to me. Don’t feel like you can’t talk to me because we all got something in common. They can relate because they’ve been there. They’ve done that. I feel comfortable talking to one of them because they understand where I’m coming from. (RESIDENT #6)

Staff with lived experience offered valuable insight that support individuals in the early stages of their recovery, and their practical guidance fosters trust by demonstrating a genuine understanding of the challenges faced by newer residents:

They provide us with a lot of motivation regarding sobriety and personal issues. They might slightly expand on a personal situation. They might not get into depth, but they’ll talk about, in a very general way, something they had experienced, what they learned from it, and what they utilized to get through it. So, when they converse with us and tell us those things, they’re equipping us, they tell us in recovery, even if you don’t use it now, you can shelf it. Because you kind of know what I’m going through. I think it’s easier to trust someone who understands. (RESIDENT #12)

In addition to the valuable knowledge and experience staff imparted to residents, their presence in staff roles served as a powerful symbol of hope, motivating residents to stay on their recovery path:

How is it an individual that walked the same walk that I walked, came from the same environment I came from, able to run a whole facility? And they trust him. Wow. I mean, the house manager, he came from prison here. How’d he get that position, you know? Maintenance guys, same position, you know. It makes me want to do better. (RESIDENT #2)

Another resident agreed, stating, “If he did it, I can do it, too. I can change my life around, and be successful, and stay clean for the rest of my life.” (RESIDENT #18) Residents found staff with lived experience were better equipped to help them at each point of their recovery because they have experienced it, a skill that proves useful under the philosophy that recovery is a life-long process.

3.4. Holistic recovery

Holistic recovery and perceiving recovery as a life-long, dynamic process is another element of recovery housing as mapped onto the social model domains. Residents spoke about the multiple ways the RH and its staff supported them:

They helped me get a job. They helped me get to places that I needed to get to, like doctor’s appointments, help me get to the court, give me avenues to better myself. Since I’ve been here, I got my forklift certification. They have welding classes, offer computer classes. I’m in the process of getting my credit fixed. I’m in the process of getting my license, because they are expiring now. I got a lot of things going on there. (RESIDENT #2)

Staff offer support in multiple areas of one’s life to ensure long-term, sustainable stability. RHs offer comprehensive personal and financial support to help individuals enhance their well-being, fostering a foundation for successful recovery. For the participants in this study, part of their recovery included access and support for MOUD:

No, they (staff) definitely supportive and they definitely encourage them (MOUD). Like, this is temporary. You know, like, this isn’t forever. You don’t really have to be on this forever, like, this is a steppingstone. (RESIDENT #20)

Perceiving MOUD as a part of one’s recovery process, this resident shared the role staff play in seeing MOUD as a part of one’s recovery, albeit temporary. Another resident shared a similar point of view and explained the reassurance he provides to other housemates to alleviate the pressure one may feel about choosing to include MOUD as a part of their recovery:

They (MOUD) could help them tremendously. Just let them know it’s okay. You know, if you need this (MOUD) for a couple months, it’s not a lifetime thing. If you need that just get over that hump, stay on it six months to a year. But still have people on it, it’s okay. You know, this is what you got to do. If you tried other things that didn’t work, it’s okay. (RESIDENT #8)

This resident reassured his fellow housemates that their use of MOUD only needs to be temporary. When asked how staff felt about residents prescribed MOUD, one resident explained staff acceptance despite having issues with those who begin ‘nodding’, or falling asleep, after taking their dose:

(Staff have) open arms (acceptance of MOUD). (But) nothing is being discussed. It’s one individual that nods all day. You take your medicine in the morning, but you nodding all day. Now, in my mind, I think [resident name] be high. But this isn’t me. You know, I’ve heard other individuals talk about that also, but that’s what it looks like. Now, for individuals that say they Methadone or they Suboxone, you know, and they have a little time where they get to nodding because the medicine, eventually they come out of it and get on with the day. You know, so, it’s really no stigma about none of that. I don’t feel no type of way. Staff don’t feel no type of way. Nobody is being downed because they take, they’re taking medication for opioid disorder use, misuse. (RESIDENT #10)

Recognizing that many individuals associate drowsiness related to the use of MOUD with being “high,” one resident asserted that while staff may not share this perception, they make little effort to engage in discussions about MOUD with house members. When asked whether staff speak to MOUD as a part of one’s recovery in groups meetings or RH programming, one resident stated that group topics might focus on the problem of using multiple substances, stating, “No, we just stick to the polydrugs and stuff, you know.” (RESIDENT 9) When asked if staff held stigmas about residents prescribed MOUD, another resident stated:

Half and half. Like, it’s 50/50. Some (staff) think you using that (MOUD) as a substitute. Others are, like, you weaning yourself off of it so you don’t even have to do that anymore. But, it (staff perspectives) are mixed. But, yeah (stigmas exist). (RESIDENT #20)

When asked if he felt comfortable talking to staff about his choice to obtain MOUD as a part of his recovery process, one participant stated, “Sometimes. It depends what people (which particular staff are working). Like my family, my mom, I talk with my mom about everything.” (RESIDENT #16). This same resident expanded by sharing the pressure to reduce use enacted by staff:

Because sometimes (staff) ask you, when are you going to go down? (reduce MOUD dose) When are you going to start going down? And sometimes I feel like, oh my God, you know that’s my own business. Sometimes I feel a little bit angry. But I know it’s for my own, you know benefit. But sometimes I feel like, oh my God, there we go again, man. With the same shit. (RESIDENT #16)

3.5. Governance/Role of peers

Peer governance involves residents actively participating in decision-making, fostering personal accountability and ownership of their recovery. In the settings studied, long-term residents were integrated into peer coach roles, promoting peer-driven leadership and collaborative engagement as central elements of the recovery model. When asked what he had to do to be promoted to a staff member at the facility, one resident responded:

I had to do volunteer work for two weeks. And then just be on the right path. And our boss was, like, why do you want to become a recovery coach? And I said I want to help. They’re helping me, so I want to help them. (RESIDENT #3)

Promoting residents with lived recovery experience to staff roles ensures that new residents receive support from individuals who not only understand their challenges firsthand but can also foster meaningful, trust-based relationships. With this shared experience, promoted staff can also help to further root shared decision-making and personal accountability into the recovery residences’ practices. However, this governance may be more easily challenged when residents promoted to staff face role conflict between supporting residents and adhering to recovery home rules. As one resident who had recently been promoted to a new role as recovery coach explained:

That’s the way I’ve been taught: To go by the book. You could become friends with residents but take your job seriously. And you get paid for a reason. This one time, this resident came in and he was under the influence of cocaine, and he wanted me to pee for him. I’m like, bro, I’m not peeing. And I had my walkie (radio to communicate with other staff) on, and I pressed it and the other recovery coach heard everything and what was going on. I was, like, bro, you’re messing with my recovery and job. No, I’m not going to do it for you. (RESIDENT #3)

Establishing relationships is vital for coaching and supporting others through their recovery. However, promoted staff must balance their new allegiance to other RH staff and rules without diminishing their ability to support new residents or risk their own recovery journey and placement at the RH. One resident noted that this dual role can affect relationship-building and their ability to supervise effectively:

You have to play double sides. I told her (resident-staff), like, you’re not consistent. One minute you like this, but when staff come around, you that type of shit (act a different way). And don’t be like that. Be one way. When you’re working, you’re working. You don’t have to drill sergeant us because your bosses are here. That’s unnecessary, you know. But they say staff are not our friends and that’s hard. Because what if we do develop that bond? (RESIDENT #10)

3.6. Community-oriented/Prosocial bonds within and outside the home

A key element of recovery housing is fostering peer support networks, both within and beyond the residence. In-house programming, often led by staff or former residents with lived experience is one way that residences can facilitate this. Referring to a goal-setting class, one resident shared:

I do a meeting every week on Sundays at 6:00. And we go around the room, and we say our goal for last week and our goal for this week. And then I’ll talk about something, like, what are your triggers, or what are you getting out of recovery, or what’s, what’s your biggest challenges. (RESIDENT #3)

Residents reported that sense of community was strengthened through weekly classes and programming, and they found that they could seek assistance from most staff, regardless of their level within the organization:

Whether the recovery coach, or it could anybody. You might get the program manager. (You can just say) Hey, I’m, you know, I’m in a crisis. We have morning meditation every morning. You know, you can share it. You can also, you know, and it’s just a community. Everybody can talk. (RESIDENT #8)

Having a sense of community within the RH fostered personal accountability for the programming and strengthened commitment to one another:

The most useful thing for me is, I feel a sense of obligation to do my best when I’m here. Because I know that the program manager has high standards. And because I want to live up to those strict standards. (RESIDENT #12)

The recovery environment and the bonds formed between peers and staff reinforced lessons from RH programming, providing residents with tools to resist relapse. However, those using MOUD as part of their recovery reported challenges in building these bonds due to stigma surrounding MOUD use:

A lot of people have a stigma with Methadone. People think people get on Methadone just to stay high. Some people do abuse it. If you maintain a correct dose, you don’t abuse it. In AA, you’re technically not clean because you’re on Methadone. People nodding out. It’s just a stigma on it. People think that people are just using it to stay high. (RESIDENT #08)

Residents perceived fellow residents who chose to incorporate MOUD as a part of their recovery as not truly being sober:

The stigma (in recovery residences) is something very similar to a person getting clean in prison. Oh, you didn’t really, your clean time doesn’t count because you didn’t choose it. You were obligated to do so. (RESIDENT #12)

When asked if staff held stigmatizing views around individuals who use MOUD, one resident stated:

No, not really stigmatized. The only reason I know who’s on methadone and who’s on Suboxone is by the way they behave in morning meditation. You know, so staff doesn’t tell people’s business. (RESIDENT #7)

Although staff do not share this information, residents could identify who is prescribed MOUD by observing behavior and the medication line:

People are going to find out because we’re all in the med line (together). We get our medication, and they can see you drinking a bottle. It’s kind of something that’s hard to hide. … So, you have people waiting outside in line, door wasn’t shut. You hear everybody. That bothered me, too. You can always hear what residents are getting. Some of that’s personal. Because it’s a community and we should all not judge one another. (RESIDENT #8)

When asked if he felt comfortable talking about methadone as a part of his recovery during RH meetings, one resident states:

Not really. Because some people, they don’t know about your life and I feel, when I talk about medicine, some people say, oh, there you go, oh, that’s why he sleep too much, oh, okay, he like drugs, he like this, oh, okay, that’s why. (RESIDENT #16)

4. Discussion

This study highlights how recovery home policies and practices reflect the principles across each of the SMR domains from the residents’ perspectives. While residents emphasized the critical role of staff in supporting their recovery journeys, their experiences also revealed that, despite formal acceptance of individuals on MOUD, informal social norms within the homes may conflict with these stated commitments. (Mericle et al., 2022; Mericle et al., 2023).

Residents described RHs in this study as providing safe and supportive environments (Mericle, Hemberg, et al., 2019). As noted by Polcin and colleagues, strict house rules—such as prohibitions on smoking, illicit substances, random searches, and screenings—were key to maintaining safety (Polcin et al., 2014). Support was further reinforced through structured policies like curfews, mandatory meetings, chores, and house meetings. Rent-free access allowed residents to meet program expectations without financial stress, enabling greater focus on recovery. Prescription monitoring policies, including secure storage, sign-in procedures, and scheduled access, helped reduce medication misuse. However, some residents found the lack of privacy during medication access to be stigmatizing or intrusive.

Residents highlighted recovery residences’ alignment with the social model philosophy, particularly through staff’s role in treating recovery as a lifelong process. The RHs fostered a supportive, structured environment with strategic staff presence, individualized support, and community-building programming. Staff offices were located near residents’ living areas, promoting frequent interaction. Staff provided personalized goal-setting, emotional support, and guidance. Most staff had lived experience with substance use, recovery, or the criminal legal system, enhancing relatability, building trust, and offering hope for long-term recovery.

Residents acknowledged that RHs provided emotional and programmatic support, as well as access to essential external resources like employment services, medical transportation, and documentation assistance. The integration of long-term residents into peer coaching roles reinforced the social model of recovery, though some residents noted challenges in adjusting to these responsibilities. Staff-led classes on goal setting, relapse prevention, and meditation offered structured programming that fostered accountability, recovery skills, and community. These prosocial bonds strengthened residents’ sense of belonging and prepared them for challenges after leaving the RH.

Despite feeling these general recovery supports, residents found staff perceptions of MOUD varied considerably. While some staff members are openly supportive, others adopt a more conditional stance—acknowledging the role of MOUD in recovery but emphasizing its temporary nature. Still, others express more stigmatizing views, perceiving MOUD as a replacement for illicit substances or pressuring residents to reduce or discontinue their use. These mixed attitudes contribute to an inconsistent support environment and can negatively affect residents’ confidence in their chosen recovery pathway. Therefore, even when formal policies exist to support this resident population, informal social norms may undermine them.

Despite the widespread use of MOUD among residents and slow-growing staff acceptance as found in similar studies (Gallardo, Wilkerson, et al., 2024; Majer et al., 2020), RHs in this project generally did not address MOUD-related stigma in a formal way, as noted in other studies (Jason, 2021). Although RH programming often requires attendance at Alcoholics/Narcotics Anonymous meetings, staff did little to address the tension between the medical model of many 12-step programs and the social model of recovery (Miles et al., 2020), reinforcing the stigma that those prescribed MOUD aren’t truly in recovery (Andraka-Christou et al., 2021; Madden, 2019). This gap allows stigma to persist at an intervention point in which individuals are supposed to receive recovery support (Madden, 2019). Additionally, the lack of privacy around MOUD use exposes residents to scrutiny and discrimination, leading many to feel uncomfortable discussing their medication-assisted recovery. This discomfort may limit peer support engagement and reinforce feelings of isolation.

The sustainability of SMR within RHs requires a thoughtful and purposeful approach to integrating residents receiving MOUD. Integrating recovery housing into a broader service delivery framework could enhance its recognition and establish its essential role within a comprehensive substance use continuum of care (Mericle et al., 2023). Without clear practices for integrating MOUD into other evidence-based treatments, these interventions may destabilize the recovery environment (Damian et al., 2017). While NARR and SAMHSA provide guidance on MOUD policies (e.g., lock boxes, medication logs), our study highlights the need for best practices to reduce stigma and support residents in medication-assisted recovery (Volkow & Blanco, n.d.; Department of Justice, 2022; National Alliance for Recovery Residences, 2019; Substance Abuse and Mental Health Services Administration, 2023; Tolley et al., 2016; Vigilant, 2004; Wood et al., 2022). Furthermore, without understanding how MOUD, particularly methadone works, staff may unintentionally undermine its effectiveness by encouraging subtherapeutic dosing, increasing relapse risk (Dewey et al., n.d.; Dewey et al., 2025; Joseph et al., 2024; Sivils et al., 2022; Wood et al., 2022). These findings underscore the need for evidence-based MOUD interventions tailored to RH staff and residents, with an emphasis on education and stigma reduction.

Table 2 presents concrete recommendations for RH staff.

Table 2.

RH recommendations.

Policy Level	• Establish clear MOUD policies and practices aligned with field standards • Private dosing practices
Staff Level	• Provide information about how the SMR functions with RH settings • Enhance staff training on basic recovery support and MOUD efficacy • Equip staff with continual support and educational tools to easily implement general and MOUD policies and practices

This study has several limitations that should be considered when interpreting the findings. First, the paper only focuses on residents’ perspective and therefore, the lack of staff perspective is a limitation. Further, because only in-program residents were interviewed, we do not have the perspectives of those individuals who were removed from the home for failing to adhere to house rules. Additionally, the exclusive focus on NARR Level 3 recovery residences limits the generalizability of the results to other levels of recovery housing, such as Levels 1, 2, or 4, which may operate under different structures and support models. Additionally, all participating residences were located in Chicago, an urban context that may not reflect the experiences or operational realities of RHs in suburban or rural areas, or in other states where recovery policies, resources, and cultural attitudes may differ significantly.

5. Conclusion

The findings presented here are useful for all RHs accepting individuals receiving MOUD as well as all RHs considering accepting such individuals as increasingly MOUD is recognized as an evidence-based solution for recovery. From the residents’ perspective, there is no formal effort within recovery housing programming to address the stigma surrounding MOUD, despite general tacit acceptance. Although MOUD is acknowledged as a valid recovery path, stigma persists among peers and staff, creating judgmental attitudes that can undermine the recovery environment. Without structured efforts to confront this stigma, such attitudes may weaken the effectiveness of the social model of recovery. If MOUD is viewed as a weakness rather than a legitimate recovery step, it risks contradicting the model’s principles and undermining long-term recovery.

Data availability

This research is funded through the NIH HEAL initiative, which requires that funded project share data in the HEAL Data Platform. Thus, de-identified data from the study will be archived with the University of Michigan (CPSR National Addiction & HIV Data Archive Program).