Recovery homes coping with COVID-19

Abstract

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

Thousands of people with substance use disorders (SUD) live in recovery houses across the US, and they feature social networks of friends and associates who work and are abstinent (Jason et al., 2020). The majority of the residents of recovery homes have past histories of homelessness, criminal justice involvement, psychiatric comorbidity, and chronic illnesses (Jason & Ferrari, 2010). These are all risk factors for becoming infected with COVID-19. It is important to investigate the role of recovery homes in the COVID-19 epidemic. Given the contagious nature of COVID-19, these recovery settings might provide challenges for the residents who live with others in close quarters. However, it is also possible that these settings reduce health disparities among those most vulnerable to contracting COVID-19.

Psychological impact of COVID-19

Much of the available research in the psychology of the pandemic comes from China. During the initial phases of COVID-19 in China, Wang et al. (2020) found a major source of anxiety stemmed from concerns that an individual’s family member(s) may contract the virus. Factors such as gender (being female), exhibiting physical symptoms (e.g., myalgia, dizziness), and student status were correlated with higher levels of stress, anxiety, and depression. In a survey conducted of people in China, Hong Kong, Macau, and Taiwan, Qiu et al. (2020) found increased levels of psychological problems in respondents (e.g., panic attacks and anxiety); this effect was seen especially in female respondents, younger adults (ages 18–30) and older adults (ages 60+). Increased information from social media contributed to stress in young adults while higher mortality rates increased stress in older adults. Other factors such as the level of education, availability of local medical resources, the efficiency of local healthcare systems, and preventative measures were also associated with psychological distress. The negative psychological impact was associated with isolation due to being quarantined. Utilizing surveys, Cao et al. (2020) found that anxiety was exacerbated if the respondent knew someone who contracted COVID-19, and that economic stressors and changes to daily life were associated with higher levels of anxiety. Li, Wang, Xue, Zhao, and Zhu, (2020) found that since the outbreak, expressions of negative emotions such as anxiety and depression had increased and expressions of positive emotions decreased. Based on insights from these preliminary studies, individuals who are living with others in recovery homes might have concerns about how to deal with those infected with COVID-19, but such settings might also provide an important community resource for those most vulnerable to this epidemic.

Recovery homes

Recovery homes are currently the largest psychosocial, recovery-specific, community-based support option (Polcin, Korcha, Bond, Galloway, & Lapp, 2010). To support these initiatives, Substance Abuse Prevention and Treatment block grants make at least $100,000 available annually to each state that provides loans for recovery housing, and states may provide up to $4,000 in loans to each group that requests to establish drug-free housing for individuals recovering from SUDs (Substance Use Disorder, 2018). Other examples of the federal government’s interest in this area include the two recovery housing meetings held by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2017. These meetings covered topics including research on emerging best practices in recovery housing and state recovery housing programs. In March of 2018, the United States Government Accountability Office released a report on recovery housing (Substance Use Disorder, 2018) and indicated that “Recovery housing—peer-run or peer-managed supportive residences—can offer safe, supportive, stable living environments to help individuals recovering from SUD maintain an alcohol- and drug-free lifestyle” (p. 1).

Traditional recovery homes (TRH) are low-cost, community-based residential programs for people with substance use disorders (Borkman, Kaskutas, Room, Bryan, & Barrows, 1998; National Association of Recovery Residences, 2012). Typically, residents of TRHs can stay for as long as they want so long as they abstain from substance use and pay a modest rent to the recovery homeowner. In these settings, the staff and/or owner determine who can enter the recovery homes and whether residents need to leave if they relapse or violate house rules. Although staff lives in some TRHs, it is more common that they regularly visit and monitor these settings.

In contrast with TRHs, Oxford Houses (OH) comprise a distinct model of recovery living homes; there is no professional staff associated with OHs (Jason, Ferrari, Davis, & Olson, 2006). The central difference between the two approaches is that TRHs employ house managers (paid staff) who run house meetings, enforce rules, make decisions regarding eviction due to rule violations, collect weekly rent, and oversee the overall operation of the houses. In OHs, these functions are performed by the residents themselves in a standardized, self-governing, administrative structure. OHs and TRHs comprise large networks that provide relatively inexpensive housing and support for abstinence. These settings have been especially important in providing support for high-risk, low-resource individuals who frequently cycle through substance use treatment programs, often failing to maintain abstinence because of their tenuous financial and social linkages to the mainstream community. There is a need to better understand stressors that COVID-19 has caused to those living in recovery homes, as well as the house practices are taken to keep all residents safe. We need to learn more about the attitudes of those infected with COVID-19, the other residents, and the gatekeepers and managers of the recovery homes. We also need to better understand the impact of COVID-19 within this sector of residential healthcare.

Health disparities

Residents of recovery homes often have experienced past criminal involvement, prior homelessness, and psychiatric comorbidity (Jason, Olson, & Foli, 2008). As mentioned earlier, these are all risk factors for COVID-19. One study found that 63% had experienced homelessness for an average of 6 months (Jason, Ferrari, Dvorchak, Groessl, & Molloy, 1997; Oxford House, 2018). In another sample, Majer, Jason, Ferrari, and North (2002) found that 58% of the residents reported a psychiatric disorder other than substance abuse, and 52% reported two or more psychiatric disorders. Specifically, antisocial, mood, and anxiety disorders were most common in people whose drugs of choice were cocaine, alcohol, and cannabis. In a national study of women in recovery homes, our team examined the history of trauma, substance abuse, and psychiatric symptoms of residents (Olson et al., 2003). Within this sample, 67% had experienced depression at some point in their lives and 46% had attempted suicide. Roughly 95% had experienced some form of past trauma. Clearly, individuals who reside within recovery homes represent a highly at-risk, sociodemographic group with multiple comorbidities.

Minorities are more likely to experience health disparities in the realm of substance use and treatment, as African American and other minorities experience more barriers to substance abuse services compared to European Americans (Wells, Klap, Koike, & Sherbourne, 2001). Rates of COVID-19 are also higher for African Americans and Latinx Americans. Racial minorities also have access to fewer support services than their European American counterparts, and the care minorities do receive is of comparatively lower quality (Alegria et al., 2004). This disparity of care for minority groups is problematic, as SAMHSA found that African Americans, compared to national averages, have higher rates of substance use (SAMHSA, 2017), and those under the age of 25 have the highest rates of nonmedical prescription opioid use (SAMHSA, 2017). African Americans, according to Sartor, Kranzler, and Gelernter (2014), are at a higher risk for rapid onset of opioid dependence. African Americans with opioid use disorders are also more likely to experience co-occurring health disparities, are most frequently incarcerated for drug-related charges (Carson & Anderson, 2016), are more likely to have a comorbid psychiatric illness compared to national averages (SAMHSA, 2017), and are more likely to be released from incarceration into communities with a high concentration of available, illegal opioids (Knighton, Stevens-Watkins, Staton, & Pangburn, 2018). African American men are particularly vulnerable. In addition to increased incarceration rates, they have a higher chance of accidental overdose (Centers for Disease Control and Prevention, 2017a), contracting debilitating diseases like HIV and Hepatitis (Centers for Disease Control and Prevention, 2017b), and are at a greater risk of suicidality (Ashrafioun, Bishop, Conner, & Pigeon, 2017).

Research suggests that minorities acquire more benefits from living in recovery home settings than European Americans that also benefit from the same setting. Using survival analysis, Bishop, Jason, Ferrari, and Huang (1998) found that African Americans tended to stay in recovery homes longer than Non-Hispanic, White Americans, a finding that was later replicated via a survival analysis by Harvey (2014). This study found that African Americans relapsed at lower rates than Non-Hispanic, White Americans. Brown, Davis, Jason, and Ferrari (2006) found that African Americans gained more resources than Non-Hispanic, White Americans when living in recovery homes. In another study, African Americans, as compared to Non-Hispanic, White Americans, reported significantly more work in the past 30 days in recovery homes (Belyaev-Glantsman, Jason, & Ferrari, 2009). Walt and Jason (2017) found that even though African American women living in recovery homes had a higher number of past arrests and longer incarceration periods compared to Non-Hispanic, White, American women, African American women reported less psychological stress over resources loss. This result suggests that African American women in recovery homes are less threatened by structural hardships than Non-Hispanic, White, American women. Flynn et al. (2006) found that both living in a recovery home and participating in Narcotics Anonymous (NA) had a strong effect on who African Americans turned to for support. In another dataset, Jason, Mericle, Polcin, and White (2013) found increased rates of income from employment for Latinxs in recovery homes.

Recovery homes and COVID-19

There is a paucity of information to date on the effect of the COVID-19 epidemic on those in recovery homes. It is possible to surmise that some infected COVID-19 individuals will not be allowed to stay in a recovery house, and for those individuals, it is unclear whether they would be provided re-admission to the recovery house after being hospitalized. It is certainly possible that some social workers or authorities might mandate relocation to some form of quarantined living arrangement in public housing until a vaccine is available. However, our group has learned that some recovery homes are providing those with COVID-19 a single room where they have been asked to remain in isolation for 2 weeks, with food and other essentials being brought to them. In other words, residents have been providing their infected peers a safe place to live and recover, all while not charging these individuals rent for this period of time as they have been unable to work. We have also learned that other recovery homes have devoted considerable time trying to secure state and local resources for funding as residents are having difficulty paying their rent due to a reduction in employment. Recovery homes like jails/prisons are unique settings in that they house a number of the most at-risk individuals for contracting COVID-19. Despite this, we have extremely limited information about how these large networks of recovery homes are affected by the COVID-19 epidemic.

Casey Longan (Personal Communication, May 3, 2020) and Jackson Longan (Personal Communication, May 3, 2020) help with the Oxford House organization in the Southwest of the United States. Jackson now has a COVID-19 spreadsheet for the entire OH organization, and has documented 17 confirmed cases of COVID-19 among the more than 20,000 residents of OH. As testing becomes more widespread, this number will undoubtedly increase. There are many OH residents who are at higher risk of being infected due to being obese, over the age of 60, and having chronic health problems such as hepatitis C and diabetes. However, as these residents find ways to deal with this epidemic, they demonstrate that there is a lot that both researchers and residents can learn about overcoming the challenges of living in group residential settings such as recovery homes and nursing homes. Initially, it was unclear how the epidemic would affect the self-run, democratic recovery homes comprised of 8–10 individuals, and there was considerable anxiety present as a result of this uncertainty. Casey and Jackson said the OH network was really coming together to deal with fears about COVID-19 in group living settings as the network continues to strive to find ways to help those with entry-level jobs overcome losses in employment, as well as to help residents who have become infected.

In one house, when a resident tested positive for COVID-19, the entire house self-quarantined while other houses from the chapter dropped off food and supplies during a 2-week period. Many other houses are establishing a separate room and a restroom that can be used by one person in order to self-quarantine for a 2-week period. One woman who was infected decided to leave the OH to quarantine at her mother’s house, and hopes to return to the house once she has recovered. She had been living in the OH with her child, and even though her child has stayed with her, the child has not become infected with the virus. Houses are welcoming residents back if they decide to self-quarantine in other settings. Jackson said he knows of only one house where an infected person ended up infecting two other residents. In a particular house with an infected person, the entire house wanted to get tested, but local officials said that they would not provide that type of testing for all the houses. The residents are now engaging in action to try to overturn this ruling. On the other hand, tragedies have unfortunately occurred. For example, a resident in North Carolina told others that he was COVID-19 positive and proceeded to isolate himself in his room. In this time period, he overdosed and died, and it was discovered that he was actually never infected with COVID-19.

Oxford Houses are now instituting training for house members in order to reduce risks of infection. These pieces of training include education on frequent, thorough sanitizing skills to be utilized throughout the houses. In addition, in the past, residents from groups of 10–12 houses attended monthly chapter meetings, but these monthly meetings are now occurring through Zoom so that exposure to infection is limited. When weekly house meetings occur and when there is socialization in the houses, the residents learn about how to practice social distancing along with other strategies to protect all members.

The average rent for an OH resident, $100 to $150 a week, has created challenges because many residents have lost their jobs due to the epidemic. The houses are dealing with this in creative ways. For instance, a number of houses are reducing expenses such as paying only half the monthly dues to the Oxford House organization (which is $50 per month for each house). Houses are also subsidizing individuals (as houses often have some funds in a savings account) who are not able to pay for their rent due to job loss. Also, many of the members who lost their jobs are now finding new employment opportunities at grocery stores and other outlets that are hiring more employees. Houses that are part of the National Alliance for Recovery Residences network (recovery homes that have owners or other employees running the houses) are more likely to seek government funds to help pay for resident expenses, whereas the Oxford Houses are trying to both reduce costs and find ways to subsidize their residents.

Another issue the houses are trying to deal with involves policies enacted by Governors who have banned rental evictions during this epidemic. This is a source of tension as OHs ask residents who are disruptive or using drugs to immediately leave the houses in order to protect the sobriety of the others. This is something that is still being worked through legally as the house lease is tied to the house members, thus if the house members request a person to leave, this might not violate the state guidelines. We have also learned of some unusual acts of altruism within the Oxford House network. For instance, the Squamish tribe outside of Seattle, actually gave rent checks back to house members, saying they did not have to pay during these difficult times (George Duncan, Personal Communication, April 18, 2020).

Dave Sheridan (Personal Communication, May 4, 2020), the Executive Director of the National Alliance for Recovery Residences, feels that we will have to deal with COVID-19 for at least the next 2 years, and during this time, for many in recovery homes, employment prospects will be bleak. He reported that 60% of residents have lost jobs due to being laid off from restaurants and retail sales. Even when some of these businesses begin to open, due to social distancing, only half the number of employees will be rehired as there will be reduced maximum capacity in most settings. He felt that we need to know more about whether residents are now more likely to relapse, and whether they are being retained in these settings. Also, the ways that homes are operated needs to be examined. He expressed that some federal officials are encouraging residents to move out of their houses if they are working, as their exposure to the public is a risk to the other residents. He said that this was unfortunate as many residents do not have safe settings to move to. Dave also said that those who live in these settings are often marginalized, and we need to better understand what their experience is in order to assist them properly. In addition to losing employment, many residents also lose contact with community settings that have been so instrumental to their recovery, such as mutual aid groups. While many are trying Zoom meetings to get these types of support, there is burnout occurring with Zoom sessions. Additionally, these virtual meetings do not provide the same support as in-person meetings. In the past, some states have sent those from the criminal justice system to recovery homes, but in the present climate, some states such as Kentucky have stopped making any referrals to recovery homes. Consequently, a supply of new residents has dried up, affecting recovery homes. Further, these affects could vary due to differences between urban and rural area Oxford Homes. The NARR organization, which oversees many TRHs, is hosting weekly COVID-19 webinars where they review how to safely screen new residents, how to quarantine residents who have symptoms of or test positive for COVID-19, how to handle resident visitation pass requests, and how to deal with the economic impact of unemployment among a significant number of residents.

Conclusion

Recovery homes represent a large network of necessary community supports for persons with SUDs, but it is unclear how these settings are dealing with the COVID-19 epidemic. There is an urgent need to better understand individual- and organizational-level responses to the COVID-19 pandemic among people in recovery homes as well as those managing and making referrals to the houses. At the present time, it is unclear what the effects of COVID-19 are on remaining in recovery homes or dropping out of them. Certainly, living in close quarters raises the risk of exposure to disease, which could disrupt house routines, social support, and interactions that might otherwise be therapeutic.

Understanding the impact of COVID-19 on the infected residents of recovery homes, as well as challenges after recovery from COVID-19, could facilitate patient-centered planning, decision-making, and utilization of residential aftercare during this epidemic. Health care workers making referrals following SUD treatment need to know how COVID-19 issues within recovery homes might influence non-compliance and relapse. Furthermore, it is critical to better understand how different subgroups (e.g., age, gender, ethnicity, medication-assisted patients), particularly those from socioeconomically disadvantaged populations, are being affected by the COVID-19 epidemic. It is also imperative to investigate how those living in distinct areas (e.g., urban, rural) are affected by the pandemic.

As mentioned above, recovery home studies by Bishop et al. (1998) and Harvey (2014) found that African Americans relapsed at lower rates than Non-Hispanic White Americans. Callahan, Jason, and Robinson (2016) found a positive relationship between the length of stay in recovery homes and income; length of stay had a significantly greater positive impact on income for women with criminal convictions. Although Majer, Bobak, and Jason (2021) found social support to mediate stress in relation to health outcomes among residents utilizing/not utilizing medication-assisted treatment (MAT), homophily (in terms of living with fellow residents who were also utilizing MAT) was found to moderate these effects (Majer et al., 2020). Thus, the availability of supportive recovery homes for persons utilizing MAT in their recovery who are at greater risk for stress and psychiatric problems will no doubt be affected by COVID-19 issues. Overall, these findings suggest that recovery homes might be particularly supportive environments with the ability to reduce health disparities among vulnerable subgroups in addition to socioeconomically disadvantaged individuals at higher risk of developing COVID-19.

We need to know more about what are the most effective housing practices during this COVID-19 epidemic. Such research will contribute to better patient-centered decision-making that will be helpful for the needs of policymakers, clinicians, and patients. For example, this information could aid patient center decision-making as well as treatment centers providing discharge planning and advice to those at risk of developing COVID-19. Such a model will lead to recommendations for better ways to organize houses, including screening methods to ensure “readiness,” a formula for an optimal mix of residents, onboarding procedures for new residents, and potentially many more efficacious adaptations to current treatment practices for those who develop COVID-19.