The destructive nature of substance use disorders and the influence of active addiction on people’s behavior can often lead to homelessness. In fact, The Substance Abuse and Mental Health Administration (SAMHSA) estimates that 38 percent of individuals experiencing homelessness are dependent on alcohol, while 26 percent abuse other drugs, including opioids. With growing recognition of housing as a critical determinant of health and recovery, we must thoughtfully consider what kinds of housing can best help people with addictions optimize their potential for recovery and re-stabilize their lives.
Two recognized housing approaches intended to help people with substance use disorders (SUDs) transition from homelessness are “recovery housing” and Housing First. These approaches operate differently and have unique histories — yet rather than advocate for one over the other, I suggest that fully supporting both approaches should be our priority.
Alcohol and drug-free (recovery) housing is a critically important and currently under-resourced intervention. It can be operated with tiered levels of supports that are matched with the needs of residents, including more intensive supportive services for those exiting homelessness to self-governed Oxford Houses or Recovery Homes. Many residents of recovery housing attest to their need for this safe and supportive living environment in order to promote their long-term recovery from addiction, their health and wellness, and their ability to stay stably housed.
In the Housing First model, the top priority for service providers is to help individuals and families secure permanent housing. Often the term “low-barrier” is applied in this model, indicating that there are no conditions on tenancy, such as sobriety or participation in treatment. Housing First is based on evidence that stable, lease-based housing plus voluntary acceptance of services can help people make progress on addressing their mental health and addiction disorders.
My advocacy for both models is rooted in 17 years of work on programs designed to help this population. Indeed, my work starting Housing First programs at Central City Concern (CCC) in Portland, Oregon and at Colorado Coalition for the Homeless in Denver was inspired in part by wanting to make sure we were “throwing everything that worked” at ending chronic homelessness and addiction. At CCC, the idea of adding Housing First programming was initially met with some resistance, especially by colleagues who were themselves in long-term recovery. Over time, however, people began to see the value and successful outcomes of offering housing that was paired with individuals’ choices.
Recovery housing can be very effective for clients who are self-initiating detox and treatment. When evidence-based supported employment services, peer recovery mentors, and coordinated outpatient treatment were incorporated into CCC’s recovery housing, we found that high percentages of individuals with primary SUDs who had been homeless completed treatment and remained housed and employed one year post-exit.
With evidence supporting both approaches to housing for people with SUDs, providers and policymakers must be open to a range of approaches to address the diverse preferences and needs of the individuals they hope to serve. For this reason, when I shared the effectiveness of CCC’s recovery housing programs with federal agencies and stakeholders around the country, I also spoke (and still do) about the importance of ensuring housing choice for homeless people with SUDs.
Likewise, the Department of Housing and Urban Development (HUD) discussed in its 2015 Recovery Housing Policy Brief the value of promoting individual choice among housing options for homeless individuals. The brief encouraged expanding the supply of permanent supportive housing and other models that use a low-barrier, Housing First approach, so as not to exclude a large number of people who are unprepared to meet sobriety or abstinence requirements. But HUD also affirmed the importance of providing recovery housing options for people who want and need a sober-living environment. HUD’s Policy Brief outlines the characteristics, practices, and outcomes it expects from recovery housing funded with its homeless dollars.
The expansion of recovery housing received broader federal support in the 2016 Surgeon General’s Facing Addiction in America report, and in another report issued in 2017 by the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Earlier this year, the National Council for Behavioral Health (NCBH) issued a Recovery Housing Guide to help states include high-quality recovery housing among the options offered by their behavioral health systems. NCBH followed this guide with a letter to every Single State Agency, alerting them to SAMHSA’s unprecedented decision to allow State Opioid Response Grants ($930 million) to fund supportive services for individuals with opioid use disorders in recovery housing.
Research is needed on the long-term effectiveness of both recovery housing and Housing First programs for people with primary SUDs. For now, states and local jurisdictions can use the practices described in the HUD and NCBH policy briefs to expand the capacity of recovery housing and improve the practices of existing programs. Recovery housing can promote housing tenure, long-term recovery, reunification with families and children, economic and educational advancement, improved health and wellness, and community involvement. Many of my colleagues whose experience of recovery housing helped cultivate my understanding of the model also report perhaps the most significant outcome of all: They say they owe their lives to it.
Current legislation in Congress addressing the nation’s opioid crisis has wide bipartisan support and includes several provisions to provide housing-related assistance for people in recovery from SUDs. As the final bill becomes law, states and communities working to combat both addiction and homelessness will become better able to offer housing choice that includes robust recovery housing programs.