An Evaluation of Recovery Housing in Missouri: Key Outcomes and Recommendations

Claire Wood¹ PhD; Brenna Lohmann¹ MSW; Kori Richardson¹ MPP; Alex Duello¹ MPH; Marsha Hourd³; Rosie Anderson-Harper² MA; and Rachel Winograd¹ PhD

Overview

Between legislative advances for increasing recovery budgets, creation of recovery housing standards by the National Alliance for Recovery Residences (NARR), and increasing support of the use of Medication for Opioid Use Disorder (MOUD) as part of an abstinence-based recovery path, recovery housing has made substantial progress in finding ways to support individuals in their recovery.

As part of SAMHSA-funded awards focused on addressing the opioid crisis, the State Targeted Response (STR) (2017-2019) and State Opioid Response (SOR) grants (2018-present), a team based out of the University of Missouri, St. Louis–Missouri Institute of Mental Health (UMSL-MIMH) conducted a robust mixed methods evaluation of recovery homes across the state. The goal of the evaluation was to provide insights to the Missouri recovery system and identify gaps and strategies to better support individuals in their recovery. The two-part evaluation of the recovery housing system included:

1. A Community Based System Dynamics (CBSD) evaluation, consisting of five workshops with recovery housing managers and residents. These workshops gave opportunities for stakeholders to voice their thoughts and provided key insights about ways to improve the recovery housing system.
2. A survey of recovery housing characteristics, designed to establish a point-in-time estimate of current recovery housing residents, assess the overall climate and acceptance of MOUD, and identify housing characteristics and variation across houses (e.g., policies, procedures, structures, external environments). This article will focus on a summary of this specific component of the evaluation.

Summary of the Housing Characteristics Survey Methodology and Results

The Recovery Housing Characteristics survey was developed through collaborations between university researchers, state-level recovery leaders, and recovery home operators. Data was collected from March to August 2019 on 95 percent of eligible houses (64 of 66). Surveying live-in house managers (as opposed to Executive Director) was prioritized due housing managers’ knowledge of day-to-day activities and the potential impact they have on the culture of each home. Surveys were administered to live-in house managers when possible, or whoever was the most involved with the day-to-day activities among houses without a live-in house manager. Only recovery houses accredited by the Missouri Coalition of Recovery Support Providers (MCRSP) (based on NARR standards) and deemed “medication friendly” (e.g., do not require individuals to taper off MOUD) were included in this evaluation. Recovery houses are predominantly located in and around metro areas across Missouri (e.g., St. Louis, Kansas City, Springfield).

Characteristics of Housing Managers and Residents

               In general, house managers were predominantly White, male, and a majority (64 percent) identified as a person in recovery and/or as a Certified Peer Specialist. Residents (as reported by house managers) were also predominantly White (77 percent) and male (68 percent). Black individuals, representing 17 percent of both house managers and residents, are underrepresented in recovery housing relative to their representation among those dying of drug overdoses in Missouri (24 percent in 2019). Among residents, histories of opioid and methamphetamine use were the most common. House managers also reported that approximately 60 percent of residents were employed full-time, 44 percent had used substances intravenously, and 30 percent had previously experienced an overdose. Because we relied on house managers’ reports (rather than self-reports from residents themselves), it is important to note that these are estimates.

Medications for Opioid Use Disorder

A primary focus of the STR/SOR grants is to increase access to and utilization of MOUD in treatment settings; thus, a safe and supportive living environment for individuals taking MOUD has become increasingly critical. Housing managers were asked about acceptance (or perceived acceptance) of MOUD in their homes, and the extent to which tapering off medications was encouraged, even if it was not a requirement for residency:

• Approximately 58 percent of house managers reported encouraging residents to taper off MOUD. However, qualitative phone-based follow-ups with a subset of respondents suggested this encouragement predominantly occurred implicitly through house managers sharing their personal experiences and recovery paths that typically did not involve MOUD. House managers also noted these conversations were often initiated by residents who did not wish to remain on MOUD long-term, likely due to a number of contributing factors (e.g., concern about being “dependent” on any substance, internalized MOUD stigma, medication side effects).
• Methadone was perceived as the least accepted medication and naltrexone was perceived as the most accepted medication.

Housing Policies & Procedures

NARR/MCRSP developed a set of established standards for accreditation, though there is flexibility in the extent to which houses must meet each of the specific requirements prior to accreditation. Furthermore, because these are standards rather than all-encompassing policies that standardize practices across recovery homes, there is substantial variability in the policies and procedures enacted.

• Most houses have a zero-tolerance policy for using substances in the home, violence, sexual misconduct, and repeated theft in the home; however, the extent to which other policy violations result in discharge (e.g., using substances outside the home) are more often determined on a case-by-case basis.
• While there are no NARR standards related to transgender residents (nor for LGBTQ+ residents more broadly), only 34 percent of men-only recovery houses reported accepting transgender men and 27 percent of women-only recovery houses reported accepting transgender women.
• Only 3 percent of houses accommodate children to live in the home with their parents.
• A majority of houses (89 percent) reported keeping naloxone on-site and 80 percent reported providing naloxone administration trainings for residents. (Note: It is an MCRSP standard that houses have naloxone on-site, so for the houses that reported not having it, it is possible managers had used their current supply and thus did not have naloxone on-site at the time of data collection or they were unaware of an existing supply.) Approximately 45 percent reported providing naloxone to residents upon discharge either routinely (9 percent) or on a case-by-case basis (36 percent).
• MCRSP accreditation standards require staff to be trained in cultural competency; however, there are no specific regulations on what that entails, thus trainings vary in content and frequency across housing organizations. Approximately 48 percent of house managers reported receiving training in one or more of the following content areas: racial/ethnic diversity, LGBTQ+, gender, cultural literacy, discrimination, allyship development, or privilege.

Recommendations

While many of the recommendations outlined below could apply to recovery homes outside of Missouri (and indeed fall in line with current advocacy efforts from many national recovery groups), we recognize there are legitimate financial, cultural, and logistical barriers to their implementation. Further, because research on recovery housing systems is so limited, it is difficult to know what will and will not work to advance a particular cause. Future research is needed to assess the extent to which these recommendations contribute to positive outcomes among residents and support individuals in their recovery.

1. Increase geographic and racial diversity in recovery housing
   • Target efforts to increase access and the number of NARR-accredited and MOUD-accepting housing provided in areas that are either currently without or with only limited access to recovery housing (e.g., rural areas, predominately-Black neighborhoods). It is additionally important to consider expanding opportunities for individuals from underrepresented groups to become recovery home owners and operators. Methods to diversify recovery home availability, ownership, and management necessitate increased funding and can include but are not limited to incentive programs, targeted assistance, and capacity-building opportunities, such as information sessions for individuals who may be interested in becoming a housing provider but need guidance when navigating the application process.
      
2. Provide additional training opportunities for recovery housing operators and residents
   • Develop and disseminate training documents, videos, and workshops offering guidance on how best to support residents pursuing all recovery pathways, including those which involve MOUD. Training content should include examples of ways in which both explicit and implicit bias can impact a resident’s decision to discontinue MOUD.
   • Integrate overdose reversal training into intake procedures for residents.
   • Develop and disseminate standardized training documents, videos, and workshops offering guidance on inclusive practices, cultural competency, and racial-responsiveness. Support attendance of the five day, 42-hour Certified Peer Specialist training, which includes cultural competency and ethics components.
   • Note: Training content and delivery should include the expertise of individuals with work and lived experience in recovery housing. 
      
3. Develop and support inclusive policies and practices
   • Develop and monitor inclusive policies and practices (e.g., adding gender neutral pronouns to housing forms). For more information on best practices for LGBTQ+ inclusion in recovery housing, see the Ohio Recovery Home Best Practice Guide. In addition, many cities have developed briefs to address racial inequities in housing since COVID-19 that can be applicable to recovery housing as well (see Seattle’s Planning Commission “A Racially Equitable & Resilient Recovery”).
   • Include questions and statements about inclusivity, equity, non-discrimination, and eliminating racial and gender bias in housing accreditation applications, site visits, and within housing operation manuals and policies.
      
4. Support new and ongoing research and evaluation efforts
   • Collect and review resident outcomes data, including an examination of outcomes by house and resident race, gender, MOUD status, length of residency by MOUD status, naloxone administered, and other variables on an ongoing basis.
   • Use data to identify specific policies and practices that are associated with favorable resident outcomes. Regularly provide targeted assistance for improvement and/or restrictive action based on outcomes achieved. 
   • Include perspectives of executive directors, who may be better able to provide insight on the broader vision and mission of housing organizations, as well as rationale for existing policies and procedures.
      
5. Increase funding for recovery housing programs and related services. In addition to the recommendations above, which necessitate increased funding for both the services themselves and the expertise of individual contributors, additional funds for recovery housing systems are sorely needed. Future funding could increase availability and access to recovery housing and wrap-around services more broadly (e.g., transportation, peer mentoring, recovery counseling, care coordination). Additional funding would also support housing children with their parents, appropriately compensating housing managers, providing naloxone to all residents, and promoting high-level coordination between treatment and recovery housing systems.

Limitations

Because this was Missouri’s first statewide evaluation of recovery housing, there are a number of limitations to this work that should be considered. First, this survey only captured a single point-in-time snapshot of the people and environments within the recovery housing system, so we cannot speak to the evolution of recovery housing that has taken place in recent years. Second, roles and responsibilities of house managers vary across organizations, and this, combined with high turnover among house managers, means some respondents had a much better understanding of house culture, policies, and practices than others, which may have impacted the accuracy of some of our survey results. These limitations, combined with those already referenced above (lack of involvement of executive directors, no reports from residents themselves), offer direction for future recovery housing research.

Conclusion

Stable housing plays a vital role for people in early recovery from substance use and addiction. Recovery homes fill this basic need while also providing social and structural support for residents who are often seeking respite from chaotic drug use and unstable environments. Recovery housing operators can take additional steps to provide an equitable and supportive environment for residents, including offering and participating in training opportunities, integrating inclusive policies and practices, and engaging in ongoing research and evaluation efforts. However, operators cannot be asked to address these challenges alone or without financial support. There is critical need for increased state and federal funding to go to recovery housing providers in their ongoing efforts to innovate, expand, and serve.

Acknowledgements

We would like to acknowledge the state leaders and recovery home operators who provided significant insight and feedback on this article. Greg Smith⁴, Jordan Hampton⁵, Ladell Flowers⁶

¹ University of Missouri – St. Louis, Missouri Institute of Mental Health
² Missouri Department of Mental Health, Division of Behavioral Health
³ Child and Family Empowerment Center
⁴ Missouri Coalition of Recovery Support Providers
⁵ Recovery House of St. Louis
⁶ Dismas House of Kansas City

The full-length evaluation reports (CBSD evaluation and recovery housing characteristics survey) provide additional goals, findings, and recommendations.