Sober homes, recovery residences and Oxford Houses — all living arrangements for people who are in recovery from substance use disorders (SUDs) — may not have any room for people in treatment with the opioid agonists methadone or buprenorphine. The National Alliance for Recovery Residences (NARR), the main organization involved in certifying recovery residences, only allows people on medications to stay in their homes if the patients are not on maintenance, but heading toward a taper.
“We haven’t issued formal guidance, but we’re pretty clear on our standards,” said Dave Sheridan, director of NARR. Sheridan calls methadone and buprenorphine maintenance “harm reduction” and said that as such, it’s not a good fit for NARR homes. “We’re perfectly happy for our homes to support people on some kind of medication-assisted treatment as long as there’s an endpoint in mind, as long as they’re working toward a zero dose,” he said.
And that endpoint can change while the person is in the residence, said Sheridan. “As long as they are working with the doctor and treatment program, we’re not insisting that you tell us what your end date is, and hold you to it,” he said.
There also needs to be medication management in the home, said Sheridan, noting that patients on buprenorphine, and even some on methadone, have their medication with them.
Sheridan added that part of the recovery residence experience is “helping people get to a stable healthy lifestyle.”
Vivitrol, which is not an opioid, hasn’t presented the same kind of problems as methadone and buprenorphine, said Sheridan. However, he said, residents on Vivitrol are cautioned to alert their residence if they’re on it, mainly because if they get hurt and need opioid pain medication, it won’t work. “’Don’t get in any car wrecks,’” said Sheridan. “And we advise all of our residences that none of these medications are silver bullets for recovery.” He added that Vivitrol isn’t even very popular among patients. “Nobody’s clamoring to be on Vivitrol,” he said.
Supportive housing in Maryland
Sheridan suggested we talk to Carlos Hardy, president of the Maryland affiliate of NARR, for another viewpoint.
And indeed, Hardy, founder and CEO of Maryland Recovery Organization Connecting Communities, called the NARR policy “discriminatory.” If patients are going to be helped in their recovery — and that includes patients on medications — they need housing, he told ADAW. “You have to be willing to provide access to housing for 100 percent of the population” with SUDs, he said.
In the third year of a three-year grant from Maryland to organize recovery organizations, Hardy is focusing on helping people find housing, whether they are on medications or not. He does think, however, that the current treatment system is “overly dependent on medication,” and that without housing and jobs, medication won’t help these patients. “But as a person in long-term recovery myself and as an activist and advocate, it’s a damn shame that we are allowed to discriminate” against patients on buprenorphine or methadone, he said.
There are now 75 supportive housing providers in Hardy’s group, with a bed capacity of 1,200, he said. About 10 of the supportive housing providers have no problem taking patients on medication-assisted treatment, he said. The state has an “unwritten policy that says you can’t discriminate” against patients on methadone or buprenorphine, he said. But even those providers who do discriminate are still allowed to access state dollars to subsidize housing, he said. “Some say ‘You can’t come in on any dose over 70 milligrams’ morphine equivalents, and some say ‘You have to be on a taper,’” said Hardy. The only way they would change their policies would be if their funding depended on it, he added.
What are providers’ objections to buprenorphine and methadone? “They say it’s against their ideology, that it disrupts the community,” said Hardy. “I’m not saying housing folks on medication-assisted treatment is easy, especially when there’s no communication with the treatment centers,” he said. “But the bottom line is that we are sentencing people to die” by keeping them off opioid agonists. “So we do the right thing and get them on medication, but they can’t go to 12-Step meetings because they’re ostracized, they can’t get a job if they’re tested and now we’re telling them they can’t have a place to live?” he said.
Oxford Houses, where many people live for months and even years, do not have an official policy on medication-assisted treatment. “They decided to leave it up to the individual residence,” said Hardy.
Paul Molloy, CEO of Oxford House, told ADAW that last year in Montgomery County, Md., 23 of 86 beds were filled with patients on buprenorphine.
Abstinence, sobriety and agonists
Stuart Gitlow, M.D., has spoken at Oxford House conventions for several years, and said that buprenorphine did come up during discussions. The immediate past president of the American Society of Addiction Medicine (ASAM), Gitlow said “part of this is simply about having the dialogue.” ASAM has no specific position on housing, he said. “But let’s face it, the folks running the sober houses aren’t necessarily clinicians, and they’re defining sobriety as not including methadone or buprenorphine,” he said.
“We recognize that a lot of people are coming out of treatment and are being prescribed buprenorphine either as a maintenance medication — which is really harm reduction — or as a taper,” said Sheridan, who said that maintenance on an opioid is not abstinence. “Our residences don’t support it because it’s not abstinence-based recovery,” he said. Patients on maintenance with methadone or buprenorphine “absolutely need a place to live,” he said. “But not here.”
As for methadone maintenance being “harm reduction,” Gitlow’s response was anger. “That’s absolute bullshit,” he said. “Harm reduction is a situation where we’re trying to reduce the morbidity that comes from the dangerous drug itself — for example, giving heroin users clean needles or giving them heroin that is pure instead of tainted with whatever they get on the street.” But a medication that is approved for treatment of a substance use disorder is not harm reduction, he said. It’s treatment.
It would be difficult to develop a consensus across ASAM on this issue, said Gitlow, noting that many members agree with Sheridan on the definition of abstinence. He put out a question to the “Like-Minded Docs” (LMDs) group — many of whom are members of ASAM — asking if a patient on buprenorphine for seven years is considered abstinent. Many of the LMDs, who are generally opposed to agonist medications, said that the patient could not be considered abstinent or sober.
Looking at the housing situation from the NARR perspective, Gitlow said a possible compromise could be having a separate house for individuals on maintenance therapy. “I can certainly understand the need to keep someone out of the house who might cause difficulties,” he said. “So why not have a separate house for people on maintenance — but at least be even-handed about it? Don’t leave these people out in the cold.”
But there is still a big gap between that view and the view of many sober home providers. Sheridan of NARR said that Hazelden Betty Ford has been interested in finding homes for outpatient clients in Southern California on buprenorphine, and NARR, despite its pro-taper policy, is helping. “It’s a long educational process with our sober living operators in California,” said Sheridan. “We’re going to show them the clinical evidence, and ask them to review it.” But change is difficult. “A lot of our best operators have been around for 20 years or more, and are pretty anti-medication,” he said. “They also operate really good recovery environments.”
Recovery residences are good housing options for people leaving residential treatment, but as a rule there’s no room in the inn for patients on methadone or buprenorphine.