Housing’s Role in Addressing Substance Use and Facilitating Recovery

Purpose

Over 771,000 individuals experienced homelessness on a single night in 2024 - an historic high.¹ Individuals experiencing homelessness have a greater prevalence and severity of substance use compared to housed individuals.^2,3 Substance use and substance use disorder (SUD) are linked with homelessness, and each can be a cause and consequence of the other.^4–7 Additionally, when unhoused, individuals experiencing SUD and other chronic medical conditions often face crisis situations leading to use of emergency departments, crisis services, and interactions with law enforcement.^8–10  While housing alone does not facilitate SUD recovery^[1], safe and stable housing mitigates some risks of initiation and progression of substance use.^2,11–13 Stable housing also supports recovery for SUD by decreasing stress, increasing the ability to focus on recovery activities and treatment, and decreasing risks of arrest and reincarceration that disrupt treatment.¹⁴ In contrast, people experiencing homelessness are often forced to move frequently, preventing consistent access to social services and health care. They may also experience arrest merely for lacking housing,¹⁵ disrupting access to SUD treatment. Stigma related to homelessness may be further compounded by stigma related to SUD or other chronic health conditions, as well as by racism, ageism, ableism, and sexism.¹⁶ In sum, housing is more than just shelter for individuals with SUD; it represents a foundation for rebuilding their lives, accessing treatment, and reintegrating into the community.¹⁷ This public policy statement recommends policies that promote stability in housing, and therefore, are important for SUD recovery and overall health and wellness.^13,18–20

Background

Securing affordable housing can be difficult for people with SUD.²¹ For example, some federal and state laws prevent people with drug-related criminal charges from accessing publicly-funded housing. When publicly funded housing is available, people experiencing homelessness and SUD may have difficulty completing applications or face long wait times.^21–23 Without a recent history of housing, people experiencing homelessness and SUD may be unable to provide references sometimes needed for privately-funded housing. 

Permanent supportive housing (PSH) and low-barrier shelter services

In the January 2024 point-in-time count, more than 152,000 individuals experiencing homelessness reported chronic patterns of homelessness.²⁴ The federal definition of “chronically homeless” is a homeless individual with a qualifying disability who has experienced recurring homelessness, or homelessness lasting for 12 months or more.²⁵ For this population, which has a high prevalence of severe SUD and other health and behavioral health disabilities, U.S. federal agencies recognize the Housing First permanent supportive housing (PSH) framework as a key intervention to promote housing stability.²⁶ The PSH model involves providing safe, non-time-limited, affordable housing paired with flexible, voluntary supportive services (e.g., employment services) or health services that meet an individual’s level of need, without the requirement for SUD treatment or abstinence for housing entry or continuation.^27–30

Studies show PSH significantly improves housing stability, and housing stability supports sustained SUD treatment.^28,31–36 Nevertheless, some people with SUD as their sole diagnosis may fail to qualify for PSH vouchers if their SUD does not significantly impede their ability to live independently or if they are currently engaging in illegal drug use.^37,38

Shelter programs can provide temporary yet often critical survival services, too, including serving as an entry point for identifying and supporting placement and connection to social and health services. There remains an insufficient supply of immediate and low-barrier access emergency shelters,^39,40 especially non-congregate shelters, that do not require alcohol and drug testing for admission. 

Recovery support through recovery residences

The ASAM Criteria now recommends an addition of a “recovery residence” to an outpatient level of care for some individuals with SUD.⁴¹ A range of terms have been used to describe recovery residences, including “sober homes,” “recovery homes,” “therapeutic communities,” and “Oxford Houses.” Recovery residences are community programs rooted in the social recovery model and operated in home-like, recovery-supportive settings that provide opportunities to learn and practice interpersonal and other life skills.⁴²  Recovery residences might or might not offer treatment services by licensed healthcare professionals.^41,43 Recovery residences do not solely serve individuals with housing instability but can be a critical resource when housing instability exists.

Recovery residences vary in cost, size, length of stay, structure and degree of linkages to clinical supports.^44,45 “Clinical” recovery residences, referred to in The ASAM Criteria as “clinically-managed low intensity residential treatment” provide clinical treatment services and a social model of nonclinical social supports through employed professional and peer staff.^41,42 Nonclinical recovery residences include “supervised,” “monitored,” and “peer-run” recovery residences, which vary in structure and staffing. ^41,42

Existing research on health effects of recovery residences has been hindered by design limitations, inconsistent terminology, and small sample sizes.^46–49 More research is needed on interventions to promote long-term housing stability for those who enter recovery residences with existing housing instability. Nevertheless, recovery residences remain a significant component of the landscape of recovery support services and may be particularly valuable for people with SUD experiencing homelessness.

Credentialing of recovery residences 

Recovery residences’ economic benefits have the potential to greatly exceed their economic costs.⁵⁰ Unfortunately, inconsistent regulation of recovery residences has sometimes resulted in problems with safety, quality of care, fraud, and abuse.^51,52 Varying nomenclature and terminology for recovery residences can lead to confusion on the types and structure of services.^41–43 While nonclinical recovery residences operate generally within a regulatory gap, some states are requiring recovery residences to obtain credentialing through certification, accreditation, or licensure⁵³ to be eligible for state or local funding, referrals, or inclusion in state-managed online directories.^54,55

The Substance Abuse and Mental Health Services Administration (SAMHSA) has disseminated national best practice standards for recovery residences,⁵⁶ and state affiliates of the National Alliance for Recovery Residences (NARR) provide voluntary certification in certain states for recovery residences that meet their quality standards for clinical and nonclinical recovery residences.^42,57,58 Some researchers have proposed a universal set of quality measures for recovery residences to improve recovery care.⁵⁹

Access to SUD medications and health care services among people experiencing homelessness

Food and Drug Administration (FDA)-approved medications for SUD, especially buprenorphine and methadone for opioid use disorder (OUD), are often essential elements in SUD care.^41,60 Long-acting injectable buprenorphine (LAIB) and long-acting injectable naltrexone can be particularly beneficial for individuals with OUD and/or alcohol use disorder experiencing housing instability, for whom storing a supply of daily medications can be more challenging.^61–63 Barriers to accessing LAIB include not only cost but restrictive laws and regulations.^64,65 More access points for methadone for OUD can also be beneficial to those with housing instability, especially in rural communities, where methadone access is particularly limited.⁶⁶

Some recovery residences,⁶⁷ PSH programs, and shelters offering clinical SUD treatment services may fail to assess residents’ need for, or recommend, FDA-approved SUD medications. Further, some recovery residences,⁶⁷ PSH programs, and shelters may not accept residents treated with certain FDA-approved SUD medications, such as buprenorphine and methadone. This can violate federal civil rights statutes that apply to individuals with SUD who are treated with indicated medications.^68–71 Moreover, the overdose reversal medication, naloxone, is currently not required on the premises of all recovery residences, PSH programs, or shelters. 

Federal Programs Addressing the Needs of Individuals Experiencing Homelessness and SUD

Various federal governmental programs attempt to address the needs of individuals at the intersection of homelessness and substance use. Such federal programs include the U.S. Department of Housing and Urban Development (HUD)-Veteran Affairs (VA) Supportive Housing (HUD-VASH) program,⁷² the U.S. Department of Agriculture (USDA) and SAMHSA Substance Abuse Recovery Housing in Rural Communities program,⁷³ and other SAMHSA programs,^74,75 including the Projects for Assistance in Transition from Homelessness (PATH) block grant. Additionally, SAMHSA’s Supplemental Security Insurance/Social Security Disability Insurance Outreach, Access, and Recovery (SOAR) program aims to support enrollment of individuals with qualifying disabilities (including co-occurring SUD) who are experiencing homelessness onto long-term public insurance benefits; however, it has no dedicated funding.⁷⁶

HUD also addresses homelessness through its Continuums of Care (CoC) program, which consists of locally organized groups of primarily non-governmental actors. While CoCs wield enormous expertise, they have little to no governing authority to design or implement policy solutions.⁷⁷ Given these constraints, the U.S. Department of Health and Human Services (HHS) partnered with HUD to integrate housing and healthcare services for homeless populations using Medicaid waivers.⁷⁸ The Centers for Medicare and Medicaid Services (CMS) allowed such waivers to address health-related social needs, including certain housing costs, in late 2022.^79,80 Various state Medicaid programs have used such waivers to support services in PSH, to support housing navigation services, and to expand home and community-based services.^20,81–84

Recommendations

The American Society of Addiction Medicine recommends that:

1. Governments eliminate and refrain from enacting laws that criminalize individuals for experiencing homelessness. Instead, governments should develop and promote model policies and programs that fund collaboration among community stakeholders to develop treatment and recovery ecosystems for health conditions closely tied to homelessness, including SUD and mental health disorders.

2. Governments develop and implement evidence-based long-term strategies that promote policy reforms designed to increase the supply of safe, affordable housing and flexible spending models across governmental agencies and programs to mitigate housing insecurity among individuals with SUD.⁸⁵

3. Policymakers increase funding for low-barrier healthcare services and shelter services for people experiencing housing instability and SUD, such as street, mobile, and walk-in healthcare programs, as well as low-barrier emergency shelter programs, including non-congregate shelters.

4. Policymakers require onsite availability of overdose reversal medication at shelter and emergency housing programs.  

5. To address chronic homelessness, policymakers significantly increase funding for, and implement policy reforms to facilitate implementation of permanent supportive housing (PSH) programs that provide safe, non-time-limited, affordable housing paired with flexible, voluntary supportive or health services that meet an individual’s level of need, without requiring SUD treatment or abstinence for entry or continuation.

a. States incentivize PSH operators to report quality measures based on existing best practices in assessing quality within supportive housing that can meet the needs of individuals with SUD.

b. States encourage PSH programs to incorporate a wide range of harm reduction⁸⁶ services and require them to distribute overdose reversal medication, train staff on opioid overdose response, and implement overdose safety planning.

c. Policymakers ensure policies provide access to PSH programs for people with SUD, regardless of whether SUD is their sole diagnosis or whether they are currently engaging in illegal drug use.

6. Governments require appropriate quality measures for recovery residences, as well as the credentialing of recovery residences through accreditation, licensure, or certification by:

a. designing credentialing processes based on (i) nationally recognized quality standards and SAMHSA’s Best Practice Standards, which include explicit support for residents’ use of prescribed medications for mental or physical health conditions, including medications for addiction treatment such as buprenorphine and methadone;⁵⁶ (ii) nomenclature and terminology in The ASAM Criteria’s residential treatment and recovery residence continuum of care; and (iii) compliance with the ADA, Rehabilitation Act, and the FHA;

b. requiring credentialing for (i) access to public funds, (ii) patient referrals from licensed or state-funded SUD treatment providers, and (iii) inclusion in government directories or registries; and

c. mandating that the following meet ASAM Level 3.1 program standards: (i) clinical recovery residences; and (ii) nonclinical recovery residences that require all residents to attend the same outpatient treatment program.

7. Governments increase funding for recovery residences, recovery support services (RSS) at recovery residences, transition services from recovery residences to PSH programs when appropriate, and support services at PSH programs.⁴¹ Specific strategies include:

a. using state plan amendments (SPA), 1115 waivers, or other Medicaid initiatives or waiver programs to cover RSS;

b. using State Opioid Response (SOR) competitive grant programs and opioid settlement dollars to create funding opportunities for recovery residences; and

c. using the Substance Use Prevention, Treatment, and Recovery Services (SUPTRS) block grant to fund RSS delivered by certified and employed recovery residence staff.

8. Governments increase funding to promote research related to understanding which supports and services within recovery residences and PSH programs maximally reduce the harms of substance use and future overdose risk and which determinants best match patients with the appropriate type of recovery residence.

9. States implement policies that make the locating of recovery residences and permanent supportive housing programs easier and less prone to legal delays or administrative complexities.⁵⁵  

10. Lawmakers and regulators, including the FDA Drug Safety and Risk Management Advisory Committee, amend statutes, regulations, and the REMS protocol to expand access to long-acting injectable buprenorphine (LAIB), explicitly supporting field-based provision (e.g., at shelters, PSH programs, or via street medicine) of LAIB by healthcare teams; and amend law or regulations to promote greater access to methadone for opioid use disorder.

11. The U.S. Department of Justice (DOJ) prioritizes enforcing the ADA, Rehabilitation Act, and the FHA, related to recovery residence, shelter, and emergency housing programs’ policies on FDA-approved SUD medications, paired with strategic educational efforts on the legal responsibility to accommodate individuals receiving SUD medications.⁷⁰

Footnotes

[1] As used in The ASAM Criteria (4^th Edition), the term “recovery” means “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

Adopted by the ASAM Board of Directors on January 23, 2025.

© Copyright 2025. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material require prior specific written permission or license from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only without editing or paraphrasing, and with proper attribution to the society. Excerpting any statement for any purpose requires specific written permission from the Society. Public Policy statements of ASAM are revised on a regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position of ASAM on the topic addressed.

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