Substance use problems are preventable; if they are left unaddressed, they often progress into a chronic disorder. While episodic, acute-care treatment is vital, it alone does not offer a holistic solution. A recovery-oriented system of care (ROSC) is a chronic-care approach that encompasses prevention, early intervention, treatment engagement and ongoing recovery management and support services. The lifeblood of ROSC is the collaboration among and between service providers and systems based on the needs of the individuals, families and communities that they have in common.
Whereas recovery is a process, people’s needs change over time. This calls for a diverse and flexible matrix of both clinical services and non-clinical recovery support. Within this matrix, recovery residences and addiction treatment meet in a number of ways. These natural partners have long referred to each other, and in some cases, they are integrated to varying degrees. As healthcare reform unfolds, the partnership opportunities between recovery residences and addiction treatment will increase.
To better understand these crossroads, one needs to unpack three concepts: the categorization of recovery residences within four distinct levels of support; what are we calling “treatment” today; and third-party reimbursement in a world of parity and affordable care.
Levels of support
In 2011, the National Alliance for Recovery Residences (NARR; formerly the National Association of Recovery Residences) defined a comprehensive recovery residence nomenclature and standard that distinguishes 4 levels of support. A certification program was developed based on the NARR standard. State affiliate organizations license the program and are responsible for certifying recovery residences in their jurisdiction. At a minimum, all four levels provide sober, safe and peer supportive environments where individuals can start and sustain long-term recovery. Service type and intensity differ across recovery residences.
The different levels can be found along a non-linear spectrum, meaning that a person seeking recovery can enter in and move between any level of support based on current need:
- Level 1 - Democratically run households where peers provide support to one another; an Oxford House serves as the primary example.
- Level 2 - Sober, safe and peer supportive living environments that are monitored by a peer, such as a resident house manager.
- Level 3 - Peer supportive environments overseen by supervised staff that provide a range of non-clinical recovery and life skills development programming as well as actively link individuals to third-party clinical services as needed.
- Level 4 - Residential programs with a foundation in peer-to-peer support that offer recovery, life skills development and clinical services.
Note, the higher levels of support integrate the medical model with the social model of recovery to varying degrees. So, the belief that “Some sober homes move dangerously close to treatment” presented in the Addiction Professional article posted on Nov. 4 is incongruent with NARR philosophy because persons in recovery need a full spectrum of options ranging from a democratically run Level 1 to a robust set of clinical and non-clinical services found in a Level 4.
Whereas the NARR standard is universal, laws defining licensed treatment differ from state to state. In general, all states require facilities providing clinical services in a residence to be licensed as inpatient residential treatment. As such, all certified Level 4 recovery residences must also be licensed by their respective state. For example, in Texas, a Level 4 recovery residence would apply for a Supportive Residential license, and in Tennessee, a Level 4 would apply for an Alcohol and Drug Halfway House Treatment Facility license.
Beyond Level 4s, there will be little to no state licensure of recovery residences. Due to federal fair housing laws, recovery residence level 1s, 2s and most 3s cannot be regulated by government. There is only one known exception. California law is written in such a way that requires Level 3 recovery residences’ non-clinical programming to be licensed as treatment.
The state-by-state confusion around what is and is not “treatment” is one of the many reasons why NARR developed a single standard that articulates the spectrum of choices that are available. Recovery residence providers need a way to promote their services ethically, in a way that does not confuse consumers or state regulators.
In the bigger picture, “treatment” is often considered more than just licensed clinical services. According to the National Survey on Drug Use and Health (NSDUH), only 10% of the population that needs addiction treatment services receives it, and the most common form of “treatment” received was through non-clinical, mutual-aid support groups such as 12-Step groups. From a historical perspective, it has only been in recent decades that addiction treatment (or the concept of treatment) has been medicalized. As we move away from an acute-care focus toward a chronic-care approach, the emphasis will be placed more on what starts and sustains recovery and less on what is used to treat the disease. And, when it comes to supporting recovery, even the lowest level of recovery residence support, a Level 1 as iconically represented by Oxford House, is listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry of Evidence-based Programs and Practices (NREPP).