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How Stable Housing Supports Recovery from Substance Use Disorders

By: Sahvanah Prescott

Substance use disorder is a pressing issue affecting the lives of millions of Americans. The most recent data from the National Vital Statistics system showed that in 2021, 106,699 drug overdose deaths occurred. In 2022, 48.7 million people aged 12 or older had a substance use disorder (SUD) in the past year. 

Due to many factors associated with substance use disorder, there is a high correlation between housing insecurity (or the state of not having stable or adequate living arrangements) and substance use disorders. The US Department of Housing and Urban Development 2023 Continuum of Care Homeless Assistance Program Homeless Populations and Subpopulations found that roughly 108,035 persons experiencing homelessness in 2023 were also experiencing chronic substance misuse. This makes up approximately 16.5% of the total homeless population in 2023. Housing insecurity also contributes to opioid-related outcomes. Opioid overdose is more common in individuals experiencing housing insecurity than in individuals who use drugs but are not homeless. As drug overdose rates and rates of homelessness continue to increase, jurisdictions may consider using opioid settlement funds on interventions that address both substance use disorder and homelessness.

A complex relationship exists between substance use disorder and homelessness. Substance use disorder can be both the cause and the result of homelessness. The heavy misuse of substances may cause some individuals to “drift” into homelessness while homelessness may also reinforce the misuse of substances as a method of coping with the stressors and dangers of living on the streets. The experience of stress has been associated with an increased vulnerability to developing substance use disorder, and therefore, many believe stable housing serves as an important factor in addressing this. There is evidence that having a safe place to live can provide stability so that individuals can focus on other aspects of their health. Efforts to prevent homelessness, like Housing First and Permanent Supportive Housing, contribute to improved substance use outcomes,  

Stable housing plays an important role in people’s recovery from substance use disorders and The Substance Abuse and Mental Health Services Administration includes access to a stable and safe place to live as one of the four major dimensions of recovery. Conversely, living without housing has been shown to amplify symptoms of SUD. However, affordable housing within the United States has become increasingly less accessible.   

The interplay of risk factors such as food insecurity, poverty, mental health, and incarceration, amongst other things can interrupt connections to care for people who use drugs and make access to housing more challenging. Integrating supportive services with stable housing can increase engagement in supportive services and lead to improved substance use outcomes. There are three evidence-based pathways jurisdictions consider for the investment in housing using Opioid Settlement Funds. They include:

1. Recovery Housing

Recovery Housing can be described as a substance-free living environment that aims to provide individuals with a previous history of substance use disorder with a safe living environment within a community of recovery-related supports. Services offered in recovery housing span a range of intensity. At a minimum, recovery residences should offer peer-to-peer recovery support with some models providing professional clinical services.

Outcomes: Recovery housing is associated with many positive outcomes including decreased substance use, reduced likelihood of return to use, lower rates of incarceration, higher income, increased employment, and improved family relationships. Section 8071 of the SUPPORT Act, allows States and the District of Columbia to provide stable, transitional housing for individuals in recovery. Funding for recovery housing covers a period of up to two years or until the individual secures permanent housing. 

Considerations: Under the recovery housing model, a great emphasis is put on remaining abstinent and substance-free. While some individuals in recovery who have expressed a preference for an abstinence-focused residential program where they can live among peers who share this same goal may select this housing model, some may find this rigid structure alienating. Some recovery housing programs may deny individuals who use MOUD due to the fear that diversion may jeopardize their legal protections as a recovery home. This presents a significant barrier for individuals engaged in MOUD who are seeking a supportive abstinence-focused environment to live. 

Example: One innovative example of the recovery housing framework is the River Haven program based in Oregon. The River Haven Recovery program is an extension of Central City Concern, a nonprofit organization dedicated to ending homelessness. The New Haven Recovery program is run out of an old 70-room hotel that has been converted into safe temporary homes for individuals receiving treatment for substance use disorders who would otherwise be homeless. The New Haven Recovery program is dedicated to offering underserved individuals culturally competent services. 

2. Permanent Supportive Housing

Permanent Supportive Housing combines affordable housing with coordinated services to help people struggling with chronic health issues maintain stable housing and receive the appropriate health care. Tenants of supportive housing generally pay no more than 30 percent of their income for rent. Services offered through supportive housing are housing-oriented, multi-disciplinary, and voluntary but intensive. Providers in permanent supportive housing offer supportive services assertively, meaning they will continue to show up and check on someone even if tenants don’t request help. Individuals do not risk losing their housing should they decide not to participate in these services but, providers continue to show up and check on these individuals even if they do not request help.

Outcomes: Permanent Supportive Housing is associated with a reduction in substance use over time, reduced homelessness, increased housing retention, and decreased emergency room visits and hospitalization. 

Considerations: Permanent supportive housing is a multidisciplinary approach to addressing homelessness that provides individuals with housing and health related services. Providers of permanent supportive housing often must braid together funding from multiple federal agencies which are often subject to strict budget constraints. As a result, many programs allocate funds through competitive application processes which can make it difficult to plan through reliance on specific sources.While Permanent Supportive Housing is an option, funding for these programs are extremely limited which can limit the number of people who can be served.

Example:  One example of the success of permanent supportive housing is the Community of Hope Program based in Washington DC. In 2022 alone, Community of Hope served 1,427 households with 99% of families remaining stably housed following completion of the program. 

3. Housing First 

The Housing First approach was designed to improve housing stability for people who traditionally have been difficult to house or have had difficulty maintaining their housing. Housing First programs place individuals experiencing homelessness into permanent housing without preconditions and barriers to entry. 

Outcomes: Housing First is associated with decreased homelessness, reductions in substance use,  increased access to mental health and substance use services, and decreased criminal justice involvement. Housing First has also been shown to reduce healthcare, criminal legal system, and other public costs. A 2004 random assignment study found that Housing First programs were more successful in reducing homelessness than programs where housing and services were contingent on sobriety and progress in treatment. When individuals were provided access to stable, affordable housing, with services under their control, 79% remained in stable housing at the end of 6 months, compared to 27% in the control group. 

Considerations: Under the Housing First model, supportive services are made available to maximize housing stability and prevent returns to homelessness. While housing placement is not contingent on using the available services it is understood that if you first assist someone experiencing homelessness into housing, they will be more capable of taking advantage of the other services offered. Housing is different from treatment, while the Housing First model promotes residential stability, this model’s primary focus is not addressing issues related to substance use. 

Example: Houston’s housing first model has been recognized by the White House and the U.S. Department of Housing and Urban Development (HUD) as the largest U.S. city to effectively end veteran homelessness  in 2015. Houston has seen an 53% decrease  in overall homelessness since 2011. Their current The Way Home Five-Year Community Plan includes coordination among governments, nonprofit providers, and the private sector to provide intensive outreach and crisis services, address barriers to accessing needed services and care. The initiative also has ongoing engagement of people with lived experience of homelessness in solving problems associated with homelessness.

Key Take-Aways

Each of these housing models provides people experiencing homelessness who also have substance use disorders with several options on a continuum to address their health and housing needs. 

By placing stable, affordable housing through the housing first approach above all else, we can not only improve the livelihood and well-being of individuals and families but also alleviate some of the tolls homelessness has on our communities. Housing First greatly reduces homelessness, is cost-effective, and positively impacts the quality of life and community functioning.  

Innovative policies and programs that target the unique needs of the homeless population have been linked to improved health, housing, and recovery outcomes. With the use of Opioid Settlement Funds, states should develop more well-rounded comprehensive housing programs to reach the homeless population. This can be done by identifying existing housing programs in the community that serve patients with opioid use disorders and supplementing existing funds. As drug overdose rates and rates of homelessness continue to increase, an intervention that addresses both substance use disorder and homelessness is essential.

About the Author:

Sahvanah Prescott is a Master of Science in Addiction Policy and Practice candidate at Georgetown University. As a student a part of the Addiction and Policy and Practice program, Sahvanah has primarily focused her research on harm reduction, and prevention efforts. Sahvanah’s academic journey has ignited her interest in researching culturally responsive solutions to addressing substance use-related issues with a specific focus on assisting communities of color and improving access to treatment for parenting mothers and individuals in carceral settings. Sahvanah is currently working as a policy intern for Shatterproof, a nonprofit organization committed to reducing the devastation of addiction through advocacy.