key: cord-0898897-4yq9o08o
authors: Mericle, Amy A.; Sheridan, Dave; Howell, Jason; Braucht, George S.; Karriker-Jaffe, Katherine; Polcin, Douglas L.
title: Sheltering in place and social distancing when the services provided are housing and social support: The COVID-19 health crisis and recovery housing
date: 2020-08-01
journal: J Subst Abuse Treat
DOI: 10.1016/j.jsat.2020.108094
sha: ee7534b767e6cfacb771b4a251f41830a1dca5e7
doc_id: 898897
cord_uid: 4yq9o08o

Recovery housing is a vital service for individuals with substance use disorders who need both recovery support and safe housing. Recovery housing is a residential service, and it relies heavily on social support provided by peers both within the residence and in outside mutual help groups. As such, efforts to keep residents safe from SARS CoV-2, the virus that causes the illness COVID-19, pose a number of challenges to social distancing. Further, residents are some of the more vulnerable individuals in recovery. They are more likely to have co-occurring health conditions that place them at risk for COVID-19, and they often have risk factors such as employment in low-wage jobs that increase their potential for negative economic impacts of the pandemic. Since most recovery housing operates outside formal substance use treatment, residents who pay out-of-pocket for services largely support these residences. Comprehensive support for those using, as well as those providing and ensuring the quality of recovery housing, is needed to ensure the viability of recovery housing.

Recovery housing is an increasingly popular service modality (Jason et al., 2020; The National Association of Recovery Residences, 2012) . Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery housing as programs designed to address a recovering person's need for a safe and healthy living environment while supplying requisite recovery and peer supports (SAMHSA, 2019). "Safe" and "healthy" to most individuals in recovery, particularly in early recovery, often means that the housing environment has specified rules about the use of alcohol and illicit drugs to support individuals in their chosen recovery pathway. Given the recent COVID-19 outbreak, these terms have taken on additional meaning for residents and recovery housing providers.

To limit the spread of infection from SARS CoV-2, the virus that causes the illness COVID-19, California was one of the first states to issue orders regarding sheltering in place for nonessential workers. By the end of March 2020, 33 states had similar orders (Mervosh, Lu, & Swales, 2020) , but plans on when and how to lift these orders have varied from state to state. In addition to these orders, federal guidelines have recommended avoiding social gatherings of more than 10 people, avoiding discretionary travel for social visits, and keeping the entire household at home if someone in it tests positive (Centers for Disease Control and Prevention [CDC], 2020a). The CDC has also developed guidance for schools, workplaces, and community organizations, including homeless service providers, retirement communities, healthcare facilities, and congregated housing (CDC 2020b, 2020c ), but none of these settings reflect the nature of recovery housing.

All recovery housing is residential and emphasizes peer support (within the house, as well as through participation in mutual help groups). Few are licensed treatment programs or staffed by licensed or certified behavioral health professionals. In fact, a hallmark of recovery housing is the value placed on experiential knowledge (Borkman, Kaskutas, Room, Bryan, & Barrows, 1998; Polcin, Mericle, Howell, Sheridan, & Christensen, 2014) . Some types of residences (e.g., Oxford Houses) are entirely peer-led. Because the majority of recovery residences operate in the periphery of the formal substance J o u r n a l P r e -p r o o f use treatment system (both public and private), there are few formal third-party-payer systems set up to reimburse or offset costs of this service, leaving individual residents to pay most of the expenses. As residents are paying out-of-pocket, there are inherent pressures to keep operating costs down by increasing the number of residents per house or by relying on residents or other volunteers to maintain the residence. There are also limited funds for emergency expenses. Lack of space to socially distance and isolate residents, limited staffing to sanitize the residence and enforce CDC guidelines, and a lack of funds for personal protective equipment could increase risk of infection among residents.

To ensure quality and promote recovery housing best practices, Oxford House, Inc., requires that all individuals wishing to open an Oxford House obtain a charter and remain in good standing. Additionally, the National Alliance for Recovery Residences (NARR) supports state-level affiliate organizations in certifying that member residences, which can range from those that are peer-run to those that provide clinical services, operate in accordance with the NARR Standard (National Alliance for Recovery Residences, 2018). The NARR Standard does include guidance on maintaining environmental health, but this guidance has been insufficient to address challenges posed by the current pandemic. There are also residences that operate without an Oxford House charter and that are not NARR-certified.

In response to COVID-19, NARR developed recovery residence-specific resources based on CDC guidance (National Alliance for Recovery Residences, 2020) and contributed to the development of guidelines for residential settings (National Council for Behavioral Health, 2020). NARR also started hosting weekly COVID-19 webinars geared toward operators of all types of recovery residences, irrespective of NARR affiliation. Topics covered on webinars have included: how to safely screen and add new residents; procedures for quarantining residents who have symptoms of or test positive for SARS CoV-2 ; what to do about resident travel and visitation pass requests; managing residents who violate community rules by using alcohol or other illicit drugs; best practices for residents coming into and out J o u r n a l P r e -p r o o f of the residence, including those who are part of the essential workforce (e.g., nurses); and how to remain financially viable when a significant number of residents becomes unemployed.

As understanding of COVID-19 and federal guidance evolves, these webinars have facilitated a virtual learning community that has been both timely and useful to providers across the country, particularly those that are primarily peer-led or operating in states without a NARR affiliate organization.

NARR is able to disseminate information regarding resources and best practices, and all participants are able to share information about their experiences to help develop additional guidance addressing new challenges. Despite the value of this work, it needs to be appreciated that those leading NARR's efforts are largely volunteers. Although the organization is attempting to diversify its revenue stream, the majority of NARR's revenue historically has been generated from affiliate fees and from delivering training to recovery housing providers. Some states have provided funding for the development and support of a network of certified recovery residences, which leaves them better prepared to pay for NARR services, but these states are the exception. Further, there are still twenty-one states without a NARR affiliate organization.

Residents in recovery housing are some of the most vulnerable individuals in recovery, simply by virtue of needing additional recovery support or affordable housing. Studies of individuals in a variety of different types of residences consistently find that residents come into them with a host of co-occurring conditions, including psychiatric and chronic health conditions, histories of criminal justice involvement and homelessness, and under-employment (Callahan et al., 2015; Majer, Komer, & Jason, 2015; Mericle, Hemberg, Stall, & Carrico, 2019; Mericle & Miles, 2017; Polcin, Korcha, Gupta, Subbaraman & Mericle, 2016; Polcin, Korcha, Mericle, Mahoney, & Hemberg, 2017) . Despite gains in recovery, residents will likely be among those hardest hit by the economic fallout from the pandemic if they are unable to work.

This will leave providers in a precarious position during a time when they are being called upon to do more for their residents. Without a dedicated commitment to supporting recovery housing providers J o u r n a l P r e -p r o o f and the work done by NARR during this time of crisis, we risk losing this important form of support for some of the most vulnerable people entering and living through early recovery.

We must do better by persons in recovery-people striving to manage substance use and other disorders by leading lives of meaning and purpose (SAMHS, 2012; The Betty Ford Institute Consensus Panel, 2007 )-by supporting them in this time of crisis. To that end, we also must do better by those who are providing services to help individuals achieve recovery. Recovery housing must be fully embraced as part of the substance use continuum of care. Without a federal agency dedicated to advocating on the behalf of the recovery housing providers and supporting the efforts of national and state-level organizations to address residents' needs (Mericle & Grella, 2016) , recovery housing providers may be hampered in their efforts to meet these needs. Addiction always has the potential to be fatal, but like the opioid crisis, the COVID-19 pandemic has further exposed the vulnerabilities of those in recovery, as well as the vulnerabilities of recovery housing providers. The field's collective response to the opioid crisis has proved enormously helpful to recovery housing providers across the country. They must not be forgotten in the response to the COVID-19 pandemic.

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