Researcher Rachel Winograd, PhD on barriers to MOUD in recovery housing. Aug 5, 2025, provided by I-STARR (Infrastructure for Studying Treatment & Addiction Recovery Residences). See Dr. Winograd’s and other I-STARR studies.
As of 2020, 36 states used NARR standards for ensuring quality in recovery residences. (1)
Although NARR’s website includes a discussion of medication-assisted recovery . . .
ACCESS TO MEDICATION-ASSISTED RECOVERY IS NOT A NARR STANDARD.
The only reference to medication in the NARR Standards (Version 3.0) is that facilities include “Policy and procedures that address residents’ prescription and non-prescription medication usage and storage consistent with the residence’s level and with relevant state law.”
Notwithstanding the NARR Standards, “No universal set of measures has been developed for widespread adoption [for recovery housing].” (2)
NARR is a private nonprofit organization which is made up of its state affiliate members, which in turn are made up of local operators, house managers, and owners of recovery residences.
CONSIDERATIONS FOR MOUD ACCESS AS A QUALITY STANDARD
Some recovery house operators, including many affiliated with NARR, strive to expand MOUD access in more recovery houses, and rightly advocate for more financial support to facilitate this.
Yet they may also oppose making access to MOUD a quality standard out of concern that a culture of negative attitudes in a particular house may lead to reduced social support for residents using MOUD, with negative effects. Such stigma-related negative effects have been reported, as described below. (Though any negative effects likely depend on the number of residents using MOUD in a particular house who may provide some social support to one another).
In the absence of such a quality standard, MOUD education could expand MOUD access, though this would require funding, and “education and training will only get you so far,” . . . a multi-pronged approach is needed, including policy change, according MOUD stigma researcher Erin F. Madden PhD.)
Recovery homes should have more funding to facilitate monitoring of MOUD, but it is unclear whether this is forthcoming. Recovery residences must maintain a milieu of abstinence from illicit substances, so houses typically check random drug screens and observe residents’ behavior.
CONTROLLING MOUD MIS-USE (IN ADDITION TO MONITORING FOR RELAPSE
OR USE OF ILLICIT SUBSTANCES)
In terms of MOUD, facilities try to minimize mis-use or diversion. They can monitor the MOUD medication in the drug screens they already collect, count pills, observe self-administration, require a log of each dose taken, and/or control access with lock boxes or a locked / restricted med room. Not all of these measures are needed for all residents using MOUD, and mis-use of MOUD does not have the same implications as relapse or use of an intoxicating substance. Many operators may have an exaggerated concern about over-taking, or even diverting MOUD medication, and may conflate this with using illicit intoxicating drugs. Buprenorphine and methadone are extremely unlikely to be intoxicating or to be used to get “high.” If they are used in amounts more than was prescribed, it is almost always related either to a prescribed dose being too low, to prevent withdrawal (if their dose was inaccessible for some reason), to try to prevent illicit opioid use, or possibly to attempt to become intoxicated, but it would not have this effect. Diversion is probably most often done to help someone else avoid withdrawal, but it can be used to generate income. Of course it is very important that all mis-use be controlled to the extent possible due to possible adverse effects on the individual and other residents. If a residence is using more staff resources than needed on controlling MOUD mis-use, it may be related to conflating MOUD, to some extent, with illicit opioids. (The word “abstinence” is often used, confusingly, to mean abstinence from illicit drugs, or abstinence from all opioids including MOUD). Efforts to control MOUD mis-use should be balanced against residents’ convenience, further stigmatizing MOUD, and unnecessary expense, since expense can be a barrier to becoming “MOUD capable.”
Advocates of MOUD as a quality standard in recovery residences recognize the need to minimize MOUD mis-use, balanced with the goal of minimizing barriers to life-saving MOUD in recovery housing for the growing numbers of individuals using MOUD. Otherwise, many such individuals will continue to die or relapse due to these barriers. In addition, the norm of denying access to these individuals perpetuates MOUD stigma.
SUPPORT FOR MOUD ACCESS IN RECOVERY RESIDENCES
William L. Wright M.A, a respected authority on recovery services, with a group of leaders in the fields of addiction treatment and recovery, wrote in 2025, “Despite the risk of encountering negative attitudes [toward MOUD], participation in recovery mutual aid groups and other recovery support institutions is associated with better MOUD clinical outcomes and a planned treatment completion.” (3)
The American Society of Addiction Medicine’s 2025 Public Policy Statement on ‘Housing’s Role in Addressing Substance Use and Facilitating Recovery‘ recommends that “Governments require . . . quality measures, … credentialing of recovery residences through accreditation, licensure, or certification … based on (i) nationally recognized quality standards and SAMHSA’s Best Practice Standards, which include explicit support for residents’ use of . . . medications for addiction treatment such as buprenorphine and methadone” . . . and (ii) that The U.S. Department of Justice prioritizes enforcing the Americans with Disabilities Act [and other federal laws] related to recovery residences’ … policies on FDA-approved SUD medications…”
According to the O’Neill Institute, MOUD restrictions are often rooted in stigma, and concerns that individuals who are not on MOUD may misuse the prescribed MOUD. MOUD Restrictions [in recovery housing] are often connected to homelessness and housing insecurity, and may exacerbate SUD symptoms. Recovery homes that deny residents access to prescribed medications, including MOUD, or deny admission to people using prescribed medications, may violate the Americans with Disabilities Act [and other federal laws’.” (4)
(SSN comment: It is well known that these federal laws are not enforced. In fact, no federal law has ever been used to protect MOUD access in recovery residences, and illegal discrimination remains common.)
According to SAMHSA’s 2023 Best Practices for Recovery Housing, best practice includes that “recovery housing operators not have any barriers or restrictions for residents to use prescribed medications for behavioral or physical health conditions …This includes the use of the FDA-approved medications for alcohol use and/or opioid use disorders—including buprenorphine, methadone, and naltrexone.” The document is no longer on the SAMHSA website, but can be found Here.
Lack of MOUD access in recovery residences is covered in the news media. Facher L. STAT News, November 12, 2024. ‘The recovery community says it offers refuge from opioid addiction. But it’s still hostile to lifesaving addiction medicationsF
“MOUD-related stigma, or prejudice and discrimination towards MOUD is rampant across the continuum of treatment and recovery services.” (5)
Approximately 40 % of treatment and recovery organizations were unwilling or hesitant to serve clients using MOUD in a 10-county area in the vicinity of Kansas City, MO. (6)
In 2018, a survey of all 16 recovery houses that accepted discharged patients from Vanderbilt University School of Medicine in Nashville, TN found that only 12.5% allow patients to remain on buprenorphine and 0% allow patients to remain on methadone. These numbers are lower than reported in a 2011 national sample that 20.9% of recovery houses allow buprenorphine, 7.8% allow methadone, and 22.0% allow naltrexone. (7)
The progress that patients on MOUD make in treatment programs can be jeopardized by the lack of appropriate housing options (8, 9)
Pervasiveness of MOUD stigma, and the resulting exclusion from recovery and treatment services, is concerning given the evidence that recovery-oriented social networks are an important factor for sustained, long-term recovery. The relationship between isolation and both morbidity and mortality in the context of addiction recovery is well established, and confirmed by the current study. (10)
Individuals taking MOUD are often prohibited from speaking at 12-step meetings, denied sponsors, and told that they are not in recovery. This causes them to disengaging from shame-inducing recovery and treatment settings, and leaving these spaces. (11, 12)
Individuals on MOUD reported that they had been unable to access recovery housing and other recovery supports due to MOUD-related stigma. (13)
The importance of peer and social processes, and importance of peer-based interventions, mutual aid and recovery housing is confirmed. (14)
In a non-randomized prospective two-year follow-up of residents in over 300 accredited recovery houses in Virginia, retention and recovery capital were measured in 509 residents on MOUD, and 8,785 not on MOUD. Results were adjusted for confounding variables.
Residents using MOUD had higher retention (63.2 %) than those who were not (57.2 %) (p-value 0.011).
Residents using MOUD and had improvements in recovery capital at 7 of the 11 follow-up assessments. In two of these (at 3 and 4.5 months) the differences were statistically significant (p values of 0.0035 and 0.002, respectively). There were no significant declines of recovery capital in those on MOUD compared with not, over the two years of follow-up. The authors concluded that “the findings suggest that practical strategies are needed to integrate MOUD within abstinence-oriented environments . . .targeted education, staff training, and ongoing technical support are essential . . .” (15)
Nearly one-third of recovery residence operators desire technical assistance (TA) on how to develop and implement medication policies. Technical Assistance is not readily available, except from NARR (16). (Comment by SSN: TA from NARR may reflect its philosphy that MOUD access is not a quality standard).
Flexible MOUD-related policies can be tailored and relatively flexible. Interviews with 138 residents and staff from Level II and III MOUD-accepting recovery homes across Texas revealed that a variety of MOUD policies (e.g., on storage, drug testing, etc.) in recovery residences had evolved through trial and error and balanced flexibility and an MOUD-supportive culture with oversight and safety. The authors conclude that recovery residences can integrate MOUD effectively with tailored policies, staff training, and stigma-reduction strategies. Policies addressed issues such as medication. While diversion did occur, it was rare. (17)
A qualitative analysis of recovery residences with residence using MOUD found that facility staff were able to support residents in multiple ways. Staff connected residents who might benefit from MOUD with appropriate providers. Staff also strengthened residents’ community of MAR-supportive peers by hosting or connecting residents to Medication-Assisted Recovery Anonymous meetings. (18)
Ongoing feedback, support, and access to information promotes adoption of evidence-based practices across other organizational settings. (19)
(Comment by SSN: Since accurate counseling and understanding is critical in forming preferences about using MOUD, it seems that a client handout with un-biased information on MOUD could be required and approved by regulators).
In a review of studies that examined health professionals’ attitudes toward MAT, Brown (2022) found that exposure, knowledge, and treatment orientation were important factors related to changing attitudes toward MATs among health professionals. (20)
In a cluster-randomized study, community corrections personnel (a) received a 3-hour training and (b) also participated in strategic planning and implementation with addiction treatment agencies over 12 months (organizational linkage), vs. training alone (control). The experimental group showed significantly greater reductions in negative perceptions of MOUD, and greater intent to refer clients for MOUD than the control group. (21)
The City of Philadelphia found success by fully funding recovery houses that meet regulatory requirements. The State of Missouri increased MOUD access in recovery houses by spending a portion of their State Targeted Response Grant funding on such houses. The States of Ohio and Texas have also provided specific funding for recovery houses with MOUD access. (22)
However, incentives and requirements for MOUD access is necessary but not sufficient. Even in 64 Missouri Recovery Homes required to be “medication friendly,” and to demonstrate a culture of MOUD acceptance, as a condition of their SAMHSA grant funding, most managers reported that tapering off MOUD was encouraged, and only one if these houses offered all three medications for OUD. (23)
1. Martin et al., 2020 National overview of recovery housing accreditation, legislation, and licensing (A Guide for Oregon Policymakers.
2. Thompson RA, et al. Establishing Quality and Outcome Measures for Recovery Housing: A Tiered Approach Supporting Service Evolution. Community Ment Health J. 2024;60(4):681-690.
3. White, W. L., Galanter, M., Kolodner, G., Kepner, W. E., Sarapas, C. & Mouton, C. L. (2025). Medications for opioid use disorder: Enhancing retention to achieve long-term remission and recovery. Chestnut Health Systems, Lighthouse Institute.
4. ‘Big Ideas’ Recovery Housing and Civil Rights Laws: Rights and Obligations Related to Medications for Opioid Use Disorder. The O’Neill Institute.
5. Gallardo KR, “Being here is saving my life”: Resident experiences of living in recovery residences for people taking medication for an opioid use disorder. Subst Use Addict Treat. 2024 Mar;158:209242.
6. Kepple NJ et al. Nowhere to go? Examining facility acceptance levels for serving
individuals using medications for opioid used disorder. Journal of Substance Abuse
Treatment, 104 (2019), pp. 42-50
7. Patel, R. et al. Persisting gaps in MOUD coverage at post-discharge recovery houses necessitate our continued advocacy Substance Abuse, 41 (1) (2020), pp. 11-13, Abstract:
8. Braucht GN, et al. (1996). Effective services for homeless substance abusers. Journal of Addictive Diseases, 14(4), 87–109.
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12. Anvari MS, et al. “In their mind, they always felt less than”: The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention.
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18. Gallardo KR, et al. Supporting medication-assisted recovery in recovery residences: staff support, managing built environment threats, and building a supportive network. Am J Drug Alcohol Abuse. 2024 Sep 2;50(5):739-747.
19. Wood CA, et al. Acceptance of medications for opioid use disorder in recovery housing programs in Missouri. J Subst Abuse Treat. 2022 Jul;138:1087476
20. Brown, A. R. (2022). Health professionals’ attitudes toward medications for opioid use disorder. Substance Abuse, 43(1), 598–614. Abstract:
21. Friedmann, P D, et al. (2015). Effect of an organizational linkage intervention on staff perceptions of medication-assisted treatment and referral intentions in community corrections. Journal of Substance Abuse Treatment, 50, 50–58.
22. Patel R, et al. Persisting gaps in MOUD coverage at post-discharge recovery houses necessitate our continued advocacy. Substance Abuse, 41 (1) (2020), pp. 11-13, 10.1080/08897077.2019.1695038
23. Wood CA, et al. Acceptance of medications for opioid use disorder in recovery housing programs in Missouri. J Subst Abuse Treat. 2022 Jul:138:108747.