Historically, the substance use disorder (SUD) treatment service delivery system has operated within an episode of care, with separate programs and unrelated options. There has been an evolution towards developing a continuum of care for substance use disorder treatment and recovery services. These community-based services meet individuals and families wherever they are on their path to recovery, increase access to assessments, referrals, and family support, and attempt to reduce any barriers to receiving needed assistance.
Employment security and housing are key social determinants of health that support individuals in all stages of substance use disorder treatment and recovery. Vocational rehabilitation counseling and employment services can be embedded within the SUD prevention, treatment, harm reduction, and recovery care systems. Also, there are existing opportunities that states can leverage to expand access to safe housing, such as permanent supportive housing (PSH) and recovery residences.
Vocational Rehabilitation Counseling in Substance Use Disorder Treatment Settings
Within substance use disorder treatment settings, vocational rehabilitation counseling provides evidence-based, person-centered, and data-informed counseling to support individuals with their stated employment goals. This includes newly employed individuals, considering career changes, and/or maintaining long-term employment while in recovery. Vocational rehabilitation counseling and treatment team support provide education, training, employment referrals with follow-up, and direct job placement within the immediate community with ongoing and brief assessments.
Permanent Supportive Housing
Safe and affordable PSH, when combined with comprehensive, person-centered support services, promotes self-sufficiency. However, PSH is not always available. While homelessness in New York State (NYS) has decreased by 18.7% between 2020-2022,1 there are still approximately 39,000 individuals experiencing homelessness in NYS, according to the 2022 United States Housing and Urban Development (HUD) Point-in-Time count.2 This data is reflected in the consistently high occupancy rates within PSH programs in NYS and necessitates innovation in the ways housing is being provided.
Recovery Residences
Dozens of studies have detailed the effectiveness of recovery residences in peer-reviewed journals and by national experts. For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) compared men and women leaving residential SUD treatment and returning to their prior living circumstances with those leaving residential treatment and moving into a recovery residence. Those who went to recovery residences showed significantly better outcomes at their two-year follow-up. Individuals who moved into a recovery residence, when compared to individuals who returned to their prior living circumstances, reduced their substance use (31% vs. 65%), probability of returning to use (22% vs. 47%), rates of incarceration (3% vs 9%), and increased their employment (76% vs 49%). Moreover, recovery residents earned $550 more monthly than their non-resident counterparts. This research demonstrates communal housing settings enhance substance use disorder treatment and recovery.3
Through linkages to community recovery supports and the influence of the recovery residence model, better outcomes have resulted for those involved. Becoming immersed in new environments filled with caring, positive, empathetic, and empowering people can significantly impact those whose ability to thrive has been compromised by substance use disorder.4 Although treatment in recovery housing varies in structure, size, etc., common elements include being centered on peer support, connection to services to promote long-term recovery, reinforcement of lifestyles free of substances, and support of medication for opioid use disorder (MOUD) and medications for co-occurring substance use and psychiatric disorders.5
State-Level Innovations in Employment, Recovery, and Housing
Qualified Vocational Rehabilitation Counseling Staff
A statewide vocational rehabilitation coordinator, in collaboration and communication with regional management, reviews and approves all electronic documentation related to academic achievement, employment counseling experience with individuals who use substances, and applicable certifications (Certified Rehabilitation Counselor, Certified Social Worker, Certified Alcoholism and Substance Abuse Counselor, Certified Recovery Peer Advocate). Additionally, statewide technical assistance and professional training for new and seasoned vocational rehabilitation counselors, including the treatment team, administration, and support staff, can ensure ongoing best practices are shared and followed.
Recovery-Ready Workplaces
Employers throughout all labor sectors are encouraged to adopt a supportive environment for their employees in recovery and hire individuals in recovery. Employment is one of the key pillars in helping individuals sustain recovery, and a mutual benefit is identified for both the employer and the employee. Recovery-ready workplaces adopt policies and practices that facilitate access to needed services, treatment, and recovery supports for employees in recovery and expand employment opportunities for people who are in or are seeking recovery.
NYS is expanding recovery-ready workplace initiatives throughout all workforces by launching the Recovery Friendly Workplace Tax Credit, the first program in the nation to help rid the workplace of the stigma surrounding addiction and increase employment opportunities for New Yorkers in recovery. All eligible employers can apply for up to $2,000 of tax credit per eligible employee hired in the current tax year.
Recovery Residences
In early 2022, NYS enacted legislation that required a process for the voluntary certification of recovery residences through the Office of Addiction Services and Supports (OASAS). These non-clinical residences provide low-threshold admission for individuals in recovery seeking a safe, healthy living environment to support them in their recovery journey. Recovery residences are a unique and essential service in the continuum of care for recovery from SUD. Recovery residences provide a home-like environment and incorporate the social model of recovery, social determinants of health, and recovery capital because they recognize multiple pathways to recovery. Recovery capital is internal and external resources that support an individual’s recovery.6 Recovery residences provide safe, quality housing by utilizing a common set of standards and code of ethics in their operations while also linking individuals to a recovery-oriented system of care.
Transitional Safety Units
In 2021, NYS piloted an innovative new program that provides temporary, transitional supportive housing for individuals in need and for whom a space in a PSH program is not currently available. The program, called Transitional Safety Units, follows the Housing First approach by providing a safe home for individuals for a short period of time, and support services staff assist them in finding an appropriate permanent housing unit. The program specifically targets individuals with SUDs who are experiencing homelessness or are at risk of homelessness and either exiting an substance use disorder treatment facility or the criminal legal system. For these populations, if PSH is not immediately available, it can create a barrier to success in maintaining recovery and staying actively engaged in supportive services. The program allows individuals to remain in these Transitional Safety Units for up to a year, with the ideal length being between 6 and 9 months, as the individual pursues permanent housing. Support services are person-centered, and as such, the subsequent permanent housing should be whatever is the best fit for the individual. They may need a place in a PSH program, or they may be able to transition into fully independent living in a private apartment.
To date, these Transitional Safety Units have been successful and have provided an important interim place to live for individuals who would otherwise be homeless. This program, operated through NYS OASAS, has expanded the continuum of care and is another way in which we can provide support and care for our vulnerable neighbors.
Conclusion
Embedding supportive employment and housing services within statewide substance use disorder treatment prevention, harm reduction, and recovery systems can provide unique opportunities to meet individuals where they are. As states focus on expanding access to community-based services, focusing on the social determinants of a person’s health can support them beyond the settings of substance use disorder treatment.
Esteban Ramos, MSW, is the Director of the Bureau of Housing Services; Brenda Harris-Collins is the Director of the Bureau of Recovery Services; Gregory James is the Assistant Director of the Bureau of Recovery Services; Angela Lockhart, MA, CRC, is the Statewide Coordinator for OASAS-VR Counseling Support and Employment Services; Henry Kurcman is a Program Specialist in the Bureau of Recovery Services; Jeffrey Strauss, MS, is a Project Manager in the Bureau of Recovery Services; Maggie Taylor, PhD, is the Assistant Director in the Bureau of Housing Services; Sarah Gorry, MS, is an Empire State Fellow in the Chief Medical Office at the NYS Office of Addiction Services and Supports (OASAS).
Footnotes
- The 2022 Annual Homelessness Assessment Report (AHAR to Congress) Part 1: Point-In-Time Estimates of Homelessness, December 2022 (gov), page 17, exhibit 1.8
- The 2022 Annual Homelessness Assessment Report (AHAR to Congress) Part 1: Point-In-Time Estimates of Homelessness, December 2022 (gov), page 28)
- Jason, L. A., Olson, B. D., Ferrari, J. R., & Lo Sasso, A. T. (2006). Communal housing settings enhance substance abuse recovery. American journal of public health, 96(10), 1727–1729. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2005.070839
- National Council for Mental Wellbeing (2021). Demonstrating the Value of Recovery Housing: Technical Expert Panel Findings. https://www.thenationalcouncil.org/wp-content/uploads/2022/02/Recovery-Housing-Report_Final.pdf
- Jason, L. A., Olson, B. D., Ferrari, J. R., Majer, J. M., Alvarez, J., & Stout, J. (2007). An examination of main and interactive effects of substance abuse recovery housing on multiple indicators of adjustment. Addiction (Abingdon, England), 102(7), 1114–1121. doi: 1111/j.1360-0443.2007.01846.x
- Cloud, W., & Granfield, R. (2008). Conceptualizing recovery capital: Expansion of a theoretical construct. Substance Use & Misuse, 43(12–13), 1971–1986. https://doi.org/10.1080/10826080802289762
