Sober homes have had a rough few years lately. They can be helpful for some folks recovering from addiction, providing drug-free environments where the newly sober can get away from old triggers while finding social support. But several recent and devastating investigations have found that unscrupulous sober homes maintain low standards and bill insurance companies astronomical amounts for offering little to residents; the worst operators are facing long prison sentences for assaulting residents and giving them drugs.
Meanwhile, states often don't regulate sober homes closely, and addiction treatment industry leaders say that's in part because states historically haven't seen recovery support as a part of the medical system, which is typically more highly regulated.
"It's been a neglected resource pretty much forever," says Dave Sheridan, president of the National Alliance for Recovery Residences, an industry group that publishes its own quality standards for sober homes.
In October of 2018, Congress and the White House tried to step in with a big opioid bill that includes one small section directing federal agencies to establish national best practices for sober-living facilities—as well as strategies for identifying bad actors. Last month, the Substance Abuse and Mental Health Services Administration posted its proposed guidance, but sober-home operators and researchers say that the new rules lack crucial detail—and an enforcement mechanism.
"There are a lot of good recommendations in there, but to me the key question is, who is going to enforce this?" Darren Urada, a researcher who studies addiction treatment policy at the University of California–Los Angeles, writes in an email. "The document says each recovery house should undergo 'a certification process by an independent agency.' What does that mean? Self-regulation through industry groups? We have already been trying that, so it's unclear how exactly that will change things."
Even those in the industry agree it's hard to tell how SAMHSA expects state regulators to actually implement the new guideline.
"There's some good principles that they cite in there," Sheridan says. But "it leaves a lot to the imagination, in terms of how a state will adopt this."
A spokesman at SAMSHA, contacted by Pacific Standard, said he would try to respond to questions about the guideline, but never did.
The guideline identifies some compassionate, big-picture minimum standards that sober homes should meet, including that homes should support evidence-based addiction treatments, including methadone and buprenophine for opioid addictions; be ready to deal with other mental-health conditions that people with addiction may have, such as post-traumatic stress disorder or depression; and be respectful of different residents' community needs and cultures, particularly those of American Indian residents, who often have concerns about programs' cultural competency, according to the guideline.
The guidance does offer some specifics, such as the stipulation that homes should have residents sign a document indicating that they've been informed of how much urine testing costs. Sober homes typically have residents submit urine tests frequently, to make sure they're still on track with their recovery, but in the past, predatory programs have turned the practice into a gold mine, billing insurance companies thousands of dollars for tests that Medicare says should cost around $100.
Urada says he's disappointed that the guideline doesn't offer specific consequences for institutions that break the rules. "How do we shut them down?" he writes.
Several industry groups have worked on standards and even model laws that states could adopt for sober homes, but the SAMHSA guideline makes no mention of them, Sheridan notes.
In addition, Peter Thomas, the quality assurance officer for the National Association of Addiction Treatment Providers, says he noticed stigmatizing language in the guideline. He was also dismayed to see the guideline's singular focus on addictions to opioids. Sober homes, like addiction in America, cover a variety substances.
"Some of the language in the draft guidelines is pejorative, such as the use of 'addicts' and 'fatal lifestyle,' and we hope the next iteration will use appropriate terminology," Thomas writes in an email. "The language in the guidelines should be expanded to also address other substance use disorders and not just [opioid addiction]."
A better draft may come in the future: SAMHSA posted a call for public comment that closes at 5 p.m. Eastern on Friday. All the industry groups I spoke with said they were preparing comments. Both Thomas and Sheridan say their organizations welcome better standards for their fields.