Cristina Rivell has been struggling with an opioid addiction since she was a teenager — going in and out of rehab for five years. The most recent time, her doctor prescribed her a low dose of buprenorphine (often known by its brand name, Suboxone), a drug that helps curb cravings for stronger opioids and prevents the symptoms of withdrawal.
As the devastating effects of the opioid crisis continue, a growing body of research supports the efficacy and safety of this sort of medication-assisted treatment (also called MAT) for drug recovery, when combined with psychotherapy. But the use of any of these medicines — a list that includes methadone and naltrexone, as well as Suboxone — remains frowned upon by most operators of sober living houses.
These "recovery houses," sometimes also referred to as sober living homes, sober homes or sobriety houses, are commercially run residences where small groups of people who are battling addiction live and eat together, go together to meetings of Narcotics Anonymous or Alcoholics Anonymous and support each other as they go to therapy.
Though such homes are only loosely regulated and have come under scrutiny in some states for cases of mismanagment, some of these facilities have also saved lines, survivors of addiction say.
But operators of the facilities often demand "cold turkey" sobriety, and that's a problem say specialists in addiction treatment.
Rivell says Suboxone helped stabilize her — it made her feel like she could get her life together, go back to school and look for a job without the distraction of constantly seeking a fix.
"People think, like, you feel something — or you're high," she says. "But when I take it, I just feel normal. I don't have my cravings."
Rivell believes that when she relapsed in the past, it was because she was trying to stay sober without emotional support.
"When you're by yourself, you kind of feel lonely," she explains, and that makes it easier to kid yourself into thinking you can skip Suboxone for one day and use heroin instead without long-term consequences.
Rivell figured if she combined her daily dose of Suboxone with a supportive living environment, she'd have a better chance of staying sober.
With her stay in a medically supervised rehab facility coming to a close, Rivell started calling around to see which sobriety house might have room for her, as a next step in her recovery. But it wasn't looking good.
"I would say, like, 'I'm Cristina. I'm on Suboxone; I'm just looking for an open bed,' " she says. "And they're like, 'We don't take people on Suboxone.' And they'd just hang up on me."
Rivell's experience is not unique. And as many doctors and government agencies now consider these medical treatments part of the standard of care for opioid addiction, some are concerned that recovery houses with rigid rules prohibiting them are pushing more users into homelessness.
After Rivell called around for a few days, she began to worry that would be her fate. Her mother told her she couldn't come home. Rivell says her therapist suggested she try going off Suboxone — to have an easier time finding housing.
But she feared she would relapse again, and she didn't want to go through forced withdrawal.
"I was scared because I thought I was going to go back through the cravings and be sick again," she says.
After a few more days of calls, Rivell found an unlikely ally in Barbara Williamson.
Williamson opened her first recovery house in Southeastern Pennsylvania in 2014, when she was just 25 and had been sober only a year herself. Initially, Williamson didn't allow people using Suboxone or methadone to live in her houses — the medicines seemed like a crutch, she says.
"I tried heroin when I was 15 years old," says Williamson, who quickly progressed to using the drug every day. She spent time homeless and on the street after that, and credits the recovery house she ultimately found with saving her life.
"I was 98 pounds and willing to do anything for the next fix," she remembers. With the support she got in the sobriety house, Williamson was able to quit heroin cold-turkey, back then; she figured others could, too.
Then, one day last November, Williamson was struck by a Facebook post she saw online from a community activist named Brooke Feldman.
"If you refuse to house residents who utilize maintenance medications or do not provide this option in your treatment programs because of personal opinion — or you believe this will 'jeopardize the recovery of people not using medication,' your misinformed blindness is part of the problem," Feldman said in her post.
The critique stung. Williamson had always seen her recovery houses as a strong part of the solution to the opioid crisis. So she set out to do some research — hoping to prove Feldman wrong.
She took some training courses and talked to a lot of doctors. And the more she learned, she says, the more she realized that the evidence points in the other direction.
Ultimately, Williamson says, it was the number of overdose deaths among young people that pushed her to try something new. She'd had a number of residents of her recovery homes die soon after they move out.
"What do I have to do to not have morgues calling parents of 18-, 19-, 20-year-old kids?" she says. "I will do anything. So if the doctors and the facts are saying that [medication-assisted treatment] helps, then I will do my part to facilitate that need."
Williamson opened her first house five months ago, just outside of Philadelphia, for residents who rely on medication-assisted treatment to wean themselves from opioid addiction.
She's since opened three more in the area — so now owns three for men and one for women. To make things easier, she decided to create housing exclusively for those on MAT, rather than integrate these clients into her other housing.
She was worried that people on MAT would feel pressure to get off problematic opioids too quickly if they were around people who were not using maintenance medication. And if people who weren't on MAT were in a house where Suboxone was being stored, even securely, she worried about the potential for its misuse.
Partly because of these sorts of liability concerns, allowing people on MAT to live in recovery housing is still unpopular with owners of the homes. Fred Way, of the Pennsylvania Association for Recovery Residences, estimates that of the 200 houses he certifies statewide, only about seven admit people taking Suboxone or similar medications.
Philosophical differences also play a role, he says. A lot of recovery house operators are closely aligned with 12-step programs, which often count methadone or buprenorphine — technically opioids — as a violation of their abstinence-only rules.
They see someone on MAT as "still using," Way says.
Nationally, less than half of all "residential facilities" allow people to be on opioid maintenance medications. (That number includes hospitals and other licensed institutional living facilities. But it excludes many recovery houses, which don't have licensing requirements and so aren't required to report to an oversight body.)
Still, researchers of addiction treatment say the evidence shows MAT reduces the risk of opioid overdose. Dr. Nora Volkow, who heads the National Institute on Drug Abuse, says that if society more often considered addiction a disease, keeping people off treatment would seem crazy.
"I don't see any other condition or disease," she says, "where you basically ask the person to forego the medication treatment," as a condition for getting help.
Williamson's new recovery houses aren't the only signs that the tide is starting to change. Earlier this year, Philadelphia began requiring that the 18 recovery houses the city funds accept people who are on medically assisted treatment for their opioid addiction.
The National Association of Recovery Residences is also working on a policy guide to educate recovery houses on how to best offer treatment.
Soon after Williamson opened her first sober house, she wrote a message to Brooke Feldman, the woman who got her thinking about all of this in the first place.
"I introduced myself," Williamson remembers, and adds with a wry smile, "I explained how I hated her guts and [that] she'd consumed me."
"She was really clear that she was upset with me," Feldman says, and laughs. "But that recovery had taught her to take a look at herself. And what started out as an attempt to sort of prove me wrong, ended up being an enlightening experience for her."
Williamson thanked Feldman for opening her mind and allowing her to help more people. The two say they plan to soon meet in person for the first time — Feldman wants to develop a training program in the use of medically assisted treatment, specifically geared toward recovery house operators. And Williamson wants to help.
NPR's Jane Gilvin contributed reporting to this story.
RACHEL MARTIN, HOST:
Imagine you are struggling with an opioid addiction and trying to get your life together. When addicts get out of rehab, many of them rely on being able to live in recovery housing. In these group residences, people share meals. They look for jobs. They go to meetings. They do it all together in a community. Recovery houses require full sobriety, and for most of them that includes a ban on medication-assisted treatment like methadone or buprenorphine. That may be changing, though, as WHYY's Nina Feldman reports.
NINA FELDMAN, BYLINE: Cristina Rivell is 22, and she's been in and out of rehab for the past five years. The most recent time her doctor prescribed her a low-dose opioid called buprenorphine. Often known by its brand name, Suboxone, it curbs cravings and prevents withdrawal.
CRISTINA RIVELL: People think, like, that you feel something or you're, like, high. But when I take it, I just feel normal. I don't have my cravings.
FELDMAN: Rivell said she knew she needed to stick with medication-assisted treatment, or MAT, to get her life back together. And she knew she wanted to be in a recovery house where she would have a support group and be required to go to therapy.
RIVELL: When you're by yourself, it's easy to say to yourself, well, one day I'm just not going to take it and I'm going to get high for one day.
FELDMAN: So with her time in rehab running out, Rivell started calling around to see who would take her. But it wasn't looking good.
RIVELL: I would say right off the bat, like, I'm Cristina, I'm on Suboxone. I'm just looking for an open bed. And they're like, we don't take people on Suboxone and just hang up on me.
FELDMAN: Rivell was worried. She had nowhere else to go, and she was afraid she would become homeless. But eventually she found an unexpected ally.
BARB WILLIAMSON: Hi, welcome. I'm Barb Williamson.
FELDMAN: Barb Williamson opened her first recovery house in southeastern Pennsylvania in 2014. She was 25 and had been sober just a year herself. And back then, when people showed up on Suboxone or methadone and asked to live in her houses, she didn't even consider it.
WILLIAMSON: I just felt like I tried heroin when I was 15 years old, I quickly was doing it every single day. I ended up homeless in the streets. I was 98 pounds and willing to do anything for my next fix. And I just thought, if someone like me could get sober, why couldn't someone like you without medication?
FELDMAN: And then one day last November, Williamson was struck by a post from a community activist she knew on social media.
WILLIAMSON: A Facebook post about recovery houses not doing enough because we weren't welcoming people on MAT, which was making the people homeless and then using again. And, you know, she was pretty harsh and just saying we were a part of the problem.
FELDMAN: Williamson took the post really personally. So she set out to do some research and prove she was right. She took a couple trainings, talked to a lot of doctors, and she began to change her mind. Now Williamson runs four recovery houses for people on MAT. Cristina Rivell lives in one of them. But houses like these are still rare. The Pennsylvania Association for Recovery Residences estimates that out of the roughly 200 homes it certifies, about seven will take people on MAT. Nationally, less than half of all long-term residential facilities for opioid addiction allow maintenance medication.
There are a few reasons for that. A lot of recovery houses are closely aligned with 12-step programs, many of which count opioid-based treatment medications as breaking their abstinence-only rules. Jennell Botero also runs a recovery house. She doesn't let people on methadone or Suboxone live there and turns people away because of that all the time. She says she sees it is just replacing one drug with another.
JENNELL BOTERO: I have seen individuals who are on it who become dependent and don't taper off as they're supposed to but more stay on it for years and years.
FELDMAN: But the evidence shows these treatments reduce risks for relapse and overdose. Dr. Nora Volkow is head of the National Institute on Drug Abuse, the lead federal agency on addiction. She says that if we thought of addiction more as a disease, keeping people off treatment would seem crazy.
NORA VOLKOW: I don't see any other condition of disease where you basically ask the person, you have to forego the medication treatment if you want to leave here under these conditions.
FELDMAN: The tide is starting to change. Earlier this year, the city of Philadelphia began requiring that the small group of recovery houses it funds except people on MAT. The National Association of Recovery Residences is preparing a policy guide on how to offer treatment. After Williamson opened her first house, she wrote a message to the woman who got her thinking about all this in the first place.
WILLIAMSON: I introduced myself. I explained how I hated her guts and she consumed me.
FELDMAN: But now the two plan to work together on a training for other recovery house owners that debunks the myths about medication-assisted treatment. For NPR News, I'm Nina Feldman in Philadelphia. Transcript provided by NPR, Copyright NPR.