Alcohol- and drug-free housing for individuals recovering  from SUD may be referred to as “recovery residences,” “sober homes,” or  other terms. For  the purposes of this report, we use the term “recovery housing” to refer to  peer-run, nonclinical living environments for individuals recovering from  SUD in general, and “recovery homes” to refer to specific homes. In addition to SAMHSA, two national nonprofit organizations that have  missions dedicated to recovery housing include NARR and Oxford  House, Inc. NARR promotes standards for recovery housing, provides  training and education to recovery housing operators and others, and  conducts research and advocacy related to recovery housing to support  individuals in recovery from SUD. Nationwide Prevalence of Recovery Housing Is Unknown, but National Organizations Collect Data on the Number and Characteristics of a Subset of Recovery Homes

The nationwide prevalence of recovery housing is unknown because  there are no comprehensive data regarding the number of recovery  homes in the United States, although NARR and Oxford House, Inc.  collect data on a subset of recovery homes across the United States. Specifically, NARR collects data only on recovery homes that seek  certification from one of its 15 state affiliates that certify homes. Oxford House, Inc. collects data annually on the prevalence and  characteristics of Oxford Houses across the United States. Four of the five states have conducted law  enforcement investigations of recovery homes in their states and some of  these investigations have resulted in arrests and changes to public and  private insurance policies. Four of Five States Have Conducted Investigations of Recovery Housing

Officials from four of the five states we reviewed (Florida, Massachusetts,  Ohio, and Utah) told us that since 2007, state agencies have conducted,  or are in the process of conducting, law enforcement investigations of  unscrupulous behavior and potential insurance fraud related to recovery  housing, and outcomes of some of these investigations included criminal  charges and changes to health insurance policies. An official from the fifth  state, Texas, told us that the state had not conducted any recent law  enforcement investigations related to recovery housing. Recruiters brokered these  individuals to SUD treatment providers, who then billed their private  insurance plans for extensive and medically unnecessary urine drug  testing and other services. Officials from the Florida state attorney’s  office told us that SUD treatment providers were paying $300 to $500 or  more per week to recovery housing operators or their staff members for  every patient they referred for treatment. Officials found  that providers were billing individual patients’ insurance $15,000 to  $20,000 a month for urine drug testing and other services. Three States Have Established Oversight Programs, and Two States Are Taking Other Steps to Support Recovery Housing

In addition to actions taken in response to state investigations, three of  the five states in our review—Florida, Massachusetts, and Utah—have  taken steps to formally increase oversight of recovery housing by  establishing state certification or licensure programs. Officials from Ohio and Texas told us that their states had not established  state oversight programs like those that exist in Florida, Massachusetts,  and Utah, but their states had provided technical assistance and other  resources to recovery homes that were intended to increase consistency,  accountability, and quality:
Officials from the Ohio substance abuse agency told us that since  2013 the state has revised its regulatory code to define recovery  housing and minimum requirements for such housing. Certain SAMHSA Grant Funding Can Be Used for Recovery Housing, and Selected States Have Used SAMHSA and State Funding to Support Recovery Housing

SAMHSA provides some funding for states to establish recovery homes. Specifically,  under its Substance Abuse Prevention and Treatment block grant, which  totaled approximately $1.9 billion in fiscal year 2017, SAMHSA makes at  least $100,000 available annually to each state to provide loans for  recovery housing. The  opioid grant is intended to supplement states’ existing opioid prevention,  treatment, and recovery support activities, and SAMHSA requires most of  states’ funding to be used for opioid use disorder treatment services, such  as expanding access to clinically appropriate, evidence-based treatment. (See the next section of this report for information on  how states have used SAMHSA funding.) Texas was the only state in our review that  used the loan funding available under SAMHSA’s block grant. Texas and Ohio also used a portion of  their SAMHSA opioid grant funding for recovery housing. Four of the five states in our review—Florida, Massachusetts, Ohio, and  Texas—have used state funding to establish and support recovery  housing and recovery housing-related activities. HHS did not have any  comments.
Why GAO Did This Study

Substance abuse and illicit drug use, including the use of heroin and the misuse of or dependence on alcohol and prescription opioids, is a growing problem in the United States. Individuals with SUD may face challenges in remaining drug- and alcohol-free. Recovery housing can offer safe, supportive, drug- and alcohol-free housing to help these individuals maintain their sobriety and can be an important resource for individuals recovering from SUD. However, the media has reported allegations about potentially fraudulent practices on the part of some recovery homes in some states.
GAO was asked to examine recovery housing in the United States. This report examines (1) what is known about the prevalence and characteristics of recovery housing across the United States; (2) investigations and actions selected states have undertaken to oversee such housing; and (3) SAMHSA funding for recovery housing, and how states have used this or any available state funding. GAO reviewed national and state data, federal funding guidance, and interviewed officials from SAMHSA, national associations, and five states—Florida, Massachusetts, Ohio, Texas, and Utah—selected based on rates of opioid overdose deaths, dependence on or abuse of alcohol and other drugs, and other criteria. State information is intended to be illustrative and is not generalizable to all states.

What GAO Found

Nationwide prevalence of recovery housing—peer-run or peer-managed drug- and alcohol-free supportive housing for individuals in recovery from substance use disorder (SUD)—is unknown, as complete data are not available. National organizations collect data on the prevalence and characteristics of recovery housing but only for a subset of recovery homes. For example, the National Alliance for Recovery Residences, a national nonprofit and recovery community organization that promotes quality standards for recovery housing, collects data only on recovery homes that seek certification by one of its 15 state affiliates that actively certify homes. The number of homes that are not certified by this organization is unknown.
Four of the five states that GAO reviewed—Florida, Massachusetts, Ohio, and Utah—have conducted, or are in the process of conducting, investigations of recovery housing activities in their states, and three of these four states have taken formal steps to enhance oversight. The fifth state, Texas, had not conducted any such investigations at the time of GAO's review. Fraudulent activities identified by state investigators included schemes in which recovery housing operators recruited individuals with SUD to specific recovery homes and treatment providers, who then billed patients' insurance for extensive and unnecessary drug testing for the purposes of profit. For example, officials from the Florida state attorney's office told GAO that SUD treatment providers were paying $300 to $500 or more per week to recovery housing operators for every patient they referred for treatment and were billing patients' insurance for hundreds of thousands of dollars in unnecessary drug testing over the course of several months. Some of these investigations have resulted in arrests and other actions, such as changes to insurance payment policies. Florida, Massachusetts, and Utah established state certification or licensure programs for recovery housing in 2014 and 2015 to formally increase oversight. The other two states in GAO's review—Ohio and Texas—had not passed such legislation but were providing training and technical assistance to recovery housing managers.
The Substance Abuse and Mental Health Services Administration (SAMHSA), within the Department of Health and Human Services (HHS), administers two federal health care grants for SUD prevention and treatment that states may use to establish recovery homes and for related activities. First, under its Substance Abuse Prevention and Treatment block grant, SAMHSA makes at least $100,000 available annually to each state to provide loans to organizations seeking to establish recovery homes. Second, states have discretion to use SAMHSA funding available under a 2-year grant for 2017 and 2018 primarily for opioid use disorder treatment services, to establish recovery homes or for recovery housing-related activities. Of the five states GAO reviewed, only two, Texas and Ohio, have used any of their SAMHSA grant funds for these purposes. Four of the five states—Florida, Massachusetts, Ohio, and Texas—have also used state general revenue funds to establish additional recovery homes.
HHS had no comments on this report.