Guidance

Part 2: recovery support services - evidence and current provision

Published 8 September 2023

Applies to England

Overview

Describing recovery support services in this chapter

This chapter describes the models of recovery support service (RSS) as we understand they currently operate in England.

There are 6 specific types of recovery support service categorised in the research, and these are useful categories to describe the range of RSS currently in England (see section ‘Types of recovery support service’ below for what these 6 types are). However, most of the research on RSS comes from the United States and there are some differences between how treatment is funded and delivered in England and the US. The line between treatment and RSS provision is more blurred in England than in the US. Alcohol and drug treatment services in England are contracted to offer some RSS elements. In the US, RSS are usually peer-led, standalone services.

So, while the descriptions of RSS below are partly based on the descriptions in published research, they have been tailored to an English context using information we have gathered for this guidance. This includes findings from:

• John Kelly’s 2017 systematic review on recovery support services in the US (PDF, 1.2MB)
• more recent evidence we have identified through a rapid review of research from 2017 to February 2022
• responses to a survey we carried out with local authority commissioners in May and June 2022

So, the descriptions are based on what we know about current practice in England and about the models identified in research. They are not intended to define best practice.

About recovery support services

RSS offer support to people in recovery and their families and benefit the wider community. They offer practical and emotional support to meet a person’s needs and build on their strengths.

RSS can be delivered by treatment providers or lived experience recovery organisations (LEROs), separately or by working in partnership. This means that most RSS are delivered by treatment or LERO workforces, including their volunteers.

Evidence for recovery support services

There is growing evidence that RSS can help people to sustain recovery long-term.

A recent study from the US modelled the potential impact of a range of strategies (Stringfellow and others, 2022), covering:

• prevention
• treatment
• recovery
• harm reduction

The study found that interventions that support people to stay in recovery had the greatest potential to reduce the number of people with opioid use disorder over 10 years. They were also among the interventions with greatest potential to reduce opioid deaths. The authors also suggest that even relatively small improvements in how effectively these interventions support individuals to stay in recovery could have disproportionately positive impacts on those long-term population outcomes.

Types of recovery support service

The current evidence base focuses on 6 types of RSS. These are:

• mutual aid and facilitated access to mutual aid
• peer-based recovery support services
• recovery check-ups and continuing care
• recovery community centres
• recovery housing
• recovery support services in educational settings

The term RSS is used in research literature to describe a range of specific interventions, settings and delivery methods, rather than standalone services.

For example, 12-step groups, the most widely available model of mutual aid, are classified as a type of RSS but cannot be classed as a service. These are peer-to-peer support groups that cannot be contracted.

In practice, most RSS incorporate several recovery support components in one or more setting types. For example, almost all recovery community centres offer peer-based recovery support and host mutual aid groups.

What we know about provision of recovery support services in England

National data

The National Drug Treatment Monitoring System (NDTMS) collects data on the availability and effectiveness of alcohol and drug treatment in England and the profile of people accessing this treatment. NDTMS also collects data on people receiving recovery support interventions alongside or after structured treatment but does not routinely capture information about all RSS provision. Not all services report what recovery support people are receiving after they leave structured treatment.

The interpretation of national data on some interventions is complicated by data quality issues, so we have used only limited data in this guidance.

We will be working with partners in government and stakeholders in the recovery and treatment field to enhance monitoring of recovery outcomes and interventions over the course of the government’s drug strategy. This will include reviewing what is currently collected though NDTMS, so we can improve this information. We will also be looking at how it can best be used to monitor practice and improve recovery support locally and nationally.

Commissioner survey

To better understand the current national provision of RSS in England, we undertook a survey of English local authority commissioners in May and June 2022. The survey asked commissioners:

• what RSS they directly commission and which are independently provided
• who provides these services and whether they are involved in local partnership meetings
• how long people can access these services
• how much of the local alcohol and drug budget is invested in these services
• how many people access these services each year
• for good practice examples of RSS and lived experience initiatives

Survey responses

Overall, 52% (78) of commissioners responded to the survey.

The local areas that responded represented 59% of the adult alcohol and drug treatment population. All but one local authority had at least one type of RSS available in their area. Peer-based recovery support services were the most commonly available type of RSS. The least common types of RSS available were recovery housing and RSS in educational settings. Very few commissioners could provide information about the use of RSS, or outcomes linked to them.

The service descriptions provided by commissioners often suggested that they had miscategorised services as RSS, which were actually prevention, treatment or recovery-focused interventions for people who were still in treatment. For this reason, we have given only the headline quantitative findings and you should read this data alongside the qualitative findings for context.

There were also cases where a commissioner did not mention a LERO known to exist in their local area. This suggests that there is a lack of connection between LEROs and local partnerships and systems in some areas.

In the rest of this chapter, we explore the 6 types of RSS in more detail, outline the evidence for each and include some quantitative and qualitative findings from the survey.

Mutual aid and facilitated access to mutual aid

Mutual aid

Mutual aid is the social, emotional and information support provided by, and to, members of a group at every stage of recovery. The most common mutual aid groups in England are:

• Alcoholics Anonymous (AA)
• Narcotics Anonymous (NA)
• Cocaine Anonymous (CA)
• Families Anonymous (FA)
• Al-Anon (for families and friends)
• SMART Recovery

Facilitated access to mutual aid

Facilitated access to mutual aid (FAMA) is a short, simple and effective method for increasing mutual aid participation. A mutual aid toolkit for alcohol and drug treatment provides guidance for commissioners, treatment providers and mutual aid organisations to facilitate access to mutual aid.

What mutual aid groups and FAMA offer

Mutual aid is not a peer support network. Mutual aid groups often include people who are abstinent and want help to remain so. These people are actively changing their behaviour using a structured programme of mutual aid.

In the UK, FAMA involves using one-to-one keyworking sessions to help people to access and engage with any mutual aid group. The basic concept of FAMA is having dedicated and structured conversations with people about mutual aid, and incorporating goals about engaging with mutual aid groups into their treatment and recovery care plans (see definition of treatment and recovery care planning in part 4 of this publication: glossary and resources). It is not enough to simply provide someone with a leaflet. Where a person wants to try mutual aid, staff should help them make contact with a group. For example, a keyworker can:

• arrange for the person to meet a mutual aid group member
• arrange transport or someone to accompany the person to their first session
• deal with any subsequent concerns

Who delivers mutual aid and FAMA

Any alcohol and drug treatment and recovery worker or LERO worker can support people to access mutual aid through FAMA.

Mutual aid organisations are independent, volunteer-run groups led by and made up of people who share a common experience. In this case, their own or someone else’s alcohol and drug use or dependence. They provide help through volunteer-led group meetings and peer-to-peer support between meetings.

The evidence for mutual aid and FAMA

A 2020 Cochrane review of the effectiveness of Alcoholics Anonymous (AA) and 12-step facilitation for alcohol use disorder (Kelly and others, 2020a) found:

• high-quality evidence that manualised versions (following a session-by-session procedure) of AA groups and 12-step facilitation are more effective than some other established treatments (such as cognitive behavioural therapy) for increasing abstinence from alcohol
• both manualised and non‐manualised versions may be at least as effective as other treatments (such as cognitive behavioural therapy and motivational enhancement therapy) for other alcohol‐related outcomes
• these interventions probably produce substantial healthcare cost savings for people with alcohol use disorders

While AA is the most studied mutual aid model, researchers have argued that, since mutual aid models are similar, it is likely that participating in other mutual aid models is similarly beneficial to people’s recovery (Kelly and Yeterian, 2012).

Kelly’s review found that AA increases abstinence rates. This includes enabling people to have longer periods of abstinence by helping them to manage change through:

• cognitive-behavioural coping skills
• abstinence self-efficacy
• recovery motivation
• spirituality
• social networks
• techniques for managing impulsivity and cravings

Current mutual aid and FAMA provision in England

Research suggests that 31% of people in treatment in the UK have ever attended mutual aid (Day and others, 2019).

Since mutual aid is widely available and all 12-step mutual aid groups are independent of commissioning, our survey asked commissioners to confirm the extent of FAMA provision in their local treatment and recovery services. Findings included:

• 79% of commissioners (62 out of 78) reported that FAMA was available locally
• 50% of FAMA provision available locally (31 out of 62) was reportedly delivered by a LERO, making it the RSS most likely to be delivered by a LERO

However, it’s likely that survey respondents overestimated FAMA provision. Most respondents described aspects of FAMA without specifying the structured sessions with a keyworker. These descriptions of FAMA often talked about more general efforts to support mutual aid participation or the growth of local mutual aid groups, such as:

• encouraging and signposting people in treatment to attend mutual aid, including written and verbal information about local groups
• hosting mutual aid groups in services, or treatment staff or volunteers delivering mutual aid groups in treatment or other settings
• buddying or assertively linking people to mutual aid groups (see definition of buddying and assertive linking in the glossary)
• training for peers to become mutual aid facilitators

Some LEROs and treatment providers also reported that they had specific in-person and remote groups that introduce mutual aid to people not currently accessing it. They also said that they proactively support the setting up of mutual aid groups if there is a need for these.

Peer-based recovery support services

Peer-based recovery support services (PBRSS) is an umbrella term encompassing a range of peer-delivered or peer-led support for people in recovery.

What peer-based recovery support services offer

PBRSS covers a range of peer support interventions aiming to help people promote and sustain recovery. This peer support also links people into programmes as they need them, including:

• harm reduction
• treatment
• mutual aid
• other health and wellbeing services
• employment support

PBRSS acknowledge that there are many different pathways into recovery. These services help people to sustain recovery in the long term by growing their personal, social and community recovery capital. Examples of PBRSS interventions include:

• recovery coaching (see definition of recovery coach in the glossary)
• peer support workers
• navigation (see definition of recovery navigator in the glossary)
• buddying and assertive linking
• community connection and access to meaningful activities

PBRSS can be delivered in treatment and recovery support services, in other community settings and at points of transition such as when leaving prison or hospital discharge. This type of support is not usually time limited, so people can access the support for as long as they need. Most types of RSS incorporate PBRSS as a core part of their model.

Who delivers peer-based recovery support services

PBRSS can be delivered by peers employed by or volunteering for a treatment or other service provider, or a lived experience recovery organisation.

Evidence for peer-based recovery support services

Research has found that PBRSS are potentially effective for people’s outcomes by:

• reducing their alcohol and drug use (Eddie and others, 2019)
• reducing relapse rates (Eddie and others, 2019)
• getting more people into treatment and supporting them to stayed engaged with it (Eddie and others, 2019)
• improving their treatment satisfaction (Eddie and others, 2019)
• helping them to secure stable housing (Bassuk and others, 2016)
• increasing recovery capital (Bassuk and others, 2016; Eddie and others, 2019)

There is consistent evidence for these outcomes across randomised controlled trials (RCTs) and single group prospective and retrospective studies of PBRSS. A recent systematic review found evidence of some effectiveness of PBRSS in both RCTs and quasi-experimental studies (Eddie and others, 2019).

A 2018 evaluation Changing Lives (PDF, 7.6MB) found that PBRSS could engage family members affected by someone else’s alcohol and drug use in a way that other services could not. This included family members:

• having a greater knowledge of drugs and alcohol, including treatment options and of their rights as carers
• getting more support from their peers and feeling less isolated and stigmatised
• being more able to develop, run and manage their own sustainable services
• being better supported to help them improve the chances of recovery for their loved one

Current peer-based recovery support service provision in England

Survey results

Respondents to our commissioner survey said that PBRSS were available in 95% (74) of local areas, making this the most common type of RSS. PBRSS were also the most likely RSS to be directly commissioned by local authorities. Just under 75% of PBRSS were commissioned as part of, or an extension to, the treatment service. PBRSS were the RSS most likely to be commissioned in this way. Less than half of PBRSS were delivered by a LERO.

Most PBRSS did not limit the length of time a person can access support, making them one of the RSS types most likely to allow unlimited access. PBRSS received less than 5% of local alcohol and drug treatment and recovery budgets.

It was clear from survey responses that local areas offer a wide range of peer-delivered and peer-led support across their treatment and recovery pathway. Most of the support that respondents described was peer-delivered harm reduction and in-treatment support, rather than PBRSS.

The PBRSS described were most often peer-delivered or peer-led aftercare groups and programmes, which provide time-limited support to a person after they leave alcohol or drug treatment (see definition of aftercare in the glossary). Some of this support was time limited (often to 12 weeks). In a few areas, peer-delivered groups in treatment services were accessible to people who had finished alcohol or drug treatment.

Peer support roles

From the survey and other sector engagement, there appears to be 3 types of peer support roles currently integrated into local alcohol and drug treatment and recovery systems.

Volunteer role (typically informal)

A person helping to deliver community events and training to raise awareness about problem alcohol and drug use and support available. They may also represent the insight and experiences of people in treatment in consultations or procurement exercises. These roles are most often informal but can also be formal volunteer positions.

Volunteer role (typically formal)

A person in early recovery practically and emotionally supporting individuals and groups into or through treatment and other services. This often includes offering advocacy, buddying, groupwork and facilitating access to mutual aid. These roles are often formal volunteer roles.

While these positions may involve people completing training, the nature and quality of this training appears to vary widely. Some peer support training is little more than an induction into volunteering, while some treatment providers and LEROs have developed accredited training matched to qualification level 1 (the equivalent of GCSE grades 3 to 1 or D to G) up to level 3 (the equivalent of A level). What qualification levels mean provides more information about what these levels and grades mean.

Formal volunteer or paid role

A person in stable recovery practically and emotionally supporting people one-on-one and in groups. These roles are either formal volunteer or paid roles. People moving into these roles are sometimes required to have completed a training course, which in some cases may be accredited.

Titles vary widely for formal volunteer and paid peer support roles and are used interchangeably for different role types. They include:

• peer volunteer
• peer supporter
• peer support worker
• recovery coach

Capability framework

It’s important to note that the above outline provides an anecdotal picture of current practice around peer support roles, rather than a description of best practice.

The forthcoming drug and alcohol treatment and recovery capability frameworks will outline the capabilities of core roles in alcohol and drug treatment and recovery services. These frameworks will identify the skills, knowledge and behaviours required in each role. The peer support worker capability framework will be published in autumn 2023.

Recovery check-ups and continuing care

Recovery check-ups and continuing care are types of post-treatment recovery management. In Recovery: linking addiction treatment and communities of recovery (PDF, 307KB), William White argues that:

we need to be doing aggressive post-treatment monitoring – in part, because drug dealers are interested in having people buy their products, and they will be doing aggressive post-treatment monitoring and marketing interventions support people to sustain their recovery and re-engage with treatment, where required.

What recovery check-ups offer

Recovery check-ups involve post-treatment monitoring and feedback.

Recovery check-ups involve post-treatment monitoring and feedback, which comprise a series of planned motivational sessions. The sessions focus on:

• checking in with people to find out how they are
• offering support and encouragement and information and advice to help people to address any needs
• using motivational interviewing techniques to support the person to re-engage in treatment where appropriate
• identifying and addressing barriers to accessing support, including treatment

Research has found that some services offer recovery check-ups for 5 years or more. Recovery check-ups are defined in the NDTMS business definitions for core data set Q.

What continuing care services offer

Continuing care involves both post-treatment monitoring and feedback and supportive interventions. It involves treatment and recovery services offering lower intensity interventions after a person has met their treatment goals. This intervention offers a more extensive (longer term) form of what has traditionally been called aftercare. Continuing care mainly involves ongoing assessment and psychosocial intervention. Psychological techniques used include:

• motivational interviewing
• individual or group relapse prevention, including identifying early warning signs and using mindfulness techniques
• behavioural contracting (where a person agrees in writing to change an identified behaviour within a specified timeframe, often for rewards)

Kelly’s review found that continuing care is typically delivered for between 3 and 12 months after a person leaves treatment. Generally, continuing care is more intensive than recovery check-ups. In-person continuing care typically involves between 8 and 26 sessions over 3 to 6 months.

Recovery check-ups and continuing care can be delivered:

• in-person
• by phone
• remotely, using digital technology

With both interventions, services tend to reduce the frequency of sessions over time, often moving from weekly to monthly.

Who delivers recovery check-ups and continuing care services

Recovery check-ups can be delivered by treatment and recovery workers or trained and supervised peer workers or volunteers.

Continuing care can be delivered by treatment and recovery service workers with the appropriate training in delivering the psychosocial interventions used in a given service model.

Evidence for recovery check-ups and continuing care

Overview of the evidence

Research has found both recovery check-ups and continuing care to be effective. The evidence for these interventions is complex because they vary in their:

• intensity
• duration
• delivery

Kelly’s review found the evidence base for these intervention types to be rigorous and concluded that:

• longer-term models may result in greater recovery benefits, but the benefits stop almost as soon as the intervention does
• while the benefits of these interventions were modest overall, people with more complex clinical profiles benefit the most
• phone-based support for people in recovery from alcohol dependence is at least as effective as in-person options, offering small to moderate benefits at reduced cost
• peer-delivered or peer-led models show promising results

Kelly’s review also found that digital delivery of these interventions may be an effective way of providing accessible and convenient recovery support. For example, supplementing usual care for people leaving residential treatment with a relapse prevention smartphone app increased the odds of abstinence from alcohol by 65% and reduced the number of heavy drinking days (Gustafson and others, 2014).

Other evidence suggests that recovery check-ups and continuing care produces better results the longer it lasts and the more proactive attempts to engage people it involves (McKay, 2009). However, the picture is complex and reviews only found small to moderate effects when results from individual studies are averaged or combined.

Models of recovery check-up

Kelly’s review found that one model of recovery check-up - recovery management check-ups - has been found to be effective in:

• reducing treatment need
• facilitating earlier return to treatment for people who need to
• increasing treatment engagement
• increasing the number of abstinent days

Recovery management check-ups involve quarterly assessment, motivational intervention and linking people to treatment, recovery support and other support as appropriate. They have been found to be more cost-efficient than quarterly assessment alone, because they produce better outcomes at similar intervention-related costs (McCollister and others, 2013).

Phone-based continuing care

Studies on phone-based delivery of continuing care have found that:

• a fully automated continuing care intervention using interactive voice response was no more effective than standard care in improving drinking outcomes (Rose and others, 2015)
• brief phone-based continuing care may be less effective than in-person interventions for people with more complex clinical profiles (Timko and others, 2019)

Current recovery check-ups and continuing care provision in England

Our survey only asked about recovery check-ups, because this is what commissioners in England are familiar with. Main findings included:

• 65% of commissioners reported that recovery check-ups were available locally
• 88% of services providing recovery check-ups were directly commissioned by the local authority
• 84% of services providing recovery check-ups were part of, or an extension to, the treatment service
• 22% of commissioners reported that recovery check-ups were delivered by LEROs
• 47% of areas reported that access to recovery check-ups was time unlimited
• 37% of areas reported that access to recovery check-ups was limited to 12 months

Survey responses often showed a lack of understanding about what a recovery check-up is. Many described other types of recovery support instead. These included:

• informal and formal recovery support provided by LEROs, including peer support for people struggling with their recovery
• post-residential treatment groups
• access to groups in treatment services post-discharge
• online support
• mutual aid
• other aftercare or recovery support options available in the community

Survey respondents told us that recovery check-ups were usually delivered by peer volunteers and workers or treatment workers. A few commissioners were planning to train peer volunteers to start delivering these interventions.

Where specified, services offered this type of support to people after leaving community or residential treatment. Some providers were delivering recovery check-ups as standard, while others provided them only where the person or service felt that they needed ongoing support.

Recovery check-ups were typically time limited for between 3 to 6 months, with some providers offering the intervention for up to a year. One local authority contract required services to offer this type of support for up to 5 years. Most respondents did not specify the frequency of the interventions. Those who did said they delivered weekly or monthly sessions.

Recovery check-ups described in the research literature were delivered either in-person or remotely by phone.

Descriptions of the nature of recovery check-up interventions by survey respondents varied widely. The intervention typically:

• had some degree of structure
• involved reviewing the person’s recovery, health and wellbeing
• involved checking on their progress against agreed goals and levels of recovery capital including what recovery support they had in place such as mutual aid
• provided motivational support and encouraged engagement in RSS and other types of community support
• functioned to get people back into treatment early, where needed

Only one respondent described a standard protocol for recovery check-ups used by their treatment provider. This was a set of questions and prompts designed to explore a person’s resilience in their recovery. It was followed by a comprehensive assessment and a treatment and recovery care plan, if the assessment identified a treatment need.

Recovery community centres

Recovery community centres (RCCs) are community spaces or hubs that are open to anyone, regardless of their treatment status. They:

• offer a range of support to help people sustain long-term recovery
• encourage and strengthen recovery networks by connecting people and families in recovery
• reduce stigma by making recovery visible to the wider community

Research suggests that RCCs are accessed by both people in early recovery (less than a year) and those in longer-term recovery (from 1 to 5 years) (Kelly and others, 2020b).

What recovery community centres offer

Recovery community centres can provide a range of RSS, such as:

• peer support
• mutual aid
• recreational, social and wellbeing sessions
• employment, training and education support and opportunities including volunteering
• support to promote and maintain engagement with treatment, where appropriate
• training including overdose reversal and relapse prevention skills
• access to other community-based services

Ideally, RCCs should be in locations where people can access them easily. In the UK, some treatment providers and lived experience initiatives run public-facing social enterprises such as recovery cafes. These centres and enterprises function not only to provide recovery support but also:

• create job and volunteering opportunities for people in recovery to ‘give back’ by working in peer support roles
• strengthen pathways into treatment, recovery support and other services
• destigmatise problem alcohol and drug use and recovery through their visibility in the community

Who delivers services in recovery community centres

RCCs are generally co-ordinated by a small paid staff team, often peer-led, and supported by a larger group of peer volunteers.

Evidence for recovery community centres

While some interventions typically delivered in recovery community centres have well established evidence of effectiveness (most notably mutual aid), the evidence for the effectiveness of recovery community centres is less well developed (Kelly, 2017).

The available evidence suggests that recovery community centres are effective in supporting people to build their recovery capital (Kelly and others, 2020b). Research suggests that people accessing recovery community centres for at least 6 months tend to:

• maintain abstinence (Kelly and others, 2021; Mericle and others, 2014)
• secure stable housing (Haberle and others, 2014)
• move into employment (Haberle and others, 2014; Mericle and others, 2014)
• attend more mutual aid groups (Mericle and others, 2014)
• report improved psychological wellbeing and quality of life (Kelly and others, 2021)

So, while evidence of their effectiveness is only emerging, there is a pragmatic case for developing these recovery-supportive spaces and networks in community, outside of treatment services but with active and supported pathways into treatment where appropriate.

Current recovery community centre provision in England

The main findings from survey of commissioners about recovery community centre provision included:

• 54% of commissioners (42 out of 78) reported that RCCs were available locally, with 81% of these directly commissioned by the local authority
• 67% of RCCs were either part of, or an extension to, the treatment service with 33% of these RCCs being led by a LERO
• 86% of RCCs (36 out of 42) did not limit the length of time a person could access support, making them one of the RSS-types most likely to offer time-unlimited access

However, the descriptions of RCCs provided by the respondents suggest that these findings overestimate RCC provision in England. Thirteen survey respondents who reported having a local RCC actually described a treatment and recovery service focused on delivering treatment, with some provision of:

• peer-delivered and other groups
• mutual aid
• activities that involve people in treatment in forums or consultations
• social opportunities

Some local authorities commission separate, standalone recovery services providing recovery support interventions to people who have left treatment. These recovery services tend to be delivered by treatment service providers, sometimes in collaboration with a local LERO. These recovery services often include a programme of courses and sessions delivered by peers and local community services covering a wide range of topics such as:

• sustaining recovery
• health and wellbeing
• employment
• training and education
• creativity

There are also LERO-led RCCs using standalone or temporary spaces in the community, which are closest to the RCCs described in US research.

Four respondents were setting up RCCs, including social enterprises.

Recovery housing

Recovery housing is structured, alcohol and drug-free accommodation in which residents access in-house peer support and are assertively linked into recovery activities. In the US, these houses are often peer-led.

What recovery housing services offer

Recovery houses:

• offer substance-free accommodation
• have written procedures
• are democratically run
• have house meetings and share house management
• offer direct connection with peers living in the house and wider peer support networks
• offer access to services and support that promote recovery, such as mutual aid and treatment services
• help people to move on to independent living

Some recovery housing schemes require residents to engage with an associated therapeutic programme to retain their tenancy.

The levels of care and standards of practice in recovery houses varies widely. In the US, the National Alliance for Recovery Residences (NARR) has identified 4 levels of support.

Level 1 (peer-run) is a single house that is entirely run by residents that has no time limit on length of stay.

Level 2 (monitored) is a single house or group of flats with a paid house manager that has no time limit on length of stay.

Level 3 (supervised) are houses that:

• are regulated
• vary in structure and levels of resident participation
• are run by paid staff (such as a house manager, director and administrative support)
• provide certified and supervised peer support

Level 4 (treatment provider) are a type of supervised recovery housing specifically delivered by treatment providers.

Who delivers recovery housing services

Recovery housing is often staffed or overseen by paid workers working for private or social landlords or charitable organisations. Some recovery houses, like Oxford Houses, are entirely peer-led (level 1 in the NARR levels).

Evidence for recovery housing

There is evidence of effectiveness from the available rigorous studies of recovery housing (Kelly, 2017).

Oxford Houses

Oxford Houses are a type of level 1 (peer-run) recovery housing. They offer self-sustaining, peer-led accommodation and are led by residents who manage the house (including the finances), rather than being led by paid staff. Residents must remain abstinent from alcohol and other drugs. While they are not affiliated with 12-step mutual-aid organisations, residents are traditionally encouraged to attend 12-step meetings.

Residents pay rent and can stay long term if they follow house rules. There is a manual to help set up and quality assure Oxford Houses. Decisions about what happens when people break house rules are made collectively by other house members. House leadership positions are limited to 6 months. This means that members all have a chance to lead decision-making. Where surplus funds are generated, these can be invested in setting up further Oxford Houses.

There are individual studies that have found that Oxford Houses are effective in:

• reducing the odds of relapse by 63% compared to care as usual, with people living in Oxford Houses more than twice as likely to be abstinent at 2-year follow up (Chavarria and others, 2012)
• increasing resident productivity (measured by monthly income (Jason and others, 2006) and more days of paid employment (Jason and others, 2015)
• decreasing criminal justice system involvement (imprisonment)

One study estimated the overall net benefit per Oxford House stay was around £25,000 (Lo Sasso and others, 2012). This estimate is based on estimated savings in the costs associated with:

• healthcare
• criminal activity
• imprisonment
• alcohol and drug use
• employment

The longer someone stays in an Oxford House, the more people in recovery they add to their social network (Mueller and Jason, 2014). The benefits of recovery housing may be enhanced by high levels of engagement with mutual aid (Groh and others, 2009).

Sober living houses

Some individual studies suggest sober living houses, a level 2 type of recovery housing, may be effective in reducing:

• homelessness and stabilising accommodation (Polcin and Korcha, 2017)
• psychiatric distress (Polcin and Korcha, 2017)
• alcohol and drug use (Polcin and others, 2018)
• criminal activity (Polcin and others, 2018)
• HIV risk (Polcin and others, 2018)
• employment outcomes in people under community supervision (probation or parole) (Polcin and others, 2018).

The operational management of sober living houses may affect outcomes for residents (Mericle and others, 2019). For example, residents in a house that is part of a larger organisation or group of houses have increased odds of abstinence at 6 and 12 months compared to smaller operational models. Similarly, residents had increased odds of employment where the sober living house was affiliated with a treatment programme.

Supervised recovery housing

Supervised recovery housing models (level 3) are associated with longer episodes of outpatient treatment (Mericle and others, 2021).

Recovery house residents have reported a range of benefits (Mericle and others, 2021). These include:

• additional structure and recovery support
• increased accountability
• the opportunity to learn and practice life skills
• improved coping skills
• receiving emotional and social support from peers

In an evaluation of a 28-bed, peer-led, quasi-residential supported housing programme run by a LERO – The Well Communities, in North West England – residents and staff identified the benefits as increased abstinence and pathways into volunteering and employment (Best and others, 2020).

An evidence review on what outcomes can be expected of the drug treatment and recovery system in England found that housing insecurity may contribute to an increased risk of relapse. The case for investing in evidence-based, structured recovery housing is good.

Current recovery housing provision in England

Treatment data

In English drug treatment data, interventions are very rarely recorded as having been delivered in recovery housing (either during or after structured treatment). NDTMS recorded only 95 people in treatment in England in 2022 to 2023 as having received an intervention in this setting.

Survey findings

The main findings from our survey of commissioners about recovery housing showed us that:

• 40% of commissioners (31 out of 78) reported that recovery housing was available locally
• 35% of recovery housing (11 out of 31) was directly commissioned by the local authority
• 36% of recovery housing (11 out of 31) was delivered by a LERO
• 74% of recovery housing provision (23 out of 31) limited the length of time a person can access support, making it the RSS type most likely to be time limited
• recovery housing residency was typically limited to between 1 and 5 years

Most of the recovery housing described by commissioners in response to our survey was:

• ‘dry’ (alcohol-free) and drug-free housing, often delivered in collaboration with local specialist treatment and recovery service providers
• supervised recovery housing led by a LERO
• quasi-residential rehabilitation programmes delivered by specialist providers
• independent housing often delivered by homelessness or faith-based providers

Commissioners did not describe any level 1 or 2 recovery housing. Four local authorities were planning to expand their recovery housing provision.

Comparing UK and US provision

The housing provision described in the survey responses did not neatly map on to the US levels of recovery housing, and appeared to be closest to level 4 in nature. It was unclear how much structured support, linkage to recovery activities and peer support was available in the housing schemes described, which are all fundamental to recovery housing.

In the US, NARR co-ordinates 30 affiliate organisations that support more than 25,000 people living in 2,500 certified recovery houses. There are an estimated 17,900 recovery houses in the US (Jason and others, 2020). In the UK, we think that recovery housing is available at all 4 levels but information about recovery housing is patchy and the sector lacks consistency, regulation and collaboration.

One research study describes a 28-bed, peer-led, quasi-residential supported housing scheme in the north-west of England (Best and others, 2020). This scheme is closest to level 3 recovery housing provision in the US. In this scheme, residents must engage in a structured programme to continue to stay in the housing. This programme includes:

• mutual aid engagement
• life skills
• exercise
• employment
• training
• education
• volunteering

One third of recovery housing staff in this scheme are former residents.

Recovery support services in educational settings

In the US, there are recovery support services embedded in secondary, further and higher education.

What collegiate recovery programmes offer

Collegiate recovery programmes are supported programmes in higher and further education institutions for university students in recovery. They enable students to access specialist recovery support while studying. This recovery support typically includes:

• peer support (one-to-one and group)
• educational sessions about recovery
• access to mutual aid in the educational setting and wider community
• advocacy
• support with issues affecting people’s studies

These programmes generally have dedicated space on campus and are often complemented by recovery housing for students.

Collegiate recovery programmes in universities are well established models in the US. Completing higher education and gaining qualifications are important sources of recovery capital, but maintaining and building recovery can be difficult on a university campus. Research found that the frequent and heavy alcohol and drug use associated with student culture can present challenges for people in recovery, notably those staying in halls of residence (Bell and others, 2010).

Collegiate recovery programmes offer specialist recovery support to students to help sustain recovery while maintaining academic performance.

Kelly’s 2017 review found that in the US, students who engage with collegiate recovery programmes have typically been in recovery for 2 years or more. These students had often left education during adolescence and experienced at least a decade of dependence before engaging in this university-based recovery support.

What recovery high schools offer

Recovery high schools help secondary school students to sustain recovery and support academic performance. While some standalone recovery high schools exist in the US, many are embedded within a school that is not a recovery high school.

Recovery high schools are an emerging form of provision in the US (see definition of recovery high schools in the glossary). Most students engaged in school-based recovery support programmes in the US have previously been in specialist treatment (Moberg and Finch, 2008).

Who delivers recovery support services in education settings

Collegiate recovery programmes usually have a director or project manager employed by the university, but are mainly peer-led. Without university leadership, it can be challenging to integrate a collegiate recovery programme into university life. However, there are successful examples where external LEROs have developed a collegiate recovery programme on a university campus.

Recovery high schools are typically staff-led, because of the potential safeguarding issues related to the younger age of participants.

Evidence for recovery support services in educational settings

Research suggests that students who access recovery support services in educational settings may benefit from reduced alcohol and drug use and improved social and academic outcomes (Kelly, 2017).

Research indicates that collegiate recovery programmes:

• allow students to access and create networks of people supportive of recovery that offset frequent triggers and cues to lapse or relapse (Cleveland and others, 2010)
• help students to manage the ‘self-stigma’ associated with dependence and recovery (Scott and others, 2016)
• are linked to relapse rates in graduates of between 2.2% (Botzet and others, 2008) and 10.2% (Brown and others, 2019) compared to average relapse rates between 40% and 60% in people treated for drug dependence (McLellan and others, 2000)

Students who have accessed collegiate recovery programmes identify the benefits as:

• having a peer network supportive of recovery
• access to specialist recovery support
• the opportunity to informally or formally support other students in recovery

There is evidence that recovery high schools can:

• reduce self-reported current alcohol and drug use (for example, in one study, current use reduced from 90% to 7% and days of abstinence increased from 32 to 82) (Moberg and Finch, 2008)
• decrease absenteeism (Hennessy and others, 2018)

One study found that attending recovery high schools did not significantly improve grades or reduce truancy compared to mainstream schools (Hennessy and others, 2018).

Current recovery support services in educational settings in England

Our survey of commissioners found that 15% of respondents (12 out of 78) reported that RSS in educational settings were available locally. However, their descriptions of the interventions that they had included in this category suggest that only one of the 12 interventions could be classed as an RSS in an educational setting. The services they miscategorised as RSS in educational settings were:

• young people’s substance misuse prevention and treatment access interventions
• adult and young people’s education, training and employment provision
• referral pathways from educational settings into treatment services

In the US, there are an estimated 150 collegiate recovery programmes (Brown and others, 2018). The Association of Recovery Schools estimates there were just over 40 recovery high schools in 2020.

In England, there are no recovery high schools and just 2 collegiate recovery programmes, which are at:

• Teesside University and Middlesbrough College in Middlesbrough (led by Recovery Connections, a LERO)
• University of Birmingham
• University of Sunderland

Recovery Connections, a local LERO, runs the collegiate recovery programmes at Teesside University and Middlesbrough College with in-kind support from the educational institutions.

Early findings from Birmingham’s collegiate recovery programme suggests that two-thirds of students have shorter periods of recovery than in the US, and the majority also experience significant mental health problems (Trainor, 2023).

Recommendations for future research

The fact that most of the evidence for RSS was conducted in the US raises questions about how the findings apply in a UK context. Developing a UK-specific typology of RSS and lived experience initiatives would help to better deliver, design and study these services in this country. Studies of RSS and lived experience initiatives in the UK would help to understand the similarities with, and differences from, US service models.

There is also a need for further research on:

• developing a taxonomy of the specific interventions offered by RSS, to help researchers better identify which interventions are most effective
• defining and differentiating various types of lived experience initiatives
• developing effective training approaches for peer support worker roles
• whether recovery community centres affect people’s levels of social support
• the various recovery housing models with greater specificity and analysis of their cost-effectiveness
• mapping the extent and nature of the recovery housing available in the UK
• the effectiveness of RSS in educational settings in the UK

References

Bassuk EL, Hanson J, Greene RN, Richard M and Laudet A. Peer-Delivered Recovery Support Services for Addictions in the United States: A Systematic Review. Journal of Substance Abuse Treatment 2016: volume 63, pages 1 to 9.

Bell NJ, Kanitkar K, Kerksiek KA, Watson W, Das A, Kostina-Ritchey E, Russell MH and Harris K. “It Has Made College Possible for Me”: Feedback on the Impact of a University-Based Center for Students in Recovery. Journal of American College Health 2009: volume 57, issue 6, pages 650 to 658.

Best D, Higham D, Pickersgill G, Higham K, Hancock R and Critchlow T. Building Recovery Capital through Community Engagement: A Hub and Spoke Model for Peer-based Recovery Support Services in England. Alcoholism Treatment Quarterly 2020: volume 39, issue 1, pages 3 to 15.

Botzet AM, Winters K and Fahnhorst T. An Exploratory Assessment of a College Substance Abuse Recovery Program: Augsburg College’s StepUP Program. Journal of Groups in Addiction and Recovery 2008: volume 2, issue 2-4, pages 257 to 270.

Brown A, Ashford R, Thompson Heller A, Whitney J and Kimball T. Collegiate Recovery Students and Programs: Literature Review from 1988-2017. Journal of Recovery Science 2018: volume 1, issue 1.

Brown AM, Ashford RD and others. Alumni Characteristics of Collegiate Recovery Programs: A National Survey. Alcoholism Treatment Quarterly 2019: volume 37, issue 2, pages 149 to 162.

Chavarria J, Stevens EB, Jason LA and Ferrari JR. The Effects of Self-Regulation and Self-Efficacy on Substance Use Abstinence. Alcoholism Treatment Quarterly 2012: volume 30, issue 4, pages 422 to 432.

Cleveland HH, Wiebe RP and Wiersma JD. How Membership in the Collegiate Recovery Community Maximizes Social Support for Abstinence and Reduces Risk of Relapse. In: Substance Abuse Recovery in College. Advancing Responsible Adolescent Development. Springer, 2010.

Day E, Kirberg S and Metrebian N. Affiliation to alcoholics anonymous or narcotics anonymous among patients attending an English specialist addiction service. Drugs and Alcohol Today 2019: volume 19, issue 4, pages 257 to 269.

Eddie D, Hoffman L, Vilsaint C, Abry A, Bergman B, Hoeppner B, Weinstein C and Kelly JF. Lived Experience in New Models of Care for Substance Use Disorder: A Systematic Review of Peer Recovery Support Services and Recovery Coaching. Frontiers in Psychology 2019: volume 10.

Groh DR, Jason LA, Ferrari JR and Davis MI. Oxford House and Alcoholics Anonymous: The Impact of Two Mutual-help Models on Abstinence. Journal of Groups in Addiction and Recovery 2009: volume 4, issues 1 to 2, pages 23 to 31.

Gustafson DH, McTavish FM, Chih YM, Atwood AK, Johnson RA, Boyle MG, Levy MS, Driscoll H, Chisholm SM, Dillenburg L and Isham A. A Smartphone Application to Support Recovery From Alcoholism: A Randomized Clinical Trial. JAMA Psychiatry 2014: volume 71, issue 5, pages 566 to 572.

Haberle BJ, Conway S, Valentine P, Evans AC, White WL and Davidson L. The Recovery Community Center: A New Model for Volunteer Peer Support to Promote Recovery. Journal of Groups in Addiction and Recovery 2014: volume 9, issue 3, pages 257 to 270.

Hennessy EA, Tanner-Smith EE, Finch AJ, Sathe N and Kugley S. Recovery schools for improving behavioral and academic outcomes among students in recovery from substance use disorders: a systematic review. Campbell Systematic Reviews 2018: volume 14, pages 1 to 86.

Jason LA, Olson BD, Ferrari JR and Lo Sasso LT. Communal housing settings enhance substance abuse recovery. American Journal of Public Health 2006: volume 96, issue 10, pages 1727 to 1729.

Jason LA, Olson BD and Harvey R. Evaluating Alternative Aftercare Models for Ex-Offenders. Journal of Drug Issues 2015: volume 45, issue 1, pages 53 to 68.

Jason LA, Wiedbusch E and others. Estimating the Number of Substance Use Disorder Recovery Homes in the United States. Alcoholism Treatment Quarterly 2020: volume 38, issue 4, pages 506 to 514.

Kelly JF, Fallah-Sohy N, Cristello J, Stout RL, Jason LA and Hoeppner BB. Recovery community centers: Characteristics of new attendees and longitudinal investigation of the predictors and effects of participation. Journal of Substance Abuse Treatment 2021: volume 124, article number 108287.

Kelly JF, Humphreys K and Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews 2020a: issue 3.

Kelly JF, Stout RL, Jason LA, Fallah-Sohy N, Hoffman LA and Hoeppner BB. One-Stop Shopping for Recovery: An Investigation of Participant Characteristics and Benefits Derived From U.S. Recovery Community Centers. Alcohol Clinical and Experimental Research 2020b: volume 44, issue 3, pages 711 to 721.

Kelly JF and Yeterian JD. Empirical Awakening: The New Science on Mutual Help and Implications for Cost Containment under Health Care Reform. Substance Abuse 2012: volume 33, issue 2, pages 85 to 91.

Lo Sasso AT, Byro E, Jason LA, Ferrari JR and Olson B. Benefits and costs associated with mutual-help community-based recovery homes: The Oxford House model. Evaluation and Program Planning 2012: volume 35, issue 1, pages 47 to 53.

McCollister KE, French MT, Freitas DM, Dennis ML, Scott CK and Funk RR. Cost-effectiveness analysis of Recovery Management Checkups (RMC) for adults with chronic substance use disorders: evidence from a 4-year randomized trial. Addiction 2013: volume 108, issue 12, pages 2166 to 2174.

McLellan AT, Lewis DC, O’Brien CP and Kleber HD. Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. Journal of the American Medical Association 2000: volume 284, pages 1689 to 1695.

McKay JR. Continuing care research: What we have learned and where we are going?. Journal of Substance Abuse Treatment 2009: volume 36, pages 131 to 145.

Mericle AA, Cacciola J, Carise D and Miles J. Supporting Recovery in the Community: Six-month outcomes of clients participating in the Phoenix House Bronx Community Recovery Center (BCRC). Journal of Community Psychology 2014: volume 42, issue 5, pages 509 to 518.

Mericle AA, Mahoney E, Korcha R, Delucchi K and Polcin DL. Sober living house characteristics: A multilevel analyses of factors associated with improved outcomes. Journal of Substance Abuse Treatment 2019: volume 98, pages 28 to 38.

Mericle AA, Slaymaker V, Gliske K, Ngo Q and Subbaraman MS. The role of recovery housing during outpatient substance use treatment. Journal of Substance Abuse Treatment 2021: volume 133, article number 108638.

Moberg DP and Finch AJ. Recovery High Schools: A Descriptive Study of School Programs and Students. Journal of Groups in Addiction and Recovery 2008: volume 2, issue 2-4, pages 128 to 161.

Mueller DG and Jason LA. Sober-Living Houses and Changes in the Personal Networks of Individuals in Recovery. Health Psychology Research 2014: volume 2, issue 1.

Polcin DL and Korcha R. Housing Status, Psychiatric Symptoms, and Substance Abuse Outcomes Among Sober Living House Residents over 18 Months. Addictive Disorders and their Treatment 2017: volume 16, issue 3, pages 138 to 150.

Polcin DL, Korcha R, Witbrodt J, Mericle AA and Mahoney E. Motivational Interviewing Case Management (MICM) for Persons on Probation or Parole Entering Sober Living Houses. Criminal Justice and Behavior 2018: volume 45, issue 11, pages 1634 to 1659.

Rose GL, Skelly JM, Badger GJ, Ferraro TA and Helzer JE. Efficacy of automated telephone continuing care following outpatient therapy for alcohol dependence. Addictive Behaviors 2015, volume 41, pages 223 to 231.

Scott A, Anderson A, Harper K and Alfonso ML. Experiences of Students in Recovery on a Rural College Campus: Social Identity and Stigma. SAGE Open 2016: volume 6, issue 4.

Stringfellow EJ, Lim TY, Humphreys K, DiGennaro C, Stafford C, Beaulieu E, Homer J, Wakeland W, Bearnot B, McHugh RK, Kelly J, Glos L, Eggers SL, Kazemi R and Jalali MS. Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis. Science Advances 2022: volume 8, issue 25.

Timko C, Below M, Vittorio L, Taylor E, Chang G, Lash S, Festin FED and Brief D. Randomized controlled trial of enhanced telephone monitoring with detoxification patients: 3- and 6-month outcomes. Journal of Substance Abuse Treatment 2019: volume 99, pages 24 to 31.

Trainor L. Being better than well at the University of Birmingham. Journal of Substance Use and Addiction Treatment 2023: volume 146, article number 208949.