Substance Misuse Treatment and Recovery: Federal Guidance Needs to Address Work Arrangements for Those Living in Residential Facilities

Fast Facts

For the millions of Americans struggling with substance misuse, residential treatment and recovery facilities may provide much-needed housing and healthcare. Some facilities require residents to have jobs—which can provide financial stability and structure. But working too soon could be detrimental to their recovery, according to Department of Health and Human Services officials.

HHS has some guidance on the role of work in treatment and recovery. But 4 of 5 state substance misuse agencies we spoke to said more guidance would be helpful, such as when it's best for residents to start work.

We recommended HHS address this, and more.

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Highlights

What GAO Found

Based on GAO's survey of residential treatment and recovery facilities, an estimated 14 to 33 percent of state-licensed treatment facilities nationwide require residents to work. A higher percentage of certified recovery residences, which Department of Health and Human Services (HHS) officials said focus primarily on helping residents transition from treatment to day-to-day life, require work (see figure). Of the 35 licensed treatment facilities that reported either requiring or encouraging work, 11 reported that residents might start work immediately after arriving or after completing basic orientation. Among the 44 licensed treatment facilities that reported some of their residents work (e.g., for the facility or an external entity), 13 reported some residents work for no or reduced pay.

Estimated Range of the Percentage of Residential Treatment and Recovery Facilities Where Work is Required or Encouraged

Notes: Licensed treatment facilities are generally licensed by state agencies. Statistical estimates are generalizable to the nationwide population. Certified recovery residences are generally certified by National Alliance of Recovery Residences (NARR) state affiliates. Statistical estimates are generalizable to the population of certified recovery residences located in states with a NARR affiliate where the state substance misuse agency has contact information for these facilities. Bars shown in the figure represent the range between the lower and upper bound of the 95 percent confidence interval.

Selected stakeholders that GAO spoke with generally agreed that work can contribute to individuals' successful recovery, and that facilities should consider factors such as the timing of work and adequate pay when incorporating work into substance misuse treatment and recovery programs.

HHS has published some informational guidance on the role of work in treatment and recovery. However, four of the five state substance misuse agencies GAO spoke with said additional guidance would be helpful, such as guidance on when best to start work. By developing a process to request and use state agencies' feedback, HHS could better promote effective work arrangements and help state agencies and facilities support residents' recovery. Furthermore, HHS officials told GAO that treatment facilities should not require work as a condition of receiving services. However, HHS' application and related documents for its Substance Use Prevention, Treatment, and Recovery Services (SUPTRS) Block Grant do not clearly provide guidance on work requirements at residential treatment or recovery facilities. Without clarifying guidance, HHS risks block grant funding going to facilities that are not fully in line with its best practices.

Why GAO Did This Study

Millions of Americans struggle with substance misuse. Some pursue treatment and recovery at over 3,660 residential facilities, according to 2020 HHS data. Some of these facilities may require residents to work.

GAO was asked to review work practices at these facilities. This report examines (1) the prevalence of facility work and pay practices, (2) selected stakeholders' views on the role of work in substance misuse treatment and recovery, and (3) the extent to which federal guidance and enforcement address work and pay at facilities.

In March to June 2023 GAO surveyed a statistical sample of facilities and obtained generalizable responses from 96 licensed treatment facilities and 48 certified recovery residences. GAO visited facilities, some covertly, selected for geographic variation and other considerations; interviewed HHS and Department of Labor officials and selected stakeholders such as state substance misuse agency officials and researchers; and reviewed relevant federal laws, regulations, and agency documents.

Recommendations

GAO recommends that HHS (1) develop a process to consult state substance misuse agencies about their guidance needs for incorporating work into treatment and recovery and (2) state in SUPTRS Block Grant documents if and when work requirements are acceptable as a condition of accessing services in residential treatment and recovery facilities. HHS agreed with GAO's recommendations.

Recommendations for Executive Action

Agency Affected	Recommendation	Status
Department of Health and Human Services	The Assistant Secretary of SAMHSA should incorporate single state agencies (SSA) into existing guidance development processes or develop a formal process to proactively consult SSAs about the information they need regarding how work should be incorporated into substance misuse treatment and recovery, and use the SSA feedback from such processes to inform the development of publicly available guidance. (Recommendation 1)	Open When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Health and Human Services	The Assistant Secretary of SAMHSA should explicitly state in SUPTRS Block Grant application materials (1) that incorporating work into a treatment facility resident's treatment plan should involve an individualized assessment to determine if and when work is appropriate, and that requiring work as a condition for accessing treatment services is not acceptable, and (2) if and when requiring work as a condition of accessing services is acceptable at recovery housing. (Recommendation 2)	Open When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.