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.