Housing instability and economic insecurity across the continuum of active substance use,treatment,and recovery among women involved in the criminal legal system

Abstract

Background:

Prior research on the widespread housing instability, such as homelessness, and economic insecurity, such as difficulties gaining employment, faced by women with a history of opioid use disorder (OUD) highlights the need to explore the impact of these hardships on experiences of active addiction, medications for OUD (MOUD) treatment uptake, and recovery outcomes.

Objectives:

This study examines how the compounding and interactive effects of housing instability and economic insecurity impact the experiences of women involved in the criminal legal system (CLS) across the continuum of active addiction, treatment, and recovery.

Design:

This study utilizes semi-structured qualitative interviews.

Methods:

Qualitative interviews were conducted with 42 participants, including women with a history of OUD and CLS involvement (N = 20), treatment providers (N = 12), and criminal legal professionals (N = 10), and analyzed with inductive thematic coding to explore substance use trajectories and issues with MOUD treatment.

Results:

Findings revealed housing instability and economic insecurity significantly influenced women’s experiences across the continuum of active substance use, treatment, and recovery. During active addiction, women faced hardship-related vulnerabilities due to low socioeconomic backgrounds, self-imposed isolation, and domestic violence, heightening the risk of worsening substance use. Related challenges experienced during treatment involved difficulties associated with meeting housing and medical assistance qualifications, which interfered with retention and stability. While housing instability remained a significant concern during recovery, economic insecurity became more prominent in recovery experiences compared to addiction and treatment phases.

Conclusion:

Policies should prioritize integrating interventions addressing housing instability and economic insecurity into patient-centered care across active addiction, treatment, and recovery to promote health, gender equity, and well-being for those affected by substance use. Actionable recommendations include vocational rehabilitation within carceral and treatment settings, coordinated efforts between the child welfare system and treatment system, and education about housing resources, among others.

Introduction

The United States has seen a devastating rise in opioid-related overdoses, with synthetic opioids contributing to over 70,000 overdose deaths in 2023. ¹ While opioid use disorder (OUD) affects individuals across socioeconomic statuses, experiences with economic and housing insecurity are particularly prevalent. An analysis of the Nationwide Inpatient Sample for 2012–2014 and 2016–2017 revealed that during active addiction, individuals with OUD experienced elevated rates of unemployment, homelessness, unstable work schedules, limited healthcare access, and lack of education, as compared to the broader U.S. population. ² While active addiction is a particularly complex time, the continuum of care model views addiction as spanning three domains: active substance use, treatment, and recovery. ³ Given that experiences with economic and housing insecurity are so common for individuals with OUD, understanding how these insecurities are experienced differently during each domain is essential for determining how to best support well-being.

Treatment barriers

One evidence-based treatment for OUD involves the use of medications for opioid use disorder (MOUD), which has been shown to reduce risk of both overdose and return to use, and to address other complex OUD-related needs. ⁴ Yet, research has found that there are numerous barriers to MOUD treatment initiation and retention. For example, housing and employment loss can hinder treatment initiation for people in active addiction, ⁵ and a 2021 study by Spector et al. ⁶ found that ineligibility, transiency, and reliance on illicit activities also pose barriers to initiating MOUD treatment. The impacts of these barriers extend beyond treatment initiation to also influence retention, as data from the 2017 Treatment Episode Dataset-Discharges, a national dataset collecting information about substance use treatment facility admissions and discharges annually, indicated that 64% of patients discontinue MOUD treatment before 6 months primarily due to homelessness. ⁷ Other barriers associated with housing and economic insecurity perceived by providers in the opioid treatment setting include poverty, lack of education, stigma, low social support, logistical challenges, caregiving demands, and work schedule instability. ⁸

Economic insecurity may also affect OUD outcomes differently for men and women, with the negative association between employment and retention in MOUD treatment being more pronounced for women. ⁹ Within this study, Parlier-Ahmad et al. ⁹ further discovered that employed women in outpatient substance use treatment clinics were less likely to stay in treatment compared to unemployed women. These findings stand in contrast to other cited works,^5,10 which poses an important question about how economic insecurity potentially impacts women with OUD differently at different points across the continuum of active substance use, treatment, and recovery. Ultimately, while the findings about the role employment plays in retention for MOUD treatment largely disagree with one another, they emphasize the need for qualitative work that critically examines gender-specific dynamics in greater depth; exploring individuals’ lived experiences offers an opportunity to understand the complex relationship between employment and long-term utilization of MOUD treatment from a nuanced perspective.

Recovery challenges

Housing instability and economic insecurity continually affect individuals with OUD throughout their trajectories, influencing overdose risk and protective factors beyond treatment and into periods of recovery.^11,12 Interviews of community stakeholders in three counties from the Community Collective Impact Model for Change initiative, a coordinated approach in Ohio developed to address overdose deaths and OUD treatment access, emphasized that education levels and employment types influenced economic insecurity during recovery, affecting sobriety and long-term wellness. ¹⁰

Examining women-specific needs beyond education and employment, one study highlighted housing instability as a significant correlate of sex trading among women, ¹³ and another found that pregnant women seeking MOUD treatment faced disproportionately more housing instability and food insecurity. ¹⁴ Both findings speak to the multifaceted experience of housing instability as well as how it intersects with economic insecurity. Overall, understanding socioeconomic barriers individuals with OUD encounter alongside women-specific needs is an area that warrants further investigation.

Present study

Prior research on the widespread housing instability and economic insecurity experienced by women with OUD highlights the need for in-depth qualitative analysis to capture the diverse and complex challenges among women in MOUD treatment. Understanding the impact of these barriers on MOUD treatment initiation and retention is crucial due to low engagement and high attrition rates, ¹ especially among women. ¹⁵ This is also particularly relevant for women with a history of involvement in the criminal legal system (CLS), as they tend to face interruptions to or a complete discontinuation of MOUD treatment upon incarceration.^16,17 Women involved in the CLS with lived experiences of OUD also are at a disproportionately high risk of unemployment and difficulty finding a job as well as experiencing homelessness before being incarcerated and following release.^18,19 Taken together, the often compounding barriers to MOUD treatment access, finding stable housing, and attaining secure employment encountered by women with a lifetime history of OUD and criminal legal (CL) involvement and the need for interventions that address these areas underscores the importance of the focal population within the present study.

This study aims to explore how challenges associated with housing and economic insecurity impact the experiences of women with OUD, MOUD treatment uptake, and recovery outcomes by considering women’s experiences across the continuum of active addiction, treatment, and recovery. It adds novelty to addiction sciences by examining the compounding and interactive effects of housing instability and economic insecurity across the continuum. Moreover, past studies often focus on one concept or the other, and if they do address both, housing instability is often grouped into economic insecurity, which risks leaving out the nuanced complexities associated with the multifaceted experience of homelessness. The present study aims to address this through recognizing economic insecurity and housing instability as separate yet interrelated concepts taking place in different forms across active addiction, treatment, and recovery from OUD.

This analysis of such nuanced concepts is further strengthened through the utilization of qualitative methodology over quantitative strategies employed by previous studies. Specifically, our use of semi-structured interviews draws on the perspectives of three subgroups—women with a lifetime history of MOUD treatment and CL involvement, substance use disorder (SUD) treatment professionals, and CL professionals—to illuminate the intersectionality of housing instability and economic insecurity through a variety of lived experiences; we hear from the participants in their own words instead of drawing conclusions from statistical associations. Overall, analyzing challenges associated with housing and economic insecurity along this continuum may provide insights to enhance engagement and successful completion of MOUD treatment for women with OUD.

Methods

The present manuscript is part of a larger qualitative study that examined experiences associated with OUD alongside barriers and facilitators to MOUD treatment among women with a history of CL involvement.^20–24 We conducted 42 qualitative interviews between May and July 2022 with 3 participant groups: women with a lifetime history of MOUD utilization (N = 20), SUD treatment professionals (N = 12), and CL professionals (N = 10) working with women with OUD. Although saturation was not formally evaluated, the size of the subgroups (N = 10–20) in this study were selected to follow the literature on the probability of reaching data saturation, ²⁵ with recruitment concluding upon reaching the goal of eligible participants per subgroup—at least 20 women with a history of OUD, at least 10 SUD treatment professionals, and at least 10 CL professionals. Recruitment methods were specific to each group. This work was approved by the Pennsylvania State University Institutional Review Board (STUDY00018974). Prior to their interviews, all participants provided verbal consent.

Participant recruitment

Recruitment strategies for the 20 women with a lifetime history of MOUD utilization included social media ads, chain referrals, and flyers distributed to MOUD programs in Pennsylvania (PA). Eligible participants were 18 or older, had CL involvement, resided in PA, had a history of illicit opioid use, and had past or present experience with MOUD treatment.

The 12 SUD treatment professionals were recruited through direct calls to Opioid Treatment Programs in PA, chain referrals, and online advertisements. Eligible professionals practiced in PA, were actively employed as a health professional who prescribed MOUD and/or provided care for women receiving MOUD, and worked specifically with women with OUD.

Similar to the SUD treatment professionals, the 10 CL professionals were recruited through direct calls to women’s prisons in PA, referrals, and online ads. Eligible CL professionals included parole or probation officers, judges, or drug court professionals working with women in the CLS in PA.

Exclusion criteria for participants of all subgroups included being younger than 18 and/or residing outside of PA. For the SUD treatment and CL professionals, exclusion criteria also included not working in PA and not working with women who use opioids. A web screening process in REDCap ensured eligibility.

Interview protocol

Trained qualitative interviewers employed as part of a research interviewing staff administered the hour-long phone interviews that included verbal consent, background study information, and questions tailored to participant group. These interviewers had experience conducting qualitative interviews, were all women, and each held a master’s degrees or a PhD in the social sciences. They were of similar demographic backgrounds to the women who participated in the study, had no previous relationships with the participants, and did not disclose details about their own lives and experiences to participants.

As the study only involved a one-time semi-structured interview with each participant over the phone, the interviewers never met participants in person; thus, verbal consent was approved by the IRB. At the scheduled time, interviewers called participants, explained the study, and first went through the informed consent process. If verbal consent was given, the interviewer began the interview and made sure to emphasize that participants could decline to answer any questions at any point. No participants dropped out or refused to participate.

Women with a history of OUD answered questions about their background, experiences with support services, drug treatment experiences, social determinants of health, CLS involvement, overdose experiences, and suggestions for drug treatment programs. SUD treatment professionals were asked about patient backgrounds and support service utilization, treatment barriers, CLS involvement, overdose experiences, and ways to improve treatment outcomes. CL professionals were asked about experiences and services provided to women with OUD in the CLS and optimal ways to help women with OUD in the CLS.

In interviews with women with a history of OUD, examples of questions from the study’s semi-structured interview guide (see supplementary material) focused on housing instability and economic insecurity included “Do you have any history of homelessness?” and “How do you make ends meet?” Probing questions were used to identify further employment information, government assistance, and support from family and friends as needed to capture examples and in-depth information. While the women with a history of OUD were asked about these themes across their lives, the professionals specifically were asked about the treatment and recovery phases. Examples of questions the SUD treatment professionals were asked included, “What have you noticed to be the least helpful to women in drug treatment for opioid use and other substances?” and “What do you think is the main reason women drop out of drug treatment?” For CL professionals, relevant questions included, “Do you think there are issues specific to women who are incarcerated, on parole, or probation and use opioids and/or other drugs that the justice system does not address at all or well?” and “Are there drug treatment programs for women in your facility? If so, do you think the drug treatment is helpful to the women?” The insights gleaned from SUD treatment and CL professionals are vital, as they have worked directly with many women navigating SUDs and CL issues; including the professionals’ responses offers a more well-rounded perspective of both topics and can inform future efforts within and beyond SUD treatment and CLS facilities to better meet the needs of the women they serve.

It was decided that, given the hour time commitment to the interview, a $50 gift card was sufficient compensation for the participants’ time. Participants received their gift card after the interview. The $50 gift card likely did not influence responses, as receiving the gift card did not hinge on how questions were answered.

Data analysis

The audio recordings of the phone interviews were transcribed, pseudonyms were used for confidentiality, and secure servers were utilized to store transcripts. Data analysis took place using the qualitative data software NVivo 14. ²⁶ The qualitative research design and our use of thematic analysis was guided by grounded theory research methodology, which takes an inductive approach to the analysis of data. ²⁷ Our aim was to uncover common experiences through the women’s own retelling of their stories, without presupposing what factors were most salient in their substance use and recovery journeys. Primary and secondary coding schemes were developed inductively through thorough reading of the transcripts to ensure saturation of prominent themes and codes within the transcripts.

After the coding scheme was finalized, three primary coders took the lead on coding one participant subgroup each. Following the completion of the coding process by the primary coders, the principal investigator (PI) held the role of overseeing and validating the coding by reviewing each coded transcript for accuracy and identifying discrepancies at the individual and group level. If the PI’s interpretation differed from the primary coder on a given transcript, this discrepancy was discussed by the PI and the primary coder in a collaborative manner until a resolution was reached. At the group level, if the PI flagged any variations in interpretation by the primary coders across transcripts, they were brought to the group for discussion and collectively resolved. It is important to note that discrepancies at the individual and group level were few, signaling a high degree of consistency in interpretation across the coders. Taken together, this multi-step process of the coders reading and rereading transcripts to thoughtfully apply the coding scheme, the PI identifying and facilitating collaborative discussion around discrepancies, and the research team reaching consensus on such strengthens the methodological rigor of the thematic analysis.

One primary theme was inductively formed for hardship through housing instability and economic insecurity. Temporal coding was used for the next round of analysis; we categorized experiences by the timepoints of addiction, treatment, and recovery based on when the participant’s experience occurred. A time-ordered matrix was used to organize codes and compare associations across addiction, treatment, and recovery. The reporting of this study conforms to the COREQ statement. ²⁸

Results

Participant characteristics

Most study participants were non-Hispanic White: 70% of women with OUD (mean age = 37), 66.7% of SUD professionals (mean age = 48, 10 females), and 90% of CL professionals (mean age = 44, 7 females). Nonetheless, the participants had diverse backgrounds in other ways. Among the women with a history of OUD who participated, 80% had experienced past homelessness, and 5% were currently homeless. Half of the women with a history of OUD received medical assistance, which we used as a proxy for economic insecurity. About 70% of the women had children, and 29% of those with children disclosed that they did not presently have custody of their children. All women with a history of OUD had a lifetime history of CLS involvement, and three women were currently on probation or parole. About 5% had less than a high school education, 35% had a high school diploma or equivalent, 35% had some college or an associate degree, 20% had a bachelor’s degree, and 5% reported other. For a full breakdown of participant demographic characteristics, see Table 1.

Table 1.

Full sample participant characteristics and economic insecurity and housing instability-related characteristics among women with OUD.

Variable	Women with OUD (N = 20), n (%)	SUD treatment professionals (N = 12), n (%)	CL professionals (N = 10), n (%)
Sex
Male	0 (0)	2 (17)	3 (30)
Female	20 (100)	10 (83)	7 (70)
Age
Age, mean (SD)	37 (7)	48 (5)	44 (8)
Race
Black	1 (5)	2 (17)	1 (10)
White	14 (70)	8 (66)	9 (90)
Multiracial	1 (5)	0 (0)	0 (0)
N/A	4 (20)	2 (17)	0 (0)
Education
Less than a high school degree	1 (5)
High school diploma or equivalent	7 (35)
Some college or an associate degree	7 (35)
Bachelor’s degree	4 (20)
Other	1 (5)
Past homelessness
Yes	16 (80)
No	4 (20)
Current homelessness
Yes	1 (5)
No	19 (95)
Medical assistance
Yes	10 (50)
No	10 (50)
Children
Yes	14 (70)
No	6 (30)
Child custody (N = 14)
Yes	8 (57)
No	4 (29)
N/A	2 (14)

OUD: opioid use disorder; CL: criminal legal; SD: standard deviation; SUD: substance use disorder.

Housing instability

Across the continuum of active addiction, treatment, and recovery, women with a history of OUD faced varying challenges related to housing instability. During active addiction, this encompassed experiences of domestic violence, limited accessibility of safe housing, and self-imposed isolation, all heightening the risk of worsening substance use. In the context of the women’s lived experiences, self-imposed isolation refers to intentionally distancing oneself from family members and other social relationships. Regarding the treatment phase, housing instability was a barrier to treatment success spoken to by all SUD treatment and CL professionals; the professionals shared that the women with a history of OUD they worked with often had experienced homelessness and faced difficulties meeting the qualifications for housing assistance. Lastly, while in recovery, different challenges related to housing instability emerged, with participants speaking to complications around the process of applying for individual housing and related resources as well as restrictions faced while receiving housing assistance. Taken together, housing instability impacted every stage of the women’s OUD trajectories, varying in form and importance across the continuum of addiction, treatment, and recovery.

Active use

Experiences of domestic violence

When discussing housing instability during active substance use, the women with a history of OUD described various unstable housing situations associated with domestic violence, drug-related incarceration, and their substance use itself. One woman with a history of OUD recounted living under a bridge because she had nowhere to go after experiencing domestic violence:

I lived under a bridge for a little bit for domestic violence because I had moved to an area that I didn’t know really. At that time, my boyfriend broke my phone. I ended up living under a bridge for a little bit. . . Then I went into the town, and I ended up sleeping in the alleyway for about a week.

One CL professional, a mental health court coordinator, spoke to similar complexities associated with women being put in an impossible position where they must choose to stay in or leave an unsafe environment during active addiction:

Women will stay in unsafe relationships and environments because they need a roof over their head. We have a woman right now that we’re trying to figure out, okay, how much can we pay for the hotel room to keep her out of this environment? When she’s seeing her sister being abused, but she’s there with her kid and doesn’t want her kid to see.

Taken together, the woman with a history of OUD’s story and the anecdote from the mental health court coordinator signify the importance of accessible shelters for families in crisis—a common thread throughout our interviews.

Self-imposed isolation

Another woman with a history of OUD described the unstable living circumstances she experienced due to her substance use and its impact on her close relationships:

The last three or four years I was in addiction, I was anywhere from the woods, to a car, to somebody’s house, and anywhere that I can just lay down and sleep. I wasn’t homeless. I was always offered to come back home. I just never chose to because I just didn’t want to be around anybody.

Despite the absence of stable housing, this participant did not classify herself as homeless, highlighting the need for a nuanced perspective on housing instability. Reflecting on her trajectory, she felt that housing insecurity was a self-imposed isolation during her addiction. The interplay of personal preference, lack of social support, and housing instability may impede access to available therapeutic interventions and government support.

Treatment

Housing assistance barriers during the transition out of inpatient treatment

All SUD treatment professionals and CL professionals mentioned housing insecurity as a barrier to treatment success; one SUD treatment professional working in an MOUD clinic reported that homelessness impacted nearly half of her clients. Another SUD treatment professional, a research assistant overseeing an MOUD treatment intervention, mentioned difficulties their clients faced meeting housing assistance qualifications while in residential programs. Some clients spent 3–6 months in residential treatment, only to be discharged to shelters in order to receive housing assistance. This participant shared:

There’s some women that we have that are in a halfway house or a program like that, and insurance is running out, and it’s time for them to transition to independent living, and they’re not financially secure enough to do that. If they had a little help, that would be wonderful. To try to get them help, it’s a shame. They have to go to a shelter to be homeless. They’re spending all this time in a program and stabilizing, and then now you have to step down and go to a shelter so you can qualify financially for help to be able to move into independent living. Even if they were able to just do a direct transition, there’s not a lot of low-income housing or income-based housing or support for that population.

Medical insurance covers a predetermined amount of time for residential treatment services, which can put women who lack financial resources in difficult predicaments when transitioning to independent living. This pressure adds another stressor on top of a potentially difficult treatment process, and their lack of safe housing may even take women back to “ground zero” after the time and work they have dedicated to inpatient treatment.

Heightened challenges faced by women with children

The prevalence of homelessness and other types of housing insecurity also exacerbated difficulties for women who want to regain custody of their children. One SUD treatment professional working in an inpatient facility explained:

Housing’s huge, because they come here, and then they really don’t have any money, and then they want their children back, but they can’t have their children back if they don’t have the appropriate home and amount of beds. If they’re in this area, it’s limited. A lot of times there’s a waiting list, and it’s very frustrating for us and them.

This participant explained that many women with OUD in her facility were focused on regaining custody of their children while in treatment and that being placed on a waitlist for housing could interfere with their motivation and ability to keep up with their treatment process. A plan to accommodate families’ housing needs during treatment initiation through outside community assistance could better facilitate the treatment process for women with OUD.

CL professionals expressed the same sentiment as SUD treatment professionals regarding the challenges housing instability posed for women with a history of OUD with children. One CL professional working in a drug treatment court spoke about the uncertainty faced by women with a history of OUD and CL involvement when needing to find housing to regain custody of their children:

It’s very hard to find housing now, and housing for a woman with her children, there’s waiting lists. One might be incarcerated, the kid might be in foster care, and unless we find suitable housing for their children, [they can’t get their kid back]. . . Okay, they need a two-bedroom apartment. Well, now you’re looking at $1,000 a month. Where is she going to get that money? This poor woman didn’t even finish high school.

SUD treatment and CL professionals shared similar insights on the difficulties women seeking treatment faced in relation to housing instability. These difficulties were only heightened for women with children.

Recovery

Difficulties finding safe, stable, affordable housing

Examining the impacts of housing instability on recovery revealed different challenges and complications not seen in the active substance use and treatment stages of OUD. The women with a history of OUD in our sample discussed how the untimely process of finding individual housing and the restrictions they faced even when receiving housing assistance could potentially upend their recovery progress. One woman with a history of OUD told us how difficult it was for her to find a place she could afford, “I lived in a recovery house for 15 months, though, and I finally just got my own place maybe a month ago.” Luckily, the recovery house allowed her to stay for an extended period until she could move out independently. Had she been subject to a time restriction on her stay, she would have had to leave without any place to go.

Another woman with a history of OUD acknowledged that even when receiving housing assistance, safe housing requires more than a roof over one’s head; it also requires utilities and furnishings. Building a home while facing steep rent costs can be particularly challenging for women who have lost many possessions during active substance use. When we interviewed this participant, she faced the next month’s rent bill looming over her. Her recovery program covered her first month’s rent, but she was expected to pay the next, and she had yet to acquire a job to cover the rent, utilities, and furnishings. When we asked her if she thought an extension on her housing assistance would be helpful, she told us:

Yes. At least until I get my job. I moved in here, I think, like a month and a half ago. They helped me to get in here and like a month’s rent on top of that. It just was quick from going with nothing at all to having to furnish this house because I had absolutely nothing when I moved in here.

Stigmatizing experiences, renting restrictions, and loss of housing-related resources

Even when women in recovery can find housing assistance, they are still faced with the possibility of facing social stigma from landlords who may be wary of renting to those with past or present substance use disorders (SUDs). Although community and government programs aim to assist women in finding housing, one woman with a history of OUD described feeling stigmatized when receiving recovery-specific housing assistance and being labeled as an “addict”:

I was on a program called the [redacted]. . . I don’t know what I would do without that program. I probably would be homeless. But because of that, I’ve been able to have my own place since then. It’s still hard, though, because you have to find a landlord that doesn’t know you. It’s a small area. A lot of them won’t rent to you. Do you know what I mean? Just because you have that stigma of being an addict, it’s super hard. I’m pretty sure my landlord now doesn’t want me here, and I think they might try to not renew my lease in October.

This woman with a history of OUD continued to face housing instability that threatened her newfound recovery. Similarly, another women with a history of OUD shared that she could not find a place that would rent to her due to her “background, poor credit, and a dog.” Compounding this issue further, she then lost the program that would have helped her pay:

. . .the lady (professional assisting her with housing) called me back and she was like, “I’m sorry to suspend your application, but you haven’t found a lease in enough time and there’s other people out there that need help. Unfortunately, we can’t keep your application open forever.”

Within her experience, this participant described losing hope from the difficulties faced even trying to find a place to rent—a feeling that was likely amplified by the loss of rent payment program. In many ways, housing instability in recovery was a continuation of housing instability women faced during the active substance use and treatment stages. Additionally, it was intensified by some of the limitations caused by other economic hardships that they could not entirely escape. These challenges threatened women’s longer-term stability even when offered short-term housing assistance.

Economic insecurity

Alongside of housing instability, challenges associated with economic insecurity impacted women with a history of OUD across the continuum of active addiction, treatment, and recovery. In active addiction, the women spoke to the stress of losing their possessions and having to essentially rebuild their lives from the ground up. During treatment, one key issue that emerged was a medical assistance paradox. In the context of the present study, the medical assistance paradox refers to a paradoxical barrier where employment jeopardizes eligibility for needed medical benefits like MOUD treatment, which complicated the efforts of SUD treatment professionals to assist clients in achieving stability. These challenges placed additional stress on and further hindered the treatment success of women with a history of OUD, particularly those with children, as they needed housing, income, and other resources to regain or retain custody. Finally, in the recovery phase, participants spoke to experiences of economic insecurity through having to deal with accrued debts, vocational challenges and complications associated with past CLS involvement, and the impact of low educational attainment and vocational training. Ultimately, while economic insecurity influenced women with a history of OUD across the continuum, it became more prominent in participants’ recovery experiences compared to the addiction and treatment phases.

Active use

Loss of possessions and starting over

Economic insecurity also emerged as a common theme for women with OUD during active addiction. More specifically, women with a history of OUD spoke to the detrimental impact of losing possessions while experiencing active addiction. Although the types of lost possessions vary across the women’s accounts, they all highlight a consistent experience where many women must rebuild their lives from the ground up. One woman with a history of OUD provided a brief description of having to “start all over” because of her economic insecurity. She told us, “I’ve lost houses, apartment, cars. Material things, clothing, sneakers, stuff like that. I’ve had to literally start all over multiple times.” Rebuilding one’s life from the ground up time after time creates stressors and vulnerabilities that can further motivate substance use. In this way, economic insecurity creates a feedback cycle that may feel impossible to find a way out of. This dynamic serves as another reason some women with a history of OUD report self-imposed isolation.

Treatment

The medical assistance paradox

Economic insecurity was also reported to be a common and detrimental experience for women during MOUD treatment. For women with a history of OUD who faced socioeconomic barriers during active substance use, obtaining medical assistance was crucial to receiving MOUD. However, it could become challenging to find independence through vocational or other means after receiving medical assistance due to medical assistance regulations and private insurance qualifications. This barrier means that some women with a history of OUD on medical assistance may hit a period in treatment where they are penalized for finding gainful employment. Medical assistance is crucial for receiving MOUD, but finding employment could make them ineligible for medical assistance. If their employment offers private insurance that does not adequately cover MOUD, or does not offer private insurance and does not pay enough to adequately afford insurance on the public market, becoming employed could cause a stall in treatment. One woman with a history of OUD in our sample shared her experience with this medical assistance paradox:

The methadone clinic is $110 a week. Right there, my medical [assistance], just in going to the clinic, sometimes outweighs the benefit of working. I would love to have a job, but if I would even get a part-time job, I would most likely lose my medical [assistance]. . . It’s like you get penalized if you get any type of work. I benefit more just from food stamps and the medical [assistance]. Just medical [assistance] is worth more than working part-time, if I can get hired with my background.

As this participant demonstrates, women receiving MOUD treatment may be disincentivized to work if they fear that gaining employment could impact their ability to receive medical assistance and access MOUD. The potential loss of medical assistance may not impact people typically when choosing whether to seek employment. However, the steep costs of MOUD without insurance may be enough to weigh the decision against seeking employment, as it did for this participant. Nevertheless, women who complete treatment without gaining vocational experience could also face difficulties sustaining recovery after treatment if they cannot find meaningful paid work.

Difficulties finding and transitioning to stable, gainful employment

Economic insecurity during the treatment phase also involved complexities associated with transitioning from illicit work to gainful employment. One SUD treatment professional, a nurse, shared experiences of working with women in treatment on finding stable employment opportunities:

“A lot of [women in treatment] do illegal activities still, such as sex work. Some trying to find work from home jobs and then if we’re lucky we can get a mom to put their child in daycare with CCIS [Child Care Information Services] help, and then they can work what I call regular jobs.”

This insight not only calls attention to how women in treatment tend to be searching for gainful employment but also how there may be a need for assistance in navigating challenges that can accompany being employed, such as childcare. For women in treatment, this is especially relevant, as they often must balance treatment requirements with childrearing expectations and work obligations.

Recovery

Challenges associated with past and present CLS involvement

The women with a history of OUD and CL professionals in our sample both discussed experiences of economic insecurity and their influence on recovery. Elsewhere, we highlighted adversities associated with CLS involvement from the lived experiences of women with OUD, where they spoke more broadly to the difficulties encountered following release from incarceration around unmet health needs, intersections between social stigma from CLS involvement and seeking medical care or employment opportunities, and gendered differences in resource availability and support.^21,23 Here, we expand on those difficulties as they relate to experiences of economic insecurity during the recovery timepoint of the OUD continuum. Specifically, participants spoke to the burden of accrued debts associated with involvement in the CLS: vocational challenges of facing new constraints on available career paths, disadvantages associated with a history of CLS involvement, and lacking necessary training; and barriers related to educational attainment.

The burden of accrued debts

Some individuals incurred debts due to court costs, fines, or child support accrued while incarcerated, creating additional financial obligations to navigate in recovery. For those who are incarcerated, it can take weeks if not months to apply for and receive government assistance programs again after release. However, we learned that, sometimes, individuals who are incarcerated may errantly continue receiving assistance that they then have to pay back after release—leaving another debt to bear. One CL professional explained:

Someone could have been incarcerated—even if they were arrested and they were in jail for the holding period until they got bailed out, depending on what other kind of facility it was—they may have lost any kind of government assistance that they had. . . Then they get out and are in the hole. I know that that causes a difficulty. And then if they were paid, and they owe it back, it will get taken out of their next payment. I know that that can be a hurdle, especially if someone’s in and does well in treatment and leaves clean and wants to do better.

Facing accrued debts, on top of needing to rebuild one’s life, can add stressors that can hinder women’s recovery trajectories.

Limitations on available career paths

The need to explore new careers during recovery was also mentioned as a potential source of vocational difficulties the women with a history of OUD experienced. One woman with a history of OUD described facing the uncertainty of returning to her initial career field—nursing—after developing an OUD after a physical injury. Even after 5 years in recovery, she still faced anguish over the loss of her career and uncertainty about her vocational options moving forward:

Sometimes I get really hopeless and carried away. It feels like a just dead-end. I’m trying to fight so hard to do all of this, and sometimes for what? There’s no guarantee I can return to nursing. I’m really just doing it all based off of blind faith. That’s all I’ve been doing for the past four and a half years. I think throughout sobriety, that’s always been the underlying thing is, that was my career. I don’t have a backup career. Once you’re a nurse, that’s it. There’s a lot of, I guess, fear and anxiety based on what am I going to do with my life at 37 years old, if I can’t do this?

For this participant, her former career as a nurse was a large part of her identity. She found motivation in her recovery through the hope of being able to return to nursing. She worried about what might happen if she were to find, eventually, that she could never return to her former career. In this way, her sustained recovery was tenuous and dependent on her career options.

Education-related barriers

Finally, the CL professionals we spoke to underscored the barriers that low educational attainment place on women during recovery, further amplifying economic insecurity. They highlighted the limited work options available to individuals with low educational attainment, which posed challenges for those recently released from incarceration or in the early stages of recovery. They observed instances where individuals felt compelled to revert to their previous behaviors due to the limited employment opportunities that stem from low educational attainment. One CL professional told us:

I know many people don’t even have a high school diploma, so their work options are limited when they get out. Sometimes, they don’t have a choice but to go back to what they were doing before [illegal work]. Then that leads to the same kind of decisions that got them there in the first place, which is not always a decision.

Nonetheless, women in recovery may also face challenges seeking higher education that similarly threaten the stability of their recovery. One woman with a history of OUD, for example, expressed the challenges she encountered when applying for college due to the background check involved in the application process:

“I had to do a criminal background check for a school I applied to. I was like, ‘Holy crap. I didn’t know that was a thing.’ [laughs] I have misdemeanors. My misdemeanors, again, were very episodic. I always tell the truth on my personal criminal background applications. I just filled out an application to [redacted] for example, they wanted to know every last little detail about this thing that happened, and I was like, Holy Lord.”

The ability to attain higher education can open up new vocational opportunities and routes toward financial security and provide crucial time for exploring oneself and one’s passions. If higher education protects recovery through these benefits, then any potential roadblocks imposed by past OUD to higher education could threaten recovery.

Discussion

Key findings

Prior literature has documented the impacts of housing instability and economic insecurity on substance use treatment.^29–31 However, limited attention has been given to analyzing how women with a history of OUD experience challenges associated with housing and economic insecurity throughout the addiction, treatment, and recovery continuum. Understanding these experiences is important in conceptualizing how to better address housing instability and economic insecurity among women with a history of OUD through research, policy, and practice.

The interviews in this study revealed that women with a history of OUD have different experiences surrounding the influence of housing instability and economic insecurity on their trajectory throughout the continuum of active substance use, treatment, and recovery. Specifically, challenges associated with housing and economic insecurity can contribute to substance use initiation, while substance use may contribute to conditions where relationships, shelter, and possessions are repeatedly lost. Within the treatment phase, challenges included experiencing a medical assistance paradox, facing accrued debts with no way to pay them back, navigating difficulties meeting the qualifications for housing assistance, and carrying the stigma of past involvement in the CLS as a barrier to gaining employment. Finally, in the recovery phase, many women with a history of OUD and professionals in our sample discussed how difficult it is for women to rebuild the resources, livelihoods, and relationships they may have lost during addiction. Further compounding this, low levels of educational attainment among women with a history of OUD from before their initiation of substance use can contribute to economic insecurity through low pay and employability.

Altogether, we recognize that housing instability and economic insecurity do not occur in a vacuum; these experiences of hardship intersect with and often are further complicated by additional factors. Specifically, in other manuscripts stemming from the larger qualitative study, our participants have shared their lived experiences with both general and gender-specific factors impacting treatment outcomes, including deep trauma histories, ²¹ pregnancy and motherhood, ²⁰ and multiple levels of stigma. ²⁴ Within these manuscripts, our participants have also spoken to stigmatizing experiences ²¹ and gendered differences ²³ in employment opportunities and vocational training following involvement in the CLS. ²³ Since we have looked at these intersectional influences in greater depth elsewhere, the present study focused more explicitly on understanding how housing instability and economic insecurity affect the ability of women with a history of OUD to seek, initiate, and complete MOUD treatment. Taken together, these findings provide valuable insight into the barriers faced throughout the treatment process and across the larger continuum.

Implications

Housing instability

Research, including the present study and previous work, shows that housing instability can drive or exacerbate substance use, ³² hinder treatment access, ²⁹ and impede recovery success, ³³ yet housing stability tends to improve as recovery duration increases. This underscores the need to address housing instability throughout the entire continuum of addiction, treatment, and recovery. ³² The interviews with women with a history of OUD and professionals revealed prominent themes concerning housing instability, including social isolation and housing instability during addiction, challenges related to family shelters and treatment accessibility, and difficulties in achieving stable housing while in recovery.

Drawing from the insights from our study, there are several recommendations for addressing housing instability among women with a history of OUD. First, educating women with OUD about housing assistance and available resources both in the CLS and treatment settings can facilitate recovery networking. Another suggestion involves facilitating greater interagency collaboration between SUD treatment facilities and the child welfare system. ³⁴ While professionals in child welfare alone often lack the resources to identify and help meet the needs of parents with SUDs, emerging evidence indicates that collaborative efforts between the child welfare system and treatment referral services can streamline SUD resource availability, such as housing assistance. ³⁴

Beyond increasing interagency collaboration efforts, further approaches to reduce homelessness-related stress include Housing First programs, which prioritize housing for people who use drugs and allow individuals autonomy regarding subsequent care and treatment. ³⁵ Data on Housing First programs are mixed in terms of reducing substance use, yet these programs have been shown to be effective in reducing homelessness and emergency shelter utilization.^35,36 Other housing supports for people who use drugs are Recovery Housing programs: structured, community-based housing programs that require abstinence and modest payments for rent. ³⁷ Recovery Housing programs have been shown to be effective in reducing substance use and improving employment-related outcomes among people who use drugs. ³⁷

Finally, the use of integrated treatment programs offering tailored housing services for mothers with substance use issues could expedite access to temporary and sustainable housing. Specifically, a randomized pilot study comparing Ecologically Based Treatment, which involved counseling, case management, and assistance with independent housing for mothers, to treatment as usual found preliminary evidence in support of the integrated treatment approach; mothers enrolled in the intervention condition had faster increases in housing security and faster decreases in substance use than those receiving usual services. ³⁸ As housing instability continues to impact substance use, programs that involve housing and additional supports that facilitate substance use treatment engagement can help combat housing instability faced by women across the continuum of active use, treatment, and recovery.

Economic insecurity

Challenges associated with economic insecurity include low education levels, the impact of criminal records, and OUD-related stigma, as indicated by our participants and supported by past research.^2,30,33 While these challenges are felt across the continuum of active use, treatment, and recovery, participants most often reported hardship stemming from economic insecurity during the recovery phase, with the women with a history of OUD and professionals frequently citing various employment-related barriers as being particularly difficult to navigate. To try to address economic insecurity across the continuum of active use, treatment, and recovery, we offer several evidence-based recommendations from our findings.

One mechanism of reducing economic insecurity involves expanding medical assistance eligibility to incorporate a period of transition into recovery where those receiving MOUD treatment can gain employment without the threat of losing financial access to MOUD. ³⁹ Findings from studies assessing Medicaid expansion and its influence on access to MOUD treatment show encouraging results: compared to states that did not expand Medicaid eligibility, those who did saw a significant increase in access to MOUD prescriptions among enrollees.^40,41 Ultimately, Medicaid access is essential to improving access to MOUD treatment, and incorporating a transition period that allows for individuals who are receiving MOUD treatment to stay eligible for Medicaid while they find gainful employment would likely bolster MOUD access, help relieve economic stress, and support positive recovery outcomes.

To further mitigate challenges associated with economic instability, another recommendation includes providing alternative pathways to repay debts accrued during incarceration. Results from a scoping review on the burden of accrued debts during incarceration and reentry highlighted increased access to legal assistance and financial services for individuals while incarcerated as potential solutions to mitigate this type of economic insecurity. ⁴² Specifically, lines of financial support for paying lawyers and greater access to legal-related self-help resources online may bolster access to legal assistance, whereas increased financial guidance through implementing financial literacy programs may support access to financial services. ⁴² Limiting legal-related fees themselves may also be beneficial, as the burden that these fees can place on clients’ success is not worth the small amount of money obtained by governments through these fees. ⁴²

Regarding employment-related challenges, a further suggestion involves implementing vocational rehabilitation services into carceral and treatment settings to allow women with OUD to build valuable vocational skills and networks. In a systematic review of interventions to improve employment, Magura and Marshall ⁴³ found that two programs, individual placement and support (IPS) and customized employment support (CES), were the most associated with positive outcomes. Both programs focus on supported employment; however, CES is an intervention adapted from IPS and directly tailored to individuals in treatment for SUDs. In a pilot study examining the potential utility of IPS among individuals in a methadone maintenance program, 50% of those receiving IPS achieved employment 6 months compared to only 5% of the control group. ⁴⁴ Similarly, in a study examining the potential utility of CES on employment compared to standard vocational counseling, 41% of those randomized to CES gained any paid employment, compared to 26% of the control group, though total earnings did not significantly differ by group. ⁴⁵ Taken together, these suggestions for medical assistance eligibility, accrued debts, and vocational opportunities can improve MOUD interventions and outcomes for women with OUD.

Limitations

Several limitations should be noted. First, the study’s in-depth interviews may not capture the full complexity of OUD, which is influenced by various social, biological, and environmental factors. Further research is needed to explore the diverse situations and experiences associated with OUD. Second, the study included only residents of PA with CLS and MOUD involvement, limiting generalizability to other populations. However, the nuances in participants’ experiences provide valuable insights into social and economic barriers of addiction and recovery for women with a history of OUD.

Other limitations faced by the present study centered around limited representativeness and vulnerability to potential selection bias, especially for women with a history of OUD. The recruitment methods utilized within the study to reach women with a history of OUD may have inadvertently excluded certain subgroups, such as women with unstable housing conditions who lack access to the internet or a cellphone. The lack of racial diversity in the study sample is another potential limitation; each subgroup interviewed identified predominantly as non-Hispanic White. Nonetheless, the participants had diverse backgrounds with variations in whether or not they had children, received medical assistance, and had past or present experience with homelessness, capturing a range of insights on the topics important to this study.

An additional limitation to the study’s findings involved the nature of the interviews themselves. Specifically, the variability in interview questions, stemming from the semi-structured nature of the interviews, allowed for individualization but might have missed some related barriers. Finally, it is important to note that participant experiences are also retrospective, and thus possibly leave out some details, but their insights remain valuable contributions to understanding the impact of housing instability and economic insecurity on women with OUD.

Conclusion

Addressing challenges associated with housing instability and economic insecurity is vital for equitable substance use prevention, treatment, and recovery. Healthcare professionals and policymakers can reduce disparities and improve OUD outcomes by recognizing and tackling these factors. Noting the potential influences on economic resources posed by where one lives, such as differences in rural and urban areas or additional community-specific characteristics, directions for future research could include looking at specific geographic settings and centering the community context within the analysis. Studies could also investigate challenges associated with housing and economic insecurity through longitudinal approaches to examine variations in treatment and resource needs among women as they move through different points of the continuum. Future policies should prioritize integrating interventions addressing housing instability and economic insecurity into patient-centered care across all three timepoints—active addiction, treatment, and recovery—to promote health, gender equity, and well-being for those affected by substance use.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261423390 – Supplemental material for Housing instability and economic insecurity across the continuum of active substance use, treatment, and recovery among women involved in the criminal legal system

Supplemental material, sj-docx-1-whe-10.1177_17455057261423390 for Housing instability and economic insecurity across the continuum of active substance use, treatment, and recovery among women involved in the criminal legal system by Emma M. Skogseth, Eric Harrison, Kristina Brant, Carl Latkin, Oluwaseyi H. Quadri and Abenaa A. Jones in Women's Health

Supplemental Material

sj-pdf-2-whe-10.1177_17455057261423390 – Supplemental material for Housing instability and economic insecurity across the continuum of active substance use, treatment, and recovery among women involved in the criminal legal system

Supplemental material, sj-pdf-2-whe-10.1177_17455057261423390 for Housing instability and economic insecurity across the continuum of active substance use, treatment, and recovery among women involved in the criminal legal system by Emma M. Skogseth, Eric Harrison, Kristina Brant, Carl Latkin, Oluwaseyi H. Quadri and Abenaa A. Jones in Women's Health