After two members overdosed on opioids in the same week, a South Carolina-based sober living home called Marc Burrows. They were looking for naloxone—the opioid overdose reversal drug.

“You might have these abstinence-based programs that aren’t really cool with harm reduction… but because of the overdose epidemic and so many people dying, they’re finally getting on board,” said Burrows, who runs Challenges, Inc., a harm reduction group that distributes naloxone and clean supplies to drug users in South Carolina. The organization is the only syringe exchange program in the state.

Burrows started the group after his own battle with drugs. “I used to shoot heroin and cocaine,” he said, “so I’m a person in long-term recovery from substance use.”

In addition to Challenges, Inc., Burrows founded a substance use treatment clinic. The center offers patients medication-assisted treatment or MAT, which involves prescribing patients regulated opioids, such as Suboxone and methadone, to wean them off stronger, more addictive opioids. While the medications are chemically similar to heroin, they don’t produce the same euphoric effect.

Though MAT has been proven to be safe and effective in the treatment of opioid use disorders, many sober living communities don’t allow it.

Some homes express practical concerns about the medication, like how to regulate members’ doses to prevent misuse and diversion. Supporters of MAT are often quick to offer solutions, such as pill lock boxes and one-dose dispensers.

Still, Burrows said, other concerns are based on perception. One of the sober living homes he works with didn’t want to accept individuals on MAT because “he thought you would be able to tell which guys were on Suboxone and which guys weren’t.”

But even in homes that do accept those on MAT, the treatment is highly stigmatized.

One of Burrows’ patients lives in an Oxford House, whose rules are set by members and tend to be more permissive of MAT. Regardless, the patient’s treatment has become the subject of scrutiny. He “was just telling me how much crap he has to deal with on a daily basis from the guys that live there that are constantly telling him he’s not clean,” said Burrows.

The patient is being prescribed Suboxone for an opioid misuse disorder.

Despite generally narrow views about substance use treatment, sober living homes do have “great, great benefits,” said Burows, who lived in one during his own recovery. “If you don’t have a stable, safe place to live, then yeah, it can be really effective,” he said. “It gets you out of the environment you’re in and it gets you around new people that are hopefully also living a sober lifestyle.” In addition, sober living homes usually assist members in finding steady employment.

The sober living home model is based on the founding principles of Alcoholics Anonymous (AA), a community-based fellowship established in the 1930s to help those struggling with addiction. The organization follows a 12-step program which touts abstinence from all substances, which for some, includes opioid-based medications.

“A lot of people still hold to that philosophy because they feel that’s the way,” said Gregory Plakias, the chief marketing officer at Discovery Institute, a New Jersey-based detox and rehabilitation center. At the time of its founding, AA was the only support group of its kind.

But today, options for treatment are numerous and clinical methods, such as cognitive-behavioral therapy and motivational interviewing, have been shown to be highly effective. The 12-step program, once the poster child for addiction treatment, is no longer the leading model.

In fact, in recent decades the AA approach has been sharply criticized by scholars and medical professionals who say the program lacks scientific backing. “It’s not medicine, it’s not evidence-based,” said Plakias.

Nonetheless, people have found success using the model. In a comprehensive review of 27 clinical trials published in the Oxford Academic, AA was shown to produce rates of alcohol abstinence and alcohol use comparable to first-line clinical interventions and outperform them over follow-up, meaning people in AA were more likely to avoid alcohol and drugs over time than those using other treatments.

Regardless, the goal of all treatment programs is to promote recovery. While some programs define this as abstinence, others embrace a broader definition. According to Dr. John Gallagher, a licensed clinical social worker and associate professor in the School of Social Work at Morgan State University, “Recovery is not just about someone abstaining from drugs and alcohol.” Instead, he says, “recovery is about someone improving their quality of life.”

To achieve this, Gallagher uses medication-assisted treatment, which helps patients reduce symptoms of addiction, including cravings, tolerance, and withdrawal. When these symptoms are minimized, patients are able to lead more productive, functional lives—a key sign of recovery.

And because MAT helps patients sustain an improved quality of life, the medication is often used long-term. Some people are on Suboxone or methadone their entire lives. Despite the stigma, these opioid-based medications are like any other medication used for disease management, according to Gallagher. “We don’t tell people who have diabetes, ‘Well, you’re not in real recovery from diabetes ‘cause you’ve been taking insulin for three years,’” said Gallagher.

Despite the positive outcomes, MAT remains shrouded in controversy, primarily because it involves prescribing an opioid to cure an opioid addiction. “When…critics say you’re substituting one drug for another, our response is ‘Damn right we are,’” said Gallagher. “We’re substituting addiction–10 bags of heroin a day–for recovery.”

Plakias, who has been working in the field of addiction medicine for more than a decade, used to hold these views. “Fourteen years ago, I was probably more…geared towards abstinence-based [recovery] and feeling that for someone to be in recovery, you’re going to be all in or you’re not,” he explained.

But after seeing patients go in and out of treatment—from abstinence to overdosing—his perspective on how to achieve recovery has changed. “Today I see [MAT] a lot differently,” he said. “Today I see it as saving lives.”

Since 2017, Direct Relief has provided more than 1 million doses of overdose-reversing naloxone, free-of-charge, to health facilities, harm reduction groups, and recovery organizations. Challenges, Inc. and the Discovery Institute, both featured in this story, have received donated naloxone from Direct Relief. The medication will be distributed to sober living communities and individuals in rehabilitation to prevent lethal overdoses during recovery.