Good afternoon and welcome to this program on MOUD in Recovery Residences, the ADA Rights and Responsibilities. This presentation was months in the making and recognized as a top training priority. When MARR was founded in 2016, very few operators were familiar with MAT and MOUD. Most were abstinence-based and reluctant to entertain the notion of medication for opioid use disorder. Now, 77% of MARR's 76 residences allow for MOUD. Still, there is a discord on the subject and less than a full understanding of the laws affecting admission to our residences by people who may need a policy accommodation. It is the purpose of this program to provide education on this subject and offer steps operators can take to assure compliance with the Americans with Disabilities Act. My name, by the way, is Dr. Ron Springle, the Executive Director for MARR. And now I'd like to introduce, before I introduce Dr. Harrison or before she is introduced, I'd like to turn the program over to Jenna Fould. Jenna is a technology transfer specialist for the Opioid Response Network at Brown University. Without her assistance, this program would not have been possible. Jenna. Thank you. Hi, everyone. It's a pleasure to be here today. As Dr. Springle mentioned, I'm Jenna Fould, technology transfer specialist. I work for the New England region of the Opioid Response Network, so we cover the six New England states in my region. The ORN is a substance abuse and mental health service administration-funded initiative. We're led by the American Academy of Addiction Psychiatry. We provide locally driven technical assistance through education and training in the areas of prevention, treatment, recovery, and harm reduction as they relate to opioid and stimulant use disorder. And this is all at no cost. Today's webinar will be presented by Dr. Oshi Harrison. Thank you for bringing up the slides. So before I turn the webinar over to her, I wanted to review a few of the Zoom controls that you'll be using. Please note that the live transcription, chat, Q&A, and raise hand buttons on your Zoom. The live transcript feature will be enabled if you wish to use it. Please sign into the chat and provide your name as well as your organization. You can also use the chat to discuss any need for technical support or for any topic related comments. We will be monitoring for questions and addressing them at the end of the webinar. This webinar is being recorded and all attendees will be muted and their videos turned off during the presentation. Please do use the Q&A option throughout the training if you have any questions and we will address those at the end as I mentioned. You can also use the raise hand feature when we address questions and we'll allow you to speak. We will also be providing a link and a QR code to a brief survey at the end and we really appreciate your feedback. I will now hand this over to Dr. Harrison to introduce herself. Thank you. Ron, did you want to say anything before I started? You're all set. Okay, very good. Thank you so much, Jenna, and Ron was very right. Without you, this would not be happening and thank you, Dr. Springle, for inviting me to this and giving me this opportunity to talk with everyone. My name is Oshie Harrison. For those who don't know me, I'm the manager of ADA Special Projects at the New England ADA Center. I'm the former director of the ADA Center for 22 years. At the ADA Center, we are educators. We are not lawyers and I want to tell you a little bit about the presentation and how it's going to go today. I will give the presentation. I will respond to questions afterwards. However, we're going to move on right now. Let's see if I can move this. First, before we start, a little bit about ourselves and what we're going to do. The agenda is here. I'm going to talk about how and why addiction is a disability under the ADA, civil rights of people with MOUD and recovery residences, obligations of recovery residences, specifically non-discrimination policies, practices, and procedures. We'll talk a little bit about best practices. There'll be some resources and Q&A at the end. First, I work at a very exciting place in Boston. As a matter of fact, if you're ever in town, please let me know and we'll have coffee. It's called the Institute for Human-Centered Design. Our office is located on Harrison Ave and we're a 45-year-old international non-profit specializing in design and social equity across the spectrum of ability, age, culture, gender, and economic status. Now, the Institute has been home to the New England ADA Center, seen right there, number one. Since 1996, the New England ADA Center is grant-funded and we are part of a national network and we all share a common 800-949-4232 number. When you call that number, you'll get the nearest ADA center to you. You all being in Maine, when you call that number, you'll get our center in Boston. All of the ADA centers do the same thing. We provide information, guidance, and training and do ADA research. We're not enforcers. We don't do compliance. We're educators. And when you call us, your calls are confidential and anonymous. We subcontract in each of the New England states with the state affiliate. And in Maine, our state affiliate is in Portland and they're called Alpha One. They're the state independent living center. All right. So this is the piece on addiction and why it's a disability. Now, addiction is a disability under these civil rights laws, the Americans with Disabilities Act, the Fair Housing Act, and Section 504 of the Rehabilitation Act. These civil rights laws protect people with disabilities from discrimination in many areas of life, including in recovery residences. The ADA prohibits discrimination on the basis of disability in employment and services, programs, and activities of state and local government and by businesses and nonprofits. The Fair Housing Act prohibits discrimination in housing and housing-related transactions because of disabilities. And Section 504 of the Rehab Act basically prohibits discrimination on the basis of disability in any program or activity receiving federal financial assistance. Let's look at the ADA first. The ADA is a civil rights law that ensures that people with disabilities have the same rights and opportunities as everyone else. This includes people with addiction to alcohol and those in recovery from addiction to opioids and other drugs. The ADA is very clear. Addiction is a disability. Now, there are hundreds of definitions of disability, whether you're talking about Social Security Administration or vocational rehabilitation, and the ADA has their own definition of disability. It happens to be the same definition that the Fair Housing Act uses and the Rehabilitation Act, which the ADA is based upon. So, in order to be considered a person with a disability, a person must meet one of these three prongs here, just one. So, let's go through this a bit. So, a person must have a physical or mental impairment that substantially limits one or more major life activities, such as bipolar, diabetes, or alcohol use disorder. Or a person has a history of a physical or mental impairment that substantially limits a major life activity, such as substance use disorder, cancer, or heart disease. Or a person is regarded as having an impairment. They're perceived as having an impairment, but they don't have an impairment. Now, many courts have found that people with opioid use disorder taking medication for opioid use disorder have a record, that's number two there on the prong, a record or history of an impairment that substantially limits one or more major life activities. Or let's look at number three. People with opioid use disorder with medication are regarded as currently using drugs illegally because of misunderstanding about opioid use disorder and stigma. So, what are major life activities? When we say a person has to have a physical or mental impairment that substantially limits a major life activity, here's what we mean. These are things that we do every day. We care for ourselves, think, learn, work, breathe, sleep, see, hear, concentrate, walk, lift, bend. And major bodily functions, such as the functioning of the neurological and brain system, is a major life activity. So, addiction is an impairment that substantially limits the major life activities of working, learning, sleeping, eating, concentrating, caring for oneself, remembering, and brain and neurological functioning. Addiction is both alcohol use disorder and substance use disorder are considered chronic illnesses, such as heart diseases, cancer is, and diabetes is. And like other chronic illnesses, it involves periods of remission and relapse. So, let's talk about opioid use disorder. Now, a person has civil rights who has opioid use disorder when they're in recovery and we're no longer engaging in the current illegal use of drugs. So, what does recovery mean? Well, the ADA has its own definition of recovery. It's a person in recovery from substance use disorder, the person has stopped engaging in the current illegal use of drugs, the person is participating in a supervised rehab program, or has been successfully rehabilitated. And here's what the ADA says that illegal use of drugs means. It means two things. The first, use of illegal drugs, such as heroin or cocaine, or second, use of legal drugs, such as opioids, but person has no prescription, or the person has a fraudulent prescription, or the person is using more than prescribed. So, what does current mean? This is one, this one is a little tricky. I mean, does it mean days? Does it mean weeks? Does it mean months? It means, according to the ADA, illegal use occurred recently enough to justify a reasonable belief that a person's drug use is a real and ongoing problem. So, current is not limited to the number of weeks or days, but is determined on a case-by-case basis, or what the ADA calls an individualized assessment. So, in anticipation of this presentation, there were questions that were submitted. So, here's one. When a resident has a recurrence of use, and is not, which is not a single event, but continued use of illicit substances, does the individual no longer have protections? The answer to this is yes. When a person has a reoccurrence, and it's not a single event, they do lose their protections. So, where there is no, where there is reoccurrence, there is no protection. So, I'm just going to summarize this section before we move on. The ADA protects people in recovery from opioid use disorder who are not currently engaging in the illegal use of drugs, including those who are taking medication prescribed by their doctor to treat their opioid use disorder. Okay, we're going to move on. So, some recovery residents don't allow the use of medication for opioid use disorder. Do residents have protections under the ADA? They do. A person with opioid use disorder is a person with a disability, and has a right to take their doctor prescribed medication to treat their opioid use disorder. To refuse a person with a disability entry into a home based on their medical prescription may be a violation of the ADA, the Fair Housing Act, or Section 504. If a recovery home operator disagrees, they must prove that accepting a person with medication for opioid use disorder would be, would drastically alter the nature of their program, or become an administrative burden, and the ADA calls that an undue burden. And I have to tell you that an undue burden is a very hard bar to prove. We're going to look at that a little bit later. But let's take a look at a scenario. So, Livia is a person with opioid use disorder and is taking doctor prescribed medication for her opioid use disorder. She has applied to live in a recovery residence for people in early recovery. She's denied admission because the residence has a policy of refusing to admit people with OUD and who are taking Suboxone to treat their OUD. The residence manager asks Livia to change her medication or maybe go to another house that allows MOUD because there is no staff to dispense the medication. Does Livia have protections under the ADA? She does. She's a person with a disability because she has a history of OUD. Excluding her, excluding her because of her doctor prescribed, her doctor prescription is illegal, and assuming that Livia meets the residence's other eligibility requirements. So turning someone away, asking a person to change their medication, or to go to a house that allows MOUD are all problematic under the ADA and the Fair Housing Act and Section 504. So whether the person has a history of OUD, cancer, diabetes, high blood pressure, ADHD, depression, anxiety, or traumatic brain injury, it may be illegal to turn that person away based solely upon their prescription medication. Okay, so moving on now. I do want to say this, I think most people know this though, MOUD are proven, you know, life-saving medications that reduce cravings and stop withdrawal. Okay, obligations of recovery residences under the ADA and Fair Housing Act. I was given these questions early on to answer, and I'm going to try my best to do that. And the first one is, how should an operator or a manager of a recovery residence respond when an applicant has a legal prescription for MOUD and the policy is not to accept it? What steps should an operator take in responding to a request? Does an operator need a lawyer? So, operators and managers must prepare to provide recovery housing for applicants with FDA-approved medications that are tied to their disability. This includes people with MOUD. And it starts with a non-discrimination policy, followed by training of intake staff on the policies and procedures. Let's take a look at another scenario. Dominic has a legally prescribed medication to treat his MOUD. He applies to a certified recovery residence near his home. The residence operator responds that his application is rejected due to their medication policies to not accept certain FDA-approved medications that may be MIND or MOUD-altering, including Dr. prescribed Suboxone. Dominic requests an operator make an exception or provide a reasonable accommodation. Does Dominic have any protections? Now, we've got to break this down because the residence has an inherently discriminatory policy to not accept certain FDA-approved medications that may be MIND or MOUD-altering, including the Dr. prescribed Suboxone. This is a violation of the ADA and the FHA. A decision to take a prescription medication is between a doctor and a patient and not the decision of a residence manager. An MOUD is the gold standard of treatment, the Suboxone, the Methadone, and the Vivitrol. It's the gold standard in keeping people alive and on the path to recovery. How should an operator respond? Well, they need to change their policy. A policy to not accept certain FDA-approved medications violates the law. An exception or reasonable accommodation cannot be provided to a policy that is in violation of the law. So, the residence has to change their policy and become compliant with the law. And Dominic has a right to file a complaint with the Department of Justice or Housing and Urban Development, HUD. Some other signs of discrimination. Residents may limit the number of people in the facility who can take MOUD, having designated MAT beds, or the residence may require people to taper off a dose of Methadone or Suboxone, or the residence only admits people who take under a certain dose of Methadone or Suboxone. So, another question that came in earlier before this presentation is this, is it okay to designate a recovery home for residents with medical-assisted treatment only? Well, the answer to this is designating a home for residents with MAT may be just as problematic as designating a home for residents without MAT. All right, we're going to take a look at the Fair Housing Act for a sec. The Fair Housing Act applies to residences, recovery residences, because they fall under the Fair Housing Act definition of dwelling. And accordingly, these residents may neither categorically exclude people with MOUD, nor insist that they abstain from or change or reduce their MOUD. It is illegal to exclude people with MOUD, though this type of discrimination occurs with some frequency. So, what would be a non-discriminating policy? Well, that type of policy would state that discrimination based on disability is illegal and would not be tolerated. I mean, your own recovery residence, the National Alliance for Recovery Residences emphasizes that MOUD is part of a lifelong recovery for many, many people and should be supported by recovery residences. So, a non-discrimination policy, it's clearly written policy that states that residents will not discriminate against people with disabilities with an FDA-approved medication and specifically people with OUD with all forms of FDA-approved medications for opioid use disorder. Many recovery residences in Maine already have general policies and procedures in place for residents' medication. A question we did get in before the presentation was, what if a person with OUD is on a larger dose of methadone and is simply not, in quotes, sober enough to participate? It has happened to some of us where other people in the house are not at all happy with this person bobbing and weaving in groups, etc. Is there a cutoff? What do other houses do? And do you accept folks on any amount of methadone? So, the answer to this question is to suggest the person go to a doctor to get the dosage or their schedule their schedule of dosaging reviewed. And some of the things that you have mentioned seem to be around the idea of modifications to a non-discriminatory policy. And I'm just going to get to the next slide about that. So, for example, if a person, if you have the policy that all people with opioid use disorder who have medication are allowed, accepted, welcomed into this home, we do not discriminate on the basis of disability or a person's medication, here might be a reasonable modification. A resident with take-home methadone or suboxone doses may take their doses to the residence. The residence stores MOUD on site the same way they store other controlled substances. A resident can go to their opioid treatment program for methadone or their qualified practitioner for suboxone. We're going to talk a little bit about undue burden and what that is. Now, if a recovery residence denies an application based upon an FDA approved medication, it must prove that accepting a person with a disability with their medication for OUD would drastically be an administrative or financial burden. It's the responsibility of the residence to prove an undue burden looking at expected costs, available financial and personal resources at the time of the request, the overall cost involved in light of the entire organization. Now, as I said earlier, this is an extremely high threshold to meet. I mean, to be honest, I mean a residence would have to show that financially it would literally put them out of business, but it is the responsibility of the residence to make the case for undue burden. So, I want to talk a little bit about some policies here. What are some best practices and policies that people have put into place, can put into place, should put into place? One is start with the non-discriminatory policy and practices and procedures with people with MOUD, operators and managers that have been successful at implementation. And then in terms of trainings, you know, this is education about how medication for opioid use disorder works, some of the facts and the myths. Make sure intake staff are trained that persons with MOUD are accepted into the residence and some deeper training on Fair Housing Act and the ADA requirements. You could also review your website for discriminatory language and participate in some evidence-based research on the effectiveness of MOUD in recovery housing through a civil rights lens. All right, one more thing. I'm going to talk about a case here because it's not just best practices, it's the law, people. You know, many fair housing complaints are decided in private and agreements are made in private, avoiding court and public notifications. But today, we have one public housing case under the ADA and it was against a non-profit in Colorado called Ready to Work. And Ready to Work is a non-profit that provides residential work and social services for unhoused people in Colorado. And they discriminated against a person with OUD by denying her admission to its program because she used prescribed medication for opioid use disorder. So, the settlement agreement with the Department of Justice and Ready to Work was that Ready to Work has to train staff on MOUD and ADA requirements, report on their compliance with the settlement agreement and their progress to compliance, and pay the complainant $7,500 in compensatory damages. So, to summarize, persons with OUD have civil rights protections when in recovery and free from illegally using drugs. Recovery residences must have clearly written policies and procedures accepting applicants with MOUD. It's required under the laws. Staff need to be trained on non-discriminatory MOUD policies and procedures and educated about how MOUD works. And for recovery home providers and people with OUD, civil rights can provide guidance and contribute to addressing stigma and the addiction crisis. So, to answer the question, do you need a lawyer? Here are some ways you could actually find out. You could call the ADA Center for more information anonymously and confidentially. You have a U.S. Attorney's Office of Civil Rights in Maine, which is an arm of the Department of Justice, and there is their contact information there. You could call and talk with them. You could call the technical assistance line at the Department of Justice Disability Rights section, and here are the phone numbers, and these links are hyperlinked. So, when you get a copy of this, you can just click right on and get to that section, or you can contact the Department of Housing and Urban Development. A few more resources. There are some really great resources out there. The Legal Action Center on Recovery Residences and MOUD. It's a fantastic one-sheet fact sheet about do's and don'ts around recovery residences and MOUD. There's one by your certifying agency, the National Alliance for Recovery Homes, helping recovery residences adapt medication-assisted recovery treatment. And there's a great brochure, Know Your Rights, Rights for Individuals and Medication-Assisted Treatment by SAMHSA, and there's an ADA addiction and recovery fact sheet series on the New England ADA Center website, and it just goes on and on and on. I'm not going to go through everything here, but the Department of Justice has put out a wonderful short publication on the ADA and opioid crisis and combating discrimination against people in treatment or recovery. And more and more and more. There are three more there that we have access to. And again, it's all hyperlinkable. So, now we're going to get to the question portion of our presentation.

ADA rights

recovery residences

Medication-Assisted Treatment

MOUD

laws

admission

opioid use disorder