Peer Recovery Support Services:
A Promising Approach to Combat Substance Use Disorders
By K. Ceres Wright, MA; William Scarbrough, PhD; and Jenny Twesten, MPH
February 2023
Substance Use Disorder in the United States
During 2021, an estimated 107,622 people in the United States died of a drug overdose, an increase of almost 15% from 2020 (93,655).1 People with substance use disorders (SUD) are at increased risk for one or more chronic conditions. Co-occurring SUD and mental health disorders have risen among adults ages 18 or older, from 8.07 million in 20152 to 9.54 million in 2019.3 In 2019, 20.4 million people ages 12 or older in the United States had a past-year SUD.4 Only 10.3% received SUD treatment.5 The growing prevalence of SUDs and mental health disorders suggest opportunities to improve access to and delivery of SUD treatments to prevent future deaths.
In 2019, 20.4 million people ages 12 or older in the United States had a past-year SUD.4 Only 10.3% received SUD treatment.5
Traditional and Sustained Recovery Management Model Approaches to SUD Treatment
Many SUD treatment programs are based on acute care models that reduce symptoms, stabilize the SUD, and discharge the person seeking treatment. The individual is then expected to achieve lifelong recovery relying on what they learned from treatment. Acute care models of SUD intervention are generally effective for people with low to moderate SUDs and who also have considerable recovery capital. Recovery capital is defined as “the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery,” such as physical health, financial assets, problem-solving capacities, food, and family support.7 The fundamental flaw in the acute care model is the gap in providing connections to resources to support recovery and continued abstinence, particularly among those who do not have considerable recovery capital. This flaw is reflected in the high relapse rate of those who completed SUD treatment.
To address the limitations of the acute care model for SUD, the field has shifted toward exploring the use of the sustained recovery management model (SRMM). This approach accounts for the chronic nature of addiction through the provision of continuing care and encouragement of people to leverage resources designed to provide sustained recovery. Peer recovery support is an important component of the SRMM. In this article, we review the evidence on peer recovery support and the impact it is having on addressing SUD in the United States.
Of people who complete SUD treatment, about half resume their drug use within a year of discharge, only rarely having been connected to aftercare services.6
What is peer recovery support?
Recovery is facilitated by four types of social support: emotional (compassion), informational (sharing of knowledge or training), instrumental (concrete assistance), and social (community resources). Peer recovery support services are services designed and delivered by people who have experienced both SUD and recovery. They are designed to provide hope and support to those seeking recovery from a mental health condition or SUD and can help encourage others to build the skills necessary to achieve success in recovery. Services may be delivered in whole or in part. For example, a person in recovery who is seeking a job may just need a referral for an open position but may also need job-readiness training (informational support), a ride to the interview and childcare (instrumental support), and access to social events that support sobriety (social support).8
Peer recovery support services can also extend the capacity of health care workers. A recent study by the Association of American Medical Colleges predicts that the demand for doctors will outstrip the supply by 2030 and there will be a shortage of up to 121,300 physicians.9 During this time of health care worker shortages, many communities have sought alternative ways to meet the needs of people seeking to recover from SUD. The American Association of Emergency Psychiatrists recommends expanding the capacity of psychiatrists by employing clinical social workers, psychologists, and counselors, noting that some emergency settings also employ individuals with lived experiences (peers).10 One Australian study acknowledged the lack of resources for medication-assisted treatment for opioid dependence and employed the services of pharmacists in prescribing medications, in addition to building a collaborative model of care with health care workers, academicians, patients, consumer organizations, advisory boards, and workgroups.11
Who are peer recovery support specialists and what do they do?
A peer recovery support specialist—as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA)—is “a person who uses his or her lived experience of recovery from mental illness and/or SUD, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind–body recovery and resiliency.”12 Peer recovery support specialists assist with determining goals for recovery, developing action plans, finding housing, and building a new life around sobriety, from improving job skills to making new friends. The relationship between peer recovery support specialists and peers is more supportive than directive, as peer recovery support specialists are often managing their own long-term recovery.8
Peer recovery specialists are able to leverage the flexibility inherent in peer recovery support services to customize an approach for their peers that meets their unique needs.13
Peer recovery support can be leveraged within existing SUD treatment programs in a variety of settings
As far back as the 18th century, peer-delivered services have been integrated into health care, mental health, and other community and treatment settings as a support for clinical staff. However, in the field of SUD treatment, there are special considerations for the integration of peer recovery support services, such as defining roles, setting boundaries, bridging philosophic differences, and destigmatizing drug use.14
One strength of peer recovery support is the ability to adapt service delivery within different settings, including telehealth, and customize to a variety of populations.12 This adaptability makes such services effective in expending support beyond traditional health care workers, shoring up gaps in worker shortages and lack of accessible clinics.8
Recovery Community Organization Settings
Recovery community organizations (RCOs) provide credentialed recovery services across the care continuum, including medication for opioid use disorder (MOUD), mutual-help group meetings, and access to an array of relevant programs and services, including harm-reduction services such as naloxone education and distribution, fentanyl education and testing strip distribution, syringe exchange programs, and HIV and hepatitis C testing.14
Two systematic reviews of RCOs showed positive outcomes of SUD treatment, including decreased substance use; increased abstinence; increased housing stability; increased number of primary care visits; increased recovery capital; decreased hospital, emergency room, and detoxification use; decreased criminal charges; reduced reports of anxiety and tension14; and lowered negative health events.15
Police departments
Police departments across the country are incorporating peer recovery support specialists in their quick-response teams for drug overdoses. An initiative in Madison, WI, called the Madison Addiction Recovery Initiative (MARI) is a diversion program designed to reduce crime and improve health (i.e., reduce overdose deaths). The program includes training the police officer workforce to identify and assess people eligible for the MARI program, and collaborating with clinical partners for treatment need assessment, treatment placement, and peer support services.16
Another program in Arizona, the Tempe First-Responder Opioid Recovery Project, involves training police officers to administer Narcan, and deploys a Crisis Outreach Response Team comprising social workers, substance use peer counselors, public health professionals, police researchers, and drug-policy/harm-reduction researchers.17
Community and outpatient settings
Peer recovery support specialists perform community-based outreach to people outside of the context of treatment or correctional settings. In outpatient addiction treatment and community settings, one study found that the delivery of peer recovery support services resulted in reduced substance use, injection and sexual transmission risk behaviors, and craving; improved treatment engagement and self-efficacy; and increased positive behavior change.18
A systematic review of peer recovery and recovery coaching found that peer recovery support services integrated into community outreach programs may increase participants’ self-awareness of problematic substance use and lead to reductions in alcohol and other drug use, and particularly emphasized the benefit to marginalized and/or stigmatized populations.19
One peer recovery program was established by researchers in Central Appalachia. Since the area has been disproportionately affected by the opioid epidemic and overdose fatalities, researchers at West Virginia University developed the West Virginia Peers Enhancing Education, Recovery, and Survival (WV PEERS) program. In the program, of the 63.9% of individuals who accessed services for SUDs and/or mental health problems, over half entered substance use and/or mental health treatment, and nearly a third remained in treatment over 6 months.12
Peer recovery support services have also been shown to be successful in American Indian communities. Aspects of culture that may facilitate recovery include a balance of physical, emotional, spiritual, and mental supports, such as talking circles, sweat lodges, prayer, and smudging, which are unique to American Indian populations. In a longitudinal study comparing European Americans and Navajos, the Navajos were more likely to quit drinking at an earlier age and report that treatment did not help them quit, citing family support, religion, and spirituality as the elements that supported their long-term sobriety.13
Hospital and emergency department settings
Many health care organizations have seen the advantages of implementing peer recovery support services to help encourage patients’ engagement with SUD treatment and other recovery support programs and services, and to discourage relapse.19 Patients often present to the emergency department (ED) with stated symptoms such as opioid withdrawal, acute intoxication, or medical complications related to OUD. This situation presents an opportunity for ED providers to initiate treatment and introduce the patient to peer recovery support services.20
Peer recovery support specialists can be integrated into hospitals, EDs, and other health care settings where they connect people to services such as MOUD, intensive outpatient or residential SUD treatment, social services, or harm-reduction resources. Peer recovery support specialists can also educate clinical staff on issues surrounding recovery, facilitate communication, model informal patient interactions, help reduce stigma, and facilitate changes in perceptions of people who use drugs (PWUD).14 Working within hospitals, peer recovery support specialists can reduce the amount of time from a doctor’s referral to arrival at bedside to initiate treatment, which helps to prevent discharge before the arrival of a peer recovery support specialist.18
Jail and prison settings
Peer recovery support specialists who work in jails and prisons typically have experienced incarceration and can leverage that experience to build rapport with the people they serve. Peer recovery support specialists may reach out to those with an upcoming release date to provide encouragement and develop a plan for support after release. At release, they may provide transportation to the person’s house or to community resources to obtain food or clothing. They may also help ease entry into a treatment program. One administrative data analysis using data from the Serious and Violent Offender Reentry Initiative found that the formerly incarcerated who received peer support experienced decreased substance use and recidivism. In another study, participants reported increased self-efficacy, perceived social support, positive relations with family and friends, improved quality of life, and decreased stress.14
Barriers to Delivering and Receiving Peer Recovery Support Services
Although the barriers for peer recovery support services may overlap with general barriers for SUD treatment, the following are presented within a peer recovery support services framework.
Personal barriers
A main barrier to receiving SUD treatment is the perspective of PWUD not believing they need treatment and not being ready to stop using substances. Other barriers include not being able to afford treatment without health care coverage, a lack of knowledge about where to obtain treatment, being a minority, having a psychiatric comorbidity, having low motivation, lacking basic resources, and having a fear of stigma in the workplace and the community.21
Lack of retention of peers and peer recovery support specialists
A review of the literature21 found that dropout rates for treatment programs vary significantly by population treated, substance of choice, and treatment characteristics. Rates range between 20–70% for inpatient programs, 23–50% for outpatient programs, and about 50% for office-based opioid treatment programs. People with psychiatric co-morbidities experienced higher odds of treatment dropout and shorter stays in treatment. Other demographic characteristics such as younger age, homelessness, having a history of physical or sexual abuse, unemployment, Black and Hispanic race/ethnicity, and being positive for hepatitis C had positive correlations with early dropout from substance use treatment.
Difficulty in sharing information among treatment centers
Treatment centers, hospitals, and peer services often lack the ability to share information across services. Organizations use a variety of electronic medical record systems, which typically do not interface with each other. The 42 CFR Part 2 regulations serve to protect patient records created by federally assisted programs for the treatment of substance use disorders. Such restrictions on information sharing make it difficult to coordinate care among outpatient clinics and peer recovery support services. Possible solutions include companies that are developing platforms that interface with each other to facilitate the sharing of patient data.22
Lack of national standards for scope of work and wages
Most states require peer recovery support specialists to obtain some level of certification; however, the eligibility requirements vary by state. There is a National Certified Peer Specialist certification program sponsored by the Florida Certification Board.23 However, this credentialing is not linked to tiered wage levels, and current reported wages range between $10 to $20 per hour with limited career advancement for employees. In treatment settings, peer recovery support specialists often assume additional responsibilities, such as case management, group facilitation, and advocacy, especially when program funding decreases. These additional tasks increase workloads and stress, without an accompanying increase in compensation.14
Varying processes and requirements for reimbursement
A study of interviews with state policymakers, directors of training and certification bodies, peer recovery support specialists, and other staff in mental health and substance use treatment and recovery organizations across four states identified multiple challenges with billing the Centers for Medicare & Medicaid Services for peer recovery support services. Interviewees reported that the burden of navigating a complex billing structure with little to no experience with the technology led to challenges that hindered their relationships with their peers. States and organizations may fund peer recovery support services using complex blended funding structures, such as SAMHSA grants (e.g., block grants) or state or federal drug court funds.14 In addition, many states have failed to expand Medicaid services after passage of the Affordable Care Act. Over three-quarters of all rural counties in Georgia have little or no access to SUD treatment for OUD. Integrating peer-delivered services within rural health care systems may prove beneficial and may serve as a model to states without expanded Medicaid.24
In emergency departments, it is difficult to determine whether a patient is eligible for Medicaid due to varying requirements across states. Peer recovery support services may require patients to be insured or eligible for Medicaid. As there are only 11 states where peer recovery support services may be billed to Medicaid, this requirement may prove a barrier to the uninsured.22
Call to Action
To support individuals in sustaining their recovery within a peer recovery program, the following elements are recommended for integration into community, health care, and other institutional settings:
- Educate health care professionals, policymakers, and the public on the benefits of peer recovery support services.
- Promote the inclusion of peer recovery support specialists in all aspects of primary health care and preventive services.
- Promote the equitable payment of peer recovery support specialists, whether as individuals or as part of integrated service delivery models.
- Tailor peer recovery support services to the community and populations that receive these services, with input from both community members and peer recovery support specialists.25
Peer recovery support services have been shown to be beneficial to people in SUD treatment across various settings. They can also extend the capacity of health care workers, which is desperately needed in areas with shortages of available physicians and accessible services. The integration of peer recovery support services into community, health care, and institutional settings will enhance long-term sobriety and improve the quality of life for people seeking SUD treatment.
Additional Resources
Bizzell US is poised to support federal, state, and local governments, as well as assist other stakeholders in navigating the growing demand for mental health and behavioral health care services. Bizzell’s Behavioral Health Advancement Resource Center (BHARC) is an ever-growing and trusted source for current behavioral health program development and research findings, examples of evidence-informed and promising practices, and emerging behavioral health policy and interventions. The BHARC Advisory Council consists of experts in substance use, mental health, clinical trials, pharmaceuticals, and health care standards and quality.
About Bizzell US (Bizzell)
Established in 2010, Bizzell is a U.S. Small Business Administration (SBA) HUBZone-certified strategy, consulting, and technology firm with a mission to improve lives and accelerate change. Bizzell develops innovative solutions to some of the most critical issues of our time such as health care services equity, global health, workforce innovation, and other urgent needs facing the world. Under the leadership and vision of founder, Anton C. Bizzell, MD, the company has grown into a thriving firm headquartered in New Carrollton, Maryland, with staff and offices in various regions around the country, including California, Colorado, Oklahoma, Connecticut, and Georgia, and globally in Africa, Asia, and Central America. To learn more about how we develop data-driven, research-informed, innovative solutions to complex, real-world challenges, visit: Bizzell US.
References
- Centers for Disease Control and Prevention Atlanta: CDC; 2022 [cited 2022 Nov 28]. U.S. overdose deaths in 2021 increased half as much as in 2020 – but are still up 15%. Available from: https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm
- Substance Abuse and Mental Health Services Administration (SAMHSA). Table 8.27A – Co-occurring substance use disorder and any mental illness in past year among persons aged 18 or older, by age group and demographic characteristics: numbers in thousands, 2014 and 2015 [Internet]. Rockville, MD: Author. c2016 [cited 2022 Dec 19]. Available from: https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf
- SAMHSA. Co-occurring substance use disorder and any mental illness in past year among persons aged 18 or older, by age group and demographic characteristics: numbers in thousands, 2018 and 2019 (Table 8.9A). Rockville, MD: Author. c2016 [cited 2022 Dec 19]. Available from: https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables
- SAMHSA. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. Figure 46 – People Aged 12 or Older with a Past Year Substance Use Disorder (SUD): 2019. Rockville, MD: Author. c2020 [cited 2022 Dec 19]. Available from: https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm#sud
- SAMHSA. Received Illicit Drug Use Treatment at Any Location in Past Year among Persons Aged 12 or Older with Past Year Illicit Drug Use Disorder, Received Alcohol Use Treatment at Any Location in Past Year among Persons Aged 12 or Older with Past Year Alcohol Use Disorder, and Received Substance Use Treatment at Any Location in Past Year among Persons Aged 12 or Older with Past Year Substance Use Disorder, by Age Group: Percentages, 2015-2019 (Table 7.56B). Rockville, MD: Author. c2020 [cited 2022 Dec 19]. Available from: https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables
- White WL, Kelly JF. Recovery management: what if we really believed that addiction was a chronic disorder? In: Kelly J, White W, editors. Addiction recovery management. Current clinical psychiatry. Totowa, NJ: Humana Press; 2011. p. 67-84. doi: 10.1007/978-1-60327-960-4_5
- White W, Cloud W. Recovery capital: a primer for addictions professionals. Counselor. 2008;9(5):22-27.
- Center for Substance Abuse Treatment. What are peer recovery support services? HHS Publication No. (SMA) 09-4454. Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. c2009 [cited 2023 Jan 11]. Available from: https://store.samhsa.gov/sites/default/files/sma09-4454.pdf.
- Zhang X, Lin D, Pforsich H, Lin VW. Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resource Health. 2020;18:8. doi: 1186/s12960-020-0448-3
- Richmond JS, Dragatsi D, Stiebel V, Rozel JS, Rasimus JJ. American Association for Emergency Psychiatry recommendations to address psychiatric staff shortages in emergency settings. Psychiatr Serv. 2021 Apr 1;72(4):437-443. doi: 10.1176/appi.ps.201900501
- Nielsen S, Cheetham A, Jackson J, Lord S, Petrie D, Jacka D, Picco L, Morgan K. A prospective, multisite implementation-efficacy trial of a collaborative prescriber-pharmacist model of care for medication assisted treatment for opioid dependence: protocol for the EPIC-MATOD study. Res Social Adm Pharm. 2022 Aug;18(8):3394-3401. doi: 10.1016/j.sapharm.2021.11.007
- Davis SM, Stover AN, Linn H, Dower J, McCawley D, Winstanley EL, Feinberg J. Establishing peer recovery support services to address the Central Appalachian opioid epidemic: the West Virginia Peers Enhancing Education, Recovery, and Survival (WV PEERS) pilot program. J Appalach Health. 2021 Jul 25;3(3):36-50. doi: 10.13023/jah.0303.04
- Kelley A, Bingham D, Brown E, Pepion L. Assessing the impact of American Indian peer recovery support on substance use and health. J Groups Addict Recover. 2017;12(4):296-308. doi: 10.1080/1556035x.2017.1337531
- Stack E, Hildebran C, Leichtling G, Waddell EN, Leahy JM, Martin E, Korthuis PT. Peer recovery support services across the continuum: in community, hospital, corrections, and treatment and recovery agency settings – a narrative review. J Addict Med. 2022 Jan-Feb 01;16(1):93-100. doi: 10.1097/adm.0000000000000810
- Ashford RD, Brown A, Canode B, Sledd A, Potter JS, Bergman BG. Peer-based recovery support services delivered at recovery community organizations: predictors of improvements in individual recovery capital. Addict Behav. 2021 Aug;119:106945. doi: 10.1016/j.addbeh.2021.106945
- Zgierska AE, White VM, Balles J, Nelson C, Freedman J, Nguyen TH, Johnson SC. Pre-arrest diversion to addiction treatment by law enforcement: protocol for the community-level policing initiative to reduce addiction-related harm, including crime. Health Justice 2021 9(9). doi: 10.1186/s40352-021-00134-w
- White MD, Perrone D, Watts S, Malm A. Moving beyond Narcan: a police, social service, and researcher collaborative response to the opioid crisis. Am J Crim Justice. 2021;46(4):626-643. doi: 10.1007/s12103-021-09625-w
- Liebling EJ, Perez JJS, Litterer MM, Greene C. Implementing hospital-based peer recovery support services for substance use disorder. Am J Drug Alcohol Abuse. 2021 Mar 4;47(2):229-237. doi: 10.1080/00952990.2020.1841218
- Eddie D, Hoffman L, Vilsaint C, Abry A, Bergman B, Hoeppner B, Weinstein C, Kelly JF. Lived experience in new models of care for substance use disorder: a systematic review of peer recovery support services and recovery coaching. Front Psychol. 2019 Jun 13;10:1052. doi: 10.3389/fpsyg.2019.01052
- Crowthers RA, Arya M, Venkataraman A, Lister JL, Cooper SE, Enich M, Stevens S, Bender E, Sanders R, Stagliano K, Jermyn RT. Impact of an osteopathic peer recovery coaching model on treatment outcomes in high-risk men entering residential treatment for substance use disorders. J Osteopath Med. 2022 122(10):521-9. doi: 10.1515/jom-2022-0066
- Stanojlović M, Davidson L. Targeting the barriers in the substance use disorder continuum of care with peer recovery support. Subst Abuse. 2021 Jun 17;15:1-10. doi: 10.1177/1178221820976988
- Kauffman E, Qiu Y, Frey JA, Bischof JJ. Barriers and facilitators to peer support services for patients with opioid use disorder in the emergency department. Cureus. 2022 Mar 14;14(3):e23145. doi: 10.7759/cureus.23145
- Florida Certification Board. National certified peer specialist (NCPS). Tallahassee, FL. c2022 [cited 2022 Dec 19]. Available from: https://flcertificationboard.org/certifications/national-certified-peer-specialist/
- Ashford, RD, Meeks M, Curtis BL, Brown AM. Utilization of peer-based substance use disorder and recovery interventions in rural emergency departments: patient characteristics and exploratory analysis. Rural Ment Health. 2019;43:17–29.
- Society of Behavioral Medicine. Call to action: integrating peer support in prevention and health care under the Affordable Care Act. Milwaukee, WI: Author. c2015 [cited 2022 Dec 19]. Available from: https://www.sbm.org/UserFiles/file/CALLTOACTION-communityhealthworkerstatement.pdf
