Benefits of peer support groups in the treatment of addiction

Abstract

Objective
Peer support can be defined as the process of giving and receiving nonprofessional, nonclinical assistance from individuals with similar conditions or circumstances to achieve long-term recovery from psychiatric, alcohol, and/or other drug-related problems. Recently, there has been a dramatic rise in the adoption of alternative forms of peer support services to assist recovery from substance use disorders; however, often peer support has not been separated out as a formalized intervention component and rigorously empirically tested, making it difficult to determine its effects. This article reports the results of a literature review that was undertaken to assess the effects of peer support groups, one aspect of peer support services, in the treatment of addiction.

Methods
The authors of this article searched electronic databases of relevant peer-reviewed research literature including PubMed and MedLINE.

Results
Ten studies met our minimum inclusion criteria, including randomized controlled trials or pre-/post-data studies, adult participants, inclusion of group format, substance use-related, and US-conducted studies published in 1999 or later. Studies demonstrated associated benefits in the following areas: 1) substance use, 2) treatment engagement, 3) human immunodeficiency virus/hepatitis C virus risk behaviors, and 4) secondary substance-related behaviors such as craving and self-efficacy. Limitations were noted on the relative lack of rigorously tested empirical studies within the literature and inability to disentangle the effects of the group treatment that is often included as a component of other services.

Conclusion
Peer support groups included in addiction treatment shows much promise; however, the limited data relevant to this topic diminish the ability to draw definitive conclusions. More rigorous research is needed in this area to further expand on this important line of research.

Full text

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Substance Abuse and Rehabilitation 2016:7 143–154
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REVIEW
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/SAR.S81535
Benets of peer support groups in the treatment
of addiction
Kathlene Tracy1,2
Samantha P Wallace3
1Community Research and Recovery
Program (CRRP), Department of
Psychiatry, New York University
School of Medicine, 2New York
Harbor Healthcare System (NYHHS),
New York, 3Department of
Community Health Sciences, State
University of New York Downstate
School of Public Health, Brooklyn,
NY, USA
Objective: Peer support can be defined as the process of giving and receiving nonprofessional,
nonclinical assistance from individuals with similar conditions or circumstances to achieve
long-term recovery from psychiatric, alcohol, and/or other drug-related problems. Recently,
there has been a dramatic rise in the adoption of alternative forms of peer support services to
assist recovery from substance use disorders; however, often peer support has not been sepa-
rated out as a formalized intervention component and rigorously empirically tested, making it
difficult to determine its effects. This article reports the results of a literature review that was
undertaken to assess the effects of peer support groups, one aspect of peer support services, in
the treatment of addiction.
Methods: The authors of this article searched electronic databases of relevant peer-reviewed
research literature including PubMed and MedLINE.
Results: Ten studies met our minimum inclusion criteria, including randomized controlled trials
or pre-/post-data studies, adult participants, inclusion of group format, substance use-related,
and US-conducted studies published in 1999 or later. Studies demonstrated associated benefits
in the following areas: 1) substance use, 2) treatment engagement, 3) human immunodeficiency
virus/hepatitis C virus risk behaviors, and 4) secondary substance-related behaviors such as crav-
ing and self-efficacy. Limitations were noted on the relative lack of rigorously tested empirical
studies within the literature and inability to disentangle the effects of the group treatment that
is often included as a component of other services.
Conclusion: Peer suppor t groups included in addiction treatment shows much promise; however,
the limited data relevant to this topic diminish the ability to draw definitive conclusions. More
rigorous research is needed in this area to further expand on this important line of research.
Keywords: behavioral treatment, mentorship, substance use, alcohol, drugs, recovery
Introduction
Peer support can be defined as the process of giving and receiving nonprofessional,
nonclinical assistance from individuals with similar conditions or circumstances to
achieve long-term recovery from psychiatric, alcohol, and/or other drug-related prob-
lems. Historically, peer support has been shown to be a key component of many existing
addiction treatment and recovery approaches such as the community reinforcement
approach,1–11 therapeutic communities,12,13 and 12-step programs;14,15 the community
reinforcement approach has demonstrated the importance of valued social roles in
maintaining abstinence, which is the foundation of the peer support relationship.16–18
Varying approaches that include a mixture of services such as peer support groups,
individual counseling, and case management have emerged as a highly effective and
Correspondence: Kathlene Tracy
Community Research and Recovery
Program, Department of Psychiatry, New
York University School of Medicine,
Room 2674, 423 East 23rd Street, New
York, NY 10010, USA
Tel +1 212 686 7500 Ext 3167
Fax +1 212 951 3356
Email kathlene.tracy@nyumc.org
Journal name: Substance Abuse and Rehabilitation
Article Designation: REVIEW
Year: 2016
Volume: 7
Running head verso: Tracy and Wallace
Running head recto: Benefits of peer support groups in the treatment of addiction
DOI: http://dx.doi.org/10.2147/SAR.S81535
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empowering method to manage the social context of health
issues and are particularly popular in the substance abuse and
mental health fields.19 As it relates to substance abuse recovery
for individuals and families, addiction peer support services
have emerged across time due to the shift from a biopsycho-
social approach to a sustained recovery management approach
to treat addictions.20 While in many cases, peer support groups
do not replace the need for formal treatments or supervisory
clinical guidance due to peers not having sufficient training
to manage psychiatric conditions or high-risk situations, they
still offer an augmentation to treatment that provides many
benefits to individuals with substance use disorders.21
Terminology
Various terminologies are used interchangeably within the
literature to describe peer-related support and contexts. For
the purposes of this article, we attempted to utilize consistent
language wherever possible. However, in certain instances,
a term may be part of a broader term such as mentorship is
a type of peer support, but mentorship is specific to an indi-
vidual in later recovery providing peer support to someone in
earlier recovery, which requires additional specification.21 We
adapted and built upon White’s20 definition of peer support to
include individuals with similar conditions or circumstances
and inclusion of recovery from psychiatric problems in
addition to substance use disorders. We also included this
broadened scope in our definition of peer mentorship. Table 1
provides key peer support terms used throughout this review
article and definitions.22–24
Residential and sober living
Since the 1960s, a variety of residential options have emerged
to help people with alcohol and drug addictions. These pro-
grams based on the social model of recovery provide support
for people in recovery from alcohol addiction in a residential
environment that focuses on Alcoholics Anonymous (AA)
philosophy and practices.25 AA practice follows the 12-step
guidelines based on spiritual principles and the assumption
that addiction is a disease.26 Prior work utilizing social model
programs can be found as early as the 1940s.27–29 The types
of social model programs available include social setting
detoxification, residential social model recovery programs,
neighborhood recovery centers, and sober living houses.27
Sober living houses are alcohol- and drug-free living
environments for a group of peers in recovery. Utilizing a
peer-oriented social model modality, sober living houses
rely on mutual sobriety support, self-efficacy, and resident
participation. California Sober Living Houses and Oxford
Houses are two variations of sober living houses.30–32 Previous
studies have shown sober living houses to be beneficial33 and
effective34,35 in assisting in the reduction of substance use.
For example, Jason et al35 conducted a randomized study to
test the efficacy of an Oxford House intervention compared
to usual care (ie, outpatient treatment or self-help groups)
following discharge from inpatient substance abuse treat-
ment. Results demonstrated a significant increase in monthly
income with a significant decrease in substance use and
incarceration rates among those in the Oxford House condi-
tion compared with the usual-care condition.
12-step
Some of the most popular peer support groups held outside
the formal treatment settings for addiction nationwide include
12-step programs such as AA, Narcotics Anonymous, and
Cocaine Anonymous. Twelve-step is an intervention for drug
abuse and addiction and can include dual recovery from
substance abuse problems and co-occurring mental health
disorders. Humphreys36 found 12-step groups to be the most
referred adjunct support for professionally treated substance
abuse patients. Other studies have demonstrated the effective-
ness of 12-step groups for the treatment of substance abuse
following treatment,37–39 and prior research of 12-step groups
has shown reductions in alcohol and drug use.40–42
Table 1 Key terms and denitions related to peer support
Terms Denitions
Peer support The process of giving and receiving
nonprofessional, nonclinical assistance
from individuals with similar conditions or
circumstances to achieve long-term recovery
from psychiatric, alcohol, and/or other
drug-related problems
Recovery A process of change through which individuals
improve their health and wellness, live self-
directed lives, and strive to reach their full
potential22
Peer support group Where people in recovery voluntarily gather
together to receive support and provide
support by sharing knowledge, experiences,
coping strategies, and offering understanding23
Peer provider
(eg, certied peer
specialist, peer support
specialist, mentor, and
recovery coach)
A person who uses his or her lived experience
of recovery from mental illness and/or addiction,
plus skills learned in formal training, to deliver
services in behavioral health settings to promote
mind–body recovery and resiliency24
Peer mentorship Where individuals in later recovery provide
nonprofessional, nonclinical assistance to
individuals in earlier recovery with similar
conditions or circumstances to achieve long-
term recovery from psychiatric, alcohol, and/
or other drug-related problems
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Benets of peer support groups in the treatment of addiction
AA has been shown to be a highly utilized interven-
tion for individuals with alcohol problems.43–45 Positive
outcomes such as self-efficacy and healthy coping have
been associated with AA affiliation, which has been linked
to better outcomes.37,46 For those with drinking problems
seen in treatment, certain AA activities such as having a
sponsor and doing service might be key components of
abstinence.47
In a focused review of the literature on AA effective-
ness, six criteria were required for establishing causation: 1)
magnitude of effect; 2) dose–response effect; 3) consistent
effect; 4) temporally accurate effects; 5) specific effects, and
6) plausibility. The evidence for all criteria except specific
effects was very strong. For magnitude, rates of abstinence
within AA were approximately twice as high. For dose–
response, higher rates of abstinence were related to higher
levels of attendance. For consistency, the effects were found
for different follow-up periods and different samples. For
temporal, prior AA attendance is predictive of subsequent
abstinence. For plausibility, mechanisms of action predicted
by behavioral change theories were present in AA. However,
for specificity of an effect for 12-step facilitation or AA,
experimental evidence was mixed, with evidence for both
positive and negative effects in addition to no effect.48
Although the peer support groups within 12-step
approaches have provided benefits to select populations, some
individuals with substance use disorders find the religious
nature of 12-step approaches and often lack of integration
in the treatment setting to be a deterrent.49–51 Alternatives
to 12-step approaches are needed to more closely integrate
peer support services within treatment and to provide more
options to benefit from peer support groups.
Treatment and community settings
Recently, there has been a dramatic rise in the adoption of
alternative forms of peer support services within treatment
and community settings to assist recovery from substance
use disorders, because of the potential benefits offered to
patients.52 However, often peer support has not been sepa-
rated out as a formalized intervention component and rigor-
ously empirically tested, making it difficult to determine its
effects.53
Peer support is delivered in a variety of modalities,
including, but not limited to, in-person self-help groups,
Internet support groups, peer run or operated services, peer
partnerships, peers in health care settings who serve as peer
advocates, peer specialists, and peer case managers.54 Among
peer support services available today, peer support groups
are considered an important aspect of the addiction recovery
process.55–58
Previous studies have shown positive outcomes from
participating in peer support groups. Active engagement
in peer support groups has shown to be a key predictor
of recovery,56,59,60 and sustaining recovery.61–63 In addition,
evidence demonstrates that one’s belief in their own abil-
ity can increase and influence one’s behavior by watching
other peoples’ behaviors (ie, performing activities).64 There
is a mutual benefit between the members and facilitators of
peer support groups. Oftentimes, peer support groups are
facilitated by peer workers who themselves are in recovery
and benefit positively from peer support groups.21 Benefits
for the peer worker include increased self-esteem, confidence,
positive feelings of accomplishment, and an increase in their
own ability to cope with their challenges.
Existing systematic peer support reviews
Bassuk et al65 conducted a systematic review of the evi-
dence on the effectiveness of peer support services for
people in recovery from alcohol and drug addiction, which
resulted in nine studies meeting the criteria for inclusion
in the review. Despite methodological limitations found
in the studies, the body of evidence suggested beneficial
effects on participants. In another systematic review, Reif
et al66 evaluated peer support services for individuals with
substance use disorders resulting in ten studies. The stud-
ies demonstrated increased treatment retention, improved
relationships with treatment providers and social supports,
increased satisfaction, and reduced relapse rates. Similar
to the other reviews, there were methodological limitations
that included inability to distinguish the effects of peer
recovery support from other recovery support activities,
small sample sizes and heterogeneous populations, unclear
or inconsistent outcomes, and lack of any or appropriate
comparison groups. Both of these reviews included peer
support services in general without a specific focus on peer
support groups and excluded studies with substance-using
populations with a primary focus on human immunodefi-
ciency virus (HIV)/hepatitis C virus (HCV) risk behavior
outcomes. In addition, 12-step peer support studies were
excluded.
This article reports the results of a literature review that
was undertaken to assess the use of peer support groups, one
aspect of peer recovery support services, in the treatment of
addiction. In reporting the outcomes related to this review, the
authors intend to: 1) encourage the field to generate further
research to more rigorously investigate the effectiveness of
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Tracy and Wallace
peer support groups and explore the multitude of other spe-
cific types of peer recovery support services and 2) provide
greater awareness to the advantages of peer support integra-
tion within the substance use treatment continuum for adults
with addiction problems.
Methods
To effectively complete the review, the authors used a
combination of searches on electronic scientific databases
and screening results cross-checking the eligibility criteria
to reduce the number of studies included in this article. At
certain points, the authors independently cross-checked
the results. If there was a discrepancy, further information
was gathered to make an accurate determination of how to
proceed. The process is described later and summarized in
Figure 1.
Study identication and screening: Phase I
The authors of this article searched the electronic databases
of relevant peer-reviewed research literature including
PubMed and MedLINE. Because addiction is a broad term
that can be applied to varying types of addiction beyond
alcohol- and nonalcohol-related substances (eg, gambling,
Internet, sex, and eating) that are unrelated to the scope
of this article, “substance use disorders” was the primary
terminology used in searches to yield records pertaining
to alcohol and drug problems. The initial database search
used keywords “substance use disorders and peer support”.
We also cross-checked our inclusion list by running similar
searches containing specific substance names as keywords
(eg, cocaine, alcohol, and heroin) to ensure comprehensive-
ness. This resulted in 2,291 records.
Study identication and screening: Phase II
The following keywords were used to identify all articles
associated with several domains: substance use disorders,
peer support or peer mentorship, and intervention. Including
the keyword “intervention” allowed for higher yielding of
treatment studies. While critiquing and critically reviewing
results within an article that included a systematic review of
studies,66 we found three additional studies that met our inclu-
sion criteria, which were included.67–69 Using the keywords
“substance use disorders and peer support and intervention”,
461 records were found. Using the keyword “substance
Figure 1 Flow diagram of study selection.
Study identification and
screening Phase I
Records identified through
initial database searching
and Phase I screening
Number of records excluded
Full-text articles excluded
Records identified through
database searching and
Phase II screening
Number of full-text articles
assessed for initial eligibility
Total number of studies
included in this review
n=2,291
n=488 n=472
n=6n=16
N=10
Study identification and
screening Phase II
Met initial eligibility cr
iteria
Included
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Benets of peer support groups in the treatment of addiction
use disorder and peer mentorship”, 24 records were found.
Including three studies previously mentioned, a total of 488
articles were screened for eligibility.
Initial eligibility
By design, this discussion is limited to studies that included a
peer support group component that: 1) had adult participants;
2) focused on addiction-related substance use (ie, alcohol,
tobacco, legal/illicit drugs, and prescription drugs); 3) held
in any group format; 4) included randomized controlled trials
(RCTs) or studies with pre- and post-data results, and 5) US-
conducted studies published in 1999 or later. Since certain
groups (eg, HIV, HCV, and mental health) are at greater risk
of having a substance use disorder, we did not exclude these
populations.
As previously noted, the authors used keywords peer sup-
port or mentorship and substance use disorders to generate
articles on the use of peer support groups within substance
use disorder treatment to generate the initial pool of articles.
We further narrowed our initial results in the current article
to include only studies that focused on peer support group
treatments. However, initially, we found that empirical stud-
ies assessing peer support groups solely were very limited
and that our literature search would be much improved if
we included not only peer support groups independently but
also studies that integrated peer support groups as a compo-
nent of a larger spectrum of peer services offered. We also
included traditional forms of peer support services such as
12-step in addition to including any recent advancements
within the field.
All study types that were not RCTs or quasi-experiments
were excluded, including case reports, case series, cross-
sectional surveys, and other qualitative studies. Adoles-
cents-focused studies were excluded, because they focused
generally on social support and social norms and peers may
not have self-identified as having substance use problems.
Cost-effectiveness studies were excluded. Article types such
as books, editorials, guidelines, commentaries, dissertations,
discussions, policy analyses, and newspaper or magazine
articles were excluded. Of the 488 records that underwent
review to meet the authors’ inclusion/exclusion criteria noted
earlier, 16 articles met the initial eligibility.
Final selection
Of the 16 records, ten articles were selected to be included in
the article. Of the six excluded, three studies had a primary
focus of peer support groups to train the peer support staff,
two studies did not have consistent or adequately structured
peer support groups in the design, and one study’s substance
use inclusion criteria were too minimal.
Results
The literature search revealed articles that support the use
of peer support services that include peer support groups
within addiction treatment to address: 1) substance use, 2)
treatment engagement, 3) HIV/HCV risk behaviors, and 4)
secondary substance-related behaviors. It should be noted,
however, that data were limited in finding peer support groups
that were a standalone treatment as these groups were largely
incorporated into a full array of peer support services being
delivered, thereby posing challenges in disentangling the
effects. Table 2 provides summaries of each study selected.
Substance use
Armitage et al67 discussed and evaluated Recovery Associa-
tion Project’s (RAP) Recovery Community Services Program,
a funded peer recovery service from 2003 to 2007. Recovery
Community Services Program provided a wide range of peer
recovery services, which included numerous self-help meet-
ings at the RAP center that became a popular location for
self-help meetings (eg, AA, Narcotics Anonymous, Cocaine
Anonymous, and Smart Recovery) with several scheduled
meetings daily. The outcomes measured were substance use,
consumer satisfaction, and progress toward RAP’s goals.
RAP received participant feedback from the Government
Performance Reporting Act survey and a satisfaction ques-
tionnaire. There were 152 survey participants included in
this outcome evaluation. At 6-month follow-up, most (86%)
participants receiving RAP services indicated on the Gov-
ernment Performance Reporting Act survey abstinence from
using alcohol or drugs in the past 30 days, which is much
higher than typically noted abstinence levels in this popula-
tion. These results help to demonstrate that RAP services are
associated with sustained recovery from substance use. Data
from the satisfaction questions administered at 6 months were
also high, indicating RAP’s services are effectively meeting
the needs of participants.
Boisvert et al70 established and evaluated the effective-
ness of a peer support community program. The primary
purpose was to determine whether rates of relapse would
decrease among addicts in recovery living in permanent
supportive housing and increase their perceptions of com-
munity affiliation, supportive behaviors, self-determination
(ie, proactive steps self-initiated to recovery), and quality
of life. The peer support program was implemented by an
occupational therapist and addiction professional following
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Table 2 Included studies utilizing peer support groups
Authors Design N Population Findings
Armitage et al67 Pre/posttest 152 Individuals in recovery
from addiction and their
families
86% of participants indicated no use of alcohol or drugs in the past
30 days at the 6-month follow-up
95% of participants reported strong willingness to recommend
the program to others, 89% found services helpful, and 92% found
materials helpful
Boisvert et al70 Pre-/posttest 18 Individuals in addiction
recovery living in
permanent supportive
housing
Substance use relapse rate reduced (24%–7%) for participants in the
peer support community
Pretest relapse rate was 85%; posttest rate was 33% for tenants
returning to homelessness
No differences in pre- and post-QOLR
The MOS–SSS subscales revealed signicant differences and
moderate-to-large effect sizes (r) on the MOS–SSS subscales:
emotional/informational support (P=0.005; r=0.628), tangible
support (P=0.028; r=0.493), and affectionate support (P=0.027;
r=0.494)
Tracy et al21 Pre-/posttest 40 Individuals with substance
use disorders in an
addiction treatment
program
Feasibility and acceptance data in the domains of patient interest,
safety, and satisfaction were promising
In addition, mentees signicantly reduced their alcohol use (P<0.01)
and drug use (P<0.01) from baseline to termination
The majority of mentors sustained abstinence
Fidelity measures indicated that mentors adhered to the delivery of
treatment
Tracy et al72 RCT comparing TAU +
MAP-engage vs TAU +
DRT + MAP-engage vs
TAU
96 High recidivism veterans
(mostly males) with
substance use disorders
initially recruited from an
inpatient clinic
TAU + MAP-engage alone and TAU + DRT + MAP-engage were
associated with increased adherence to post-discharge outpatient
appointments for substance use treatment (P<0.05) when compared
with TAU only
As well as for substance use treatment, general medical, and mental
health services (P<0.05 for all appointments combined) when
compared with TAU only
Mangrum68 Quasi-experimental
design comparing ATR
and substance use
treatment vs substance
use treatment
4,420 Consumers with
substance use disorders
referred from drug
courts, probation, or
child protective services
Individuals who completed the program were signicantly more
likely to have received recovery support groups (t(1)=65.75,
P<0.0001)
Purcell et al73 RCT study of peer-
mentoring intervention
INSPIRE vs a video
discussion control group
966 HIV-positive IDU
participants
Adherence rates measured at 87%, 83%, and 85% at 3 months,
6 months, and 12 months, respectively
Risk behaviors decreased among randomized participants although
no signicant differences in conditions
Latka et al74 RCT study of peer-
mentoring intervention
vs a time-equivalent
attention-control group
418 Individuals who are
HCV-positive and IDUs
Compared with the controls, participants in the intervention group
were less likely to report distributive risk behaviors at 3 months
(OR =0.46; 95% CI =0.27, 0.79) and 6 months (OR =0.51; 95% CI
=0.31, 0.83), a 26% relative risk reduction
Peer mentoring and self-efcacy were signicantly increased in the
intervention group, and intervention effects were mediated through
improved self-efcacy
Velasquez et al71 RCT study of both
individual counseling vs
peer group education/
support
253 HIV-positive men who
have sex with men with
alcohol use disorders
Treatment effect was demonstrated over each 30-day period
with regard to number of drinks consumed (OR =1.38; 95%
CI =1.02, 1.86)
As well as the number of heavy drinking days (OR =1.5; 95%
CI =1.08, 2.10) over each 30-day period
Main effect was found in the number of days in which both heavy
drinking and unprotected sex occurred over each 30-day period
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Benets of peer support groups in the treatment of addiction
Authors Design N Population Findings
Marlow et al79 Pre-/posttest 13 Formerly incarcerated
men on parole released
from prison within the
past 30 days
Findings from the assessment of psychosocial variables
demonstrated signicant improvement on two abstinence self-
efcacy subscales, negative affect (P=0.01), and habitual craving
(P=0.003)
No signicant differences in total scores for abstinence self-efcacy
or the other measures from baseline to follow-up for the 13
participants who completed the study
No signicant differences in 12-step participation with regard to
attendance, sponsor contact, or belief in 12-step framework
Andreas et al69 Pre-/posttest 509 Men and women
in recovery from
addiction who had been
incarcerated, and their
families and signicant
others
Increased self-efcacy and increased family and friend support,
quality of life, and feelings of guilt and shame were demonstrated at
12 months from baseline (no data were shown)
Peer and staff accessibility were valued
Abbreviations: ATR, access to recovery; CI, condence interval; DRT, dual recovery treatment; HCV, hepatitis C virus; HIV, human immunodeciency virus; IDU,
injection drug user; INSPIRE, Intervention for Seropositive Injectors–Research and Evaluation; MAP, Mentorship for Alcohol Problem; MAP-engage, Mentorship for Addiction
Problems to enhance engagement to treatment; MOS, Medical Outcomes Study; OR, odds ratio; QOLR, Quality of Life Rating; RCT, randomized controlled trial; SSS, Social
Support Survey; TAU, treatment as usual.
SAMHSA (Substance Abuse and Mental Health Services
Administration) recovery community model. The staff person
facilitated the first 10 weeks and then withdrew to a support-
ive background as the community became self-facilitating.
Meetings involved discussions on principles of a peer support
recovery or peer-driven community between the therapist and
residents. Documents such as handouts and readings were
provided to the community members who had interest in
being a leader within the community, and supportive meetings
were scheduled. The peer support group focused on training
in leadership, group communication, and group facilitation
with community-elected officers and conducted biweekly
meetings and social events, all being organized by members.
Using previous year relapse data to provide a comparison
rate, Boisvert et al70 found significant reductions in relapse
rates among participants in the peer support community pro-
grams. In addition, return to homelessness was dramatically
reduced by assisting participants in managing their recov-
ery. These results imply that peer and community support
groups are important in the process of relapse reduction, in
particular, groups that focus on self-determination, as it can
have a positive impact on recovery from substance abuse and
homelessness. As for the main objectives, quantitative findings
showed that three subscales (ie, emotional support, tangible
support, and affectionate support) on the Medical Outcomes
Study–Social Support Survey demonstrated significant differ-
ences, although there were no significant differences regarding
quality of life from the Quality of Life Rating.70 In addition,
qualitative findings showed that residents’ perceptions of
community affiliation and supportive behaviors improved.
Another study conducted by Tracy et al21 investigated a
new intervention, mentorship for alcohol problems (MAPs),
that included peer support groups and one-to-one mentor-
ship services for individuals with alcohol-use disorders in
community-treatment programs. Mentors participated for
6 months until multiple mentees received MAP for 12 weeks.
Behavioral and biological measures were conducted in addi-
tion to fidelity measures. Feasibility and acceptance data in
the domains of patient interest, safety, and satisfaction were
promising. In addition, mentees significantly reduced their
alcohol and drug use from baseline to termination and the
majority of mentors sustained abstinence. Fidelity measures
indicated that mentors adhered to the delivery of treatment.
Velasquez et al71 evaluated the efficacy of a theory-based
behavioral intervention that included both individual coun-
seling and peer group education/support to reduce alcohol
use among HIV-positive men who have sex with men when
compared to a control condition where participants received
resource materials. Reported treatment effects occurred in
reduction in the number of drinks per 30-day period and
number of days drank heavily per 30-day period.
Engagement to treatment
Beyond associated reductions in alcohol and drug use,
services that have included peer support groups have been
utilized to engage substance-using populations in treat-
ment. Often high recidivism substance-using patients have
difficulty connecting to outpatient treatment, contributing to
greater functioning disturbances.72 Approaches to address this
problem frequently are staff extensive. Tracy et al72 evaluated
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Tracy and Wallace
the impact of peer mentorship, which included, in addition
to other peer support services, peer support groups and/or
enhanced dual recovery treatment (DRT) on individuals who
were inpatients, substance abusing, and had a history of high
recidivism. The primary outcome was post-discharge treat-
ment attendance. Within an inpatient Veterans Administration
hospital setting, 96 patients with a history of high recidivism
and current and/or past diagnosis of substance use disorders
were randomized to either: 1) treatment as usual (TAU), 2)
TAU + DRT + mentorship for addiction problems to enhance
engagement to treatment (MAP-engage), or 3) TAU + MAP-
engage. The investigators found that overall MAP-engage
was comparable to the DRT + MAP-engage, and both of
these conditions were significantly better than TAU alone at
increasing adherence to post-discharge substance abuse, and
medical and mental health outpatient appointments with par-
ticipants in MAP-engage being three times as likely to attend
their outpatient substance abuse treatment appointments
than those in TAU 1 year post discharge. MAP-engage that
included peer support groups offered an alternative approach
to address lack of attendance to outpatient treatment appoint-
ments post discharge that is relatively low in staff reliance.
Similarly, in a large study, Mangrum68 compared access to
recovery + substance use treatment to substance use treatment
alone for consumers involved in the criminal justice system
who had substance use disorders and were referred from drug
courts, probation, or child protective services. Individuals
who completed the program were significantly more likely to
have received recovery support groups. However, it should be
noted that only a relatively small portion of the sample within
the completers group, 12%, utilized the support groups as
there were multiple treatment options, but this was still over
twice as much as in the non-completers group, 5%.
HIV/HCV risk behavior
Intervention for Seropositive Injectors–Research and Evalu-
ation study, an RCT of a peer support intervention designed
to assess the reduction in sexual and injecting-related risk
behaviors, increased use of HIV care, and increased HIV
medication adherence as primary outcomes, was discussed
by Purcell et al.73 The peer support intervention was ten
sessions over a 12-month time period, with seven sessions
being specifically devoted to peer support groups. The control
condition was eight sessions of a video intervention. One out
of the ten sessions was a peer volunteer activity during which
participants went to a local service organization for 2–4 hours
to observe, participate, and practice peer support skills. The
topics from the group sessions included setting group rules
and the power of peer mentoring, utilization of HIV primary
care and adherence, and sex and drug risk behaviors.
Of the participants randomized, 486 were assigned to the
peer support condition and 480 were assigned to the video
discussion condition, totaling a sample of 966 HIV injection
drug users (IDUs). Purcell et al73 found that randomized par-
ticipants in both conditions had retention rates of 87%, 83%,
and 85% at 3 months, 6 months, and 12 months, respectively.
Significant reductions were noted in both groups for reduc-
tions from baseline in injection and sexual transmission risk
behaviors, but there were no significant differences between
conditions. Participants in both conditions reported no change
in medical care and adherence.73
An RCT with a time-equivalent attention-control group
was conducted by Latka et al74 among 418 HCV IDUs to
examine a peer-mentoring behavioral intervention to reduce
the distribution of injection practices and equipment among
HCV IDUs. Each intervention consisted of six sessions,
2 hours each twice a week. For the peer-mentoring group
intervention, participants received information regarding
HCV and learned risk reduction skills. By the fifth session,
training participants were involved in outreach and delivered
information about reducing HCV transmission risk. The
control group watched a docudrama TV series about IDUs
and participated in a facilitated group discussion focusing
on family, education, self-respect, relationships, violence,
parenting, and employment. Compared to the control group,
participants in the peer support condition had significantly
greater reductions in injection practices that could transmit
HCV to other IDUs. Self-efficacy was significantly increased
in the experimental condition, and post-intervention self-
efficacy was a positive mediator between the intervention
and distributive risk behaviors.
In the study previously discussed in the substance use
section, Velasquez et al71 also found a reduction in the number
of days on which both heavy drinking and unprotected sex
occurred among HIV-positive men who have sex with men.
Secondary substance-related outcomes
Craving has been associated with use of substances.75–78 The
authors’ search also revealed a recently published pilot study
that evaluated a peer support program for formerly incarcer-
ated adults who transitioned back into the community that
included investigations of craving among other varriables.79
This population experiences high rates of substance use. One
of the main objectives of this study was to assess program
feasibility using a community-based participatory research
approach. Participants were 20 men on parole who were
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151
Benets of peer support groups in the treatment of addiction
released from prison within the past 30 days, with only 13
completing the 60-day peer mentor intervention. Marlow
et al78 measured 12-step meeting participation using a 13-item
questionnaire that assessed participation in 12-step programs,
belief in the 12-step framework, and investigated relation-
ships with craving and negative affect. Questions assessing
belief in 12-step framework included: I am powerless over my
drug and alcohol problem, I believe a higher power plays a
role in my recovery, I am not alone with my drug and alcohol
problem, I believe in the 12-step faith and spirituality, and I
am member of 12-step. Twelve-step meetings were attended
by participants on an average of 17 days out of 30 days and
participants contacted their sponsor on average ten times.
All participants’ belief in the 12-step framework was high.
Pre- and posttest results on two abstinence subscales, negative
affect and habitual craving, showed significant improvement,
indicating an improved confidence level in the ability to
abstain from substance use.
Andreas et al69 sought to examine Peers Reach Out
Supporting Peers to Embrace Recovery (PROSPER), a
peer-driven recovery community that provides a number of
peer-driven supports for members to be able to recover from
drug use and criminality as they transition back into the com-
munity and to provide support to their family members and
loved ones. PROSPER provided a strategic mix of services,
all planned, implemented, and delivered by peers including
peer-run groups and group activities that take place in a
light-hearted social environment away from traditional treat-
ment settings. The aims of the program were to: 1) provide
peer support environment, 2) build positive self-concept and
achievement motivation, 3) reinforce family/significant oth-
ers’ relationships and support, and 4) amplify the treatment
continuum.77 The study outcome measures were self-efficacy,
perceived social support, personal feeling, perceived stress,
and quality of life. Program effects were evaluated and dem-
onstrated at 12 months from baseline with significant and
positive changes in participants’ self-efficacy, social support
perceptions, quality of life, and feelings of guilt and shame
over a 12-month period. The result of this study suggests the
importance of peer support among people who are reentering
the community, which can promote positive outcomes such
as reduced substance use and recidivism.
Discussion
Despite the recent surge in the adoption of peer support
services within addiction treatment systems, there are rela-
tively limited data rigorously evaluating outcomes.21 These
data become even more limited when considering one form
of peer support services, such as peer support groups as in
the case of this review, due to the nature of peer support
services being delivered often in a multitude of combined
modalities. Thus, we included studies of peer support groups
that were delivered often in an array of other peer support
treatments, which diminished our ability to disentangle the
results. However, this review still provides a useful platform
to begin to explore the inclusion of these peer support groups
as a component of other peer services and associated benefits
thus far to guide the field in the future researching of this area.
Although methodological limitations existed in studies
that resulted from previous existing systematic reviews of
peer support services, beneficial effects were noted.65,66
This article builds upon these reviews by the specificity on
peer support groups, which is a common platform in treat-
ment. To the authors’ knowledge, this is the first article to
date to take such an approach reviewing controlled studies.
The previous reviews examined a range of peer support
services. Moreover, we expanded beyond existing reviews
to include substance-related HIV/HCV risk behavior stud-
ies due to the high prevalence of substance use disorders
in this population. Drug abuse is inextricably linked with
HIV due to heightened risk both of contracting HIV and of
worsening its consequences, and HCV is one of the most
common viral hepatitis infections transmitted through
drug-using high-risk behaviors, making reduction of risk
behaviors one of the priorities in substance abuse treatment
at the National Institute on Drug Abuse.80 Finally, we also
expanded our review to include 12-step studies due to their
focus on peer support groups and contributions to the peer
support movement.
Our review revealed articles that demonstrated peer
support services that include groups delivered to those with
substance use problems showing associated benefits in the
following areas: 1) substance use, 2) treatment engagement,
3) HIV/HCV risk behaviors, and 4) secondary substance-
related behaviors such as craving and self-efficacy.
Those who participated in treatments, including peer sup-
port groups, showed higher rates of abstinence than common
in substance-abusing populations while also being more satis-
fied with the treatment.67 Furthermore, significant reductions
in relapse rates were shown in addition to significant reduc-
tions in return to homelessness in a challenging population
to treat.70 Reported benefits extended beyond those being the
recipient of the peer support groups to those also delivering
the services, where significant reductions in alcohol and drug
use were shown not only for mentees but also for sustained
abstinence in the majority of mentors.21
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Tracy and Wallace
Beyond substance use, peer support groups offer unique
advantages to engaging our historically difficult-to-engage
populations. Services that included peer support groups
were found to be equally comparable to the additive of exten-
sive DRT, and both were significantly better than standard
treatment at increasing adherence to post-discharge substance
abuse and medical and mental health outpatient appointments
for high recidivism individuals with substance use disorders.72
Moreover, consumers involved in the criminal justice system
who had substance use disorders and were referred from drug
courts, probation, or child protective services, who completed
the program, were significantly more likely to have received
recovery support groups.68 However, it should be noted that
only a relatively small sample completed, thus diminishing
the impact of these results.
Peer support services that include groups have also been
associated with reductions in HIV and HCV risk behaviors
in IDUs. One study demonstrated a reduction in injection and
sexually transmitted risk behaviors in both conditions, but
there was no significant difference between the peer condition
and the control condition, which was also an intervention.73
However, another study showed not just a reduction but sig-
nificantly greater reductions in injection practices that could
transmit HCV to other IDUs when comparing the peer sup-
port condition to the control group.74 Consistent with previous
research, the study suggests that this enhanced behavioral
intervention of education and counseling was associated with
safer injection practices. Thus, providing implications that
these components (ie, skill building and education) of peer
mentoring provided to HCV-injecting drug users can lead
to safer practices of injection drug use and may contribute
to reducing the risk in IDUs and the transmission of HCV to
other IDUs. Another study demonstrated significant reduc-
tions not only in risk behaviors but also in heavy drinking
while accomplishing this.71
One of the key elements that peer support services sig-
nificantly positively impact is improvement in participants’
self-efficacy, which was also found to be a positive media-
tor between interventions and distributive risk behaviors
in one study.69 Associated positive changes have also been
demonstrated such as improvements in negative affect, social
support perceptions, reductions in habitual craving, and feel-
ings of guilt or shame.69,79 All of these areas play important
roles in one’s ability to achieve and sustain abstinence from
substances. There were conflicting results from studies on
whether or not quality-of-life improvements were associ-
ated with peer support groups being included in services.69,70
Peer support groups included in addiction treatment show
much promise in potentially reducing substance use, improv-
ing engagement, reducing HIV/HCV risk behaviors, and
improving substance-related outcomes. However, even given
their widespread use, there are relatively limited empirical
data relevant to this topic, which may diminish the ability
to draw definitive conclusions, with resulting studies being
ten. Although this is similar in number to other reviews in
related peer support topics, it is relatively low. We included
only US studies due to not having access to other non-English
search engines in addition to ruling out language barriers,
but this also limits the data. Finally, some investigators note
that self-selection into peer support groups and residential
recovery homes is important in the process in treatment,33,81
which then may confound outcomes and limit generalizabil-
ity in RCTs for those select participants who may be solely
interested in gains outside of participation such as partici-
pant payment. More rigorous research is needed, including
meta-analytic studies as more data surface in this area, to
substantiate the results of the studies included in this review
and further expand on this important line of research.
Acknowledgment
This work was supported by the National Institute on Drug
Abuse (R34DA034898) and the New York Harbor Healthcare
System.
Disclosure
The authors report no conflicts of interest in this work.
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