ArticlePDF AvailableLiterature Review

Lived Experience as Clinical Assets in New Models of Care for Substance Use Disorder: A Systematic Review of Recovery Coaching and Peer Recovery Support Services

  • Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital, Harvard Medical School

Abstract and Figures

Peer recovery support services (PRSS) are increasingly employed in a range of clinical settings to assist individuals with substance use disorder (SUD) and co-occurring psychological disorders. PRSS are peer-driven mentoring, education, and support ministrations delivered by individuals who, because of their own experience with active SUD and SUD recovery, are experientially qualified to support peers currently experiencing SUD and associated problems. This systematic review characterizes the existing experimental, quasi-experimental, single- and multi-group prospective and retrospective, and cross-sectional research on PRSS. Findings to date tentatively speak to the potential of peer supports across a number of SUD treatment settings, as evidenced by positive findings on measures including reduced substance use and SUD relapse rates, improved relationships with treatment providers and social supports, increased treatment retention, and greater treatment satisfaction. These findings, however, should be viewed in light of many null findings to date, as well as significant methodological limitations of the existing literature, including inability to distinguish the effects of peer recovery support from other recovery support activities, heterogeneous populations, inconsistency in the definitions of peer workers and recovery coaches, and lack of any, or appropriate comparison groups. Further, role definitions for PRSS and the complexity of clinical boundaries for peers working in the field represent important implementation challenges presented by this novel class of SUD interventions. There remains a need for further rigorous investigation to establish the efficacy, effectiveness, and cost-benefits of PRSS. Ultimately, such research may also help solidify PRSS role definitions, identify optimal training guidelines for peers, and establish for whom and under what conditions PRSS are most effective.
Content may be subject to copyright.
published: 13 June 2019
doi: 10.3389/fpsyg.2019.01052
Frontiers in Psychology | 1June 2019 | Volume 10 | Article 1052
Edited by:
Dana M. Litt,
University of North Texas Health
Science Center, United States
Reviewed by:
Kevin A. Hallgren,
University of Washington,
United States
Katie Witkiewitz,
University of New Mexico,
United States
David Eddie
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 14 March 2019
Accepted: 24 April 2019
Published: 13 June 2019
Eddie D, Hoffman L, Vilsaint C,
Abry A, Bergman B, Hoeppner B,
Weinstein C and Kelly JF (2019) Lived
Experience in New Models of Care for
Substance Use Disorder: A
Systematic Review of Peer Recovery
Support Services and Recovery
Coaching. Front. Psychol. 10:1052.
doi: 10.3389/fpsyg.2019.01052
Lived Experience in New Models of
Care for Substance Use Disorder: A
Systematic Review of Peer Recovery
Support Services and Recovery
David Eddie 1
*, Lauren Hoffman 1, Corrie Vilsaint 1, Alexandra Abry 1, Brandon Bergman 1,
Bettina Hoeppner 1, Charles Weinstein 2and John F. Kelly 1
1Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital, Harvard Medical School,
Boston, MA, United States, 2Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston,
MA, United States
Peer recovery support services (PRSS) are increasingly being employed in a range of
clinical settings to assist individuals with substance use disorder (SUD) and co-occurring
psychological disorders. PRSS are peer-driven mentoring, education, and support
ministrations delivered by individuals who, because of their own experience with SUD
and SUD recovery, are experientially qualified to support peers currently experiencing
SUD and associated problems. This systematic review characterizes the existing
experimental, quasi-experimental, single- and multi-group prospective and retrospective,
and cross-sectional research on PRSS. Findings to date tentatively speak to the potential
of peer supports across a number of SUD treatment settings, as evidenced by positive
findings on measures including reduced substance use and SUD relapse rates, improved
relationships with treatment providers and social supports, increased treatment retention,
and greater treatment satisfaction. These findings, however, should be viewed in light of
many null findings to date, as well as significant methodological limitations of the existing
literature, including inability to distinguish the effects of peer recovery support from other
recovery support activities, heterogeneous populations, inconsistency in the definitions
of peer workers and recovery coaches, and lack of any, or appropriate comparison
groups. Further, role definitions for PRSS and the complexity of clinical boundaries for
peers working in the field represent important implementation challenges presented by
this novel class of approaches for SUD management. There remains a need for further
rigorous investigation to establish the efficacy, effectiveness, and cost-benefits of PRSS.
Ultimately, such research may also help solidify PRSS role definitions, identify optimal
training guidelines for peers, and establish for whom and under what conditions PRSS
are most effective.
Keywords: peer recovery support services, recovery coaching, peers, substance use disorder, addiction
Eddie et al. Systematic Review of Peer Support
Substance use disorder (SUD) is one of the most pervasive
and intransigent clinical and public health challenges facing the
United States (Office of the Surgeon General, 2016). While many
who meet criteria for SUD are able to achieve remission without
formal treatment (Cunningham and McCambridge, 2012; Kelly
et al., 2017), many millions of affected individuals require
some combination of acute care, medical stabilization, long-term
recovery management, and recovery support services to sustain
remission, akin to the care of other chronic health conditions
such as diabetes and hypertension (McLellan et al., 2000). There is
evidence that such multifaceted, long-term care models for SUD
are helpful (Dennis et al., 2003; Scott and Dennis, 2009).
Existing health-care and treatment models, however, are often
not structured in ways that facilitate treatment engagement, and
linkages to services that can support long-term remission of
SUD (McLellan et al., 2000; White and Kelly, 2011). To begin to
address this care gap, many healthcare institutions have begun to
implement peer recovery support services (PRSS) to help initiate
and maintain patients’ engagement with SUD treatment and
other recovery support services, and mitigate relapse risk.
First arising in the 1990s, PRSS for individuals with SUD
emerged from a variety of predecessors inside and outside of the
addiction field. “Patient navigator” models have played important
roles for several decades in the professional coordination of care
for chronic medical conditions such as cancer (e.g., Robinson-
White et al., 2010; Freeman, 2012), and later included peers with
lived experience to aid engagement (e.g., Giese-Davis et al., 2006).
Such navigator models have also been developed in the care of
individuals with severe mental health conditions (e.g., Corrigan
et al., 2017). There is also a long tradition of community-based
12-Step mutual-support (e.g., “sponsors”), that can provide free
ongoing recovery monitoring and management using peers with
lived experience, though this class of peer support should not
be conflated with more structured PRSS that are increasingly
being incorporated into clinical settings and can support multiple
pathways to recovery.
In the SUD field, PRSS are most often peer-driven mentoring,
education, and support ministrations delivered by individuals
who, as a result of their own experience with SUD and SUD
recovery, are experientially qualified to support peers with SUD
and commonly co-occurring mental disorders. These services
represent a new category of specialized resources that are not
formal treatment and not mutual-help, which offer support as
well as linkage to traditional addiction treatment and mutual-
help recovery programs (White and Evans, 2014). These PRSS
roles emphasize respect for the diverse pathways and styles
of recovery, and stress the need for long-term continuity of
recovery support through mobilization of personal, familial,
and community help (Valentine, 2010; White, 2010). They can
be delivered through a variety of organizational venues and a
variety of service roles including paid and volunteer recovery
support specialists.
SAMHSA has previously defined PRSS as a peer-helping-
peer service alliance in which a peer leader in stable recovery
provides social support services to a peer who is seeking help
in establishing or maintaining their recovery (SAMHSA, 2009).
This broad definition provides a useful starting point that may
help guide PRSS practice and research, however, it doesn’t
describe the wide range of roles peers serve in or the highly
variable nature of their professional involvement with this work
(e.g., ad hoc, lay, peer volunteers vs. full-time, trained, paid peer
workers). In many clinical settings, unpaid lay peers are called
upon to provide support to patients with SUD across all stages
of recovery.
Common functions of PRSS include facilitating and
supporting patients’ engagement with SUD treatment and
transition between levels of care (e.g., between inpatient and
outpatient programs), in addition to connecting patients with
community based recovery support services and mutual-help
organizations in ways not possible for conventional treatment
providers who are bound by ethical considerations like not
forming dual relationships with patients (Valentine, 2010; White
and Evans, 2014). PRSS can also help individuals navigate
systems to build recovery capital, attain employment, attend
mutual-help groups, and address criminal justice issues.
Probably the largest area of SUD peer-service growth over
the past decade, however, has been in the uptake of peer
recovery coaches. Recovery coaches are peers trained to provide
informational, emotional, social, and practical support services
to people with alcohol or other drug problems through a
wide variety of organizational sponsors, including recovery
community centers, as well as hospital and outpatient clinical
settings (White, 2009). Typically they are paid employees
working part- or full-time with some degree (a high school
diploma or GED is usually required) of formal training and
certification. Due to lack of agreed standards in terminology, in
some clinical settings the term recovery coach may also refer
to “recovery allies” who support individuals with SUD, but do
not have lived experience with addiction. Such supports are not
covered in this review.
Regardless of the nature of their role, peers have the ability
to engage patients outside the confines of traditional clinical
practice. This ability to fill critical care gaps is the most probable
reason for their widespread uptake across a diverse range of SUD
treatment settings and the reason they have emerged as a critical
component of recovery management (White, 2009). SAMHSA
has made efforts to identify and describe core competencies for
peer support workers in working with individuals with SUD as
well as other psychological disorders (SAMHSA, 2015), and with
time, PRSS roles and qualifications will become better defined.
While a compelling case has been made for PRSS in a number
of theoretical articles and book chapters (e.g., White, 2009,
2010, 2011; Bora et al., 2010; Cicchetti, 2010; Valentine, 2010;
Powell, 2012; Laudet and Humphreys, 2013; White and Evans,
2014), to date empirical research on the topic is somewhat
limited. Previous reviews of the PRSS literature published in
Reif et al. (2014) and Bassuk et al. (2016) reported that overall,
existing research at the time showed PRSS were commonly
associated with reduced substance use and SUD relapse rates,
improved relationships with treatment providers and social
supports, increased treatment retention, and greater satisfaction
with treatment. Bassuk et al. ultimately concluded that there is
Frontiers in Psychology | 2June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
evidence for the effectiveness of PRSS. Overall, however, both
reviews highlighted concerns about the methodological rigor
of the then existing research, which included an inability to
distinguish the effects of peer recovery support from other
recovery support activities, small samples and heterogeneous
populations, inconsistency in the definitions of peer workers and
recovery coaches, lack of any, or appropriate comparison groups,
and inconsistencies in the quantity of peer-provider supervision.
Ultimately, Bassuk et al. noted that although evidence for
the effectiveness of PRSS exists, these limitations should offer
pause, and that additional research is necessary to determine
the effectiveness of different peer approaches and types of peer
support services, with regard to the amount, intensity, peer
skill level, service context, and effectiveness among different
populations served.
PRSS, and recovery coaching models are increasingly and
rapidly being rolled out in health care settings, despite little
empirical knowledge of best practices and sense of to what degree
services will help, and for whom. The aim of the present article
is, therefore, to report the most up to date research on PRSS
through systematic review. This review includes six new articles
published following Bassuk et al.’s review. It also extends previous
reviews by utilizing broader inclusion criteria (e.g., including
cross-sectional studies and clinical interventions linking patients
to 12-Step programs using 12-Step program volunteers) that
provides broader context for this fast-growing literature. The
review also identifies, wherever possible, for whom and under
what conditions PRSS may have utility to inform health care and
community-based PRSS delivery. We also highlight important
gaps in the knowledge base that will inform the direction
and scope of treatment and future research in this important,
emerging area.
A systematic search of the literature (as of 10/13/2018), using
the search terms “recovery coaching,” “peer recovery support,
“peer-based recovery support services,” and “individual peer
support” in combination with substance use terms, identified
158 records across four publicly available databases (i.e.,
PubMed, EMBASE, CINAHL, and PsycInfo; see Appendix A
in Supplementary Material for search term syntax). Given the
relative novelty of this line of investigation we cast a wide net
in terms of article inclusion criteria. We included randomized
controlled trials (RCTs), quasi-experimental studies, single- and
multi-group prospective and retrospective studies, and cross-
sectional/descriptive studies related to SUD. All age ranges,
substances used, and available outcomes were included. Non-
peer reviewed items, however, were not included (e.g., book
chapters, dissertations, institutional reports). Reports had to
include at least one substance use or related outcome.
A title screen removed 101 duplicate records, and 11 records
on non-relevant topics (e.g., peer support for recovery for
problem unrelated to addiction). An abstract review removed
an additional 17 records: seven book chapters (removed because
they were not peer reviewed and did not report original data),
seven records on non-relevant topics, two review articles, and
one article because it reported on a mandated to treatment
sample. A full text review removed another 17 records: seven
review and ten theoretical articles. The remaining 12 studies
were included in the analysis and are summarized in Table S1
(Supplementary Material) in addition to 12 relevant articles
identified subsequently (see Figure 1, literature review diagram)
resulting in 24 included reports.
Results Overview
We found seven RCTs, four quasi-experiments, as well as eight
single- or multi-group prospective or retrospective studies, and
two cross-sectional investigations conducted on this topic. The
review included 24 reports from 23 original studies containing
a total of 6,544 participants. On average, the reviewed studies
included more men than women (females, 37.3%; males, 62.7%),
although in the majority of studies the racial makeup of samples
was diverse, and representative of the populations being studied.
Outcomes reported were varied and included self-reported and
bioassayed substance abstinence vs. non-abstinence, Addiction
Severity Index scores (Mclellan et al., 1992), outpatient
substance use treatment attendance, 12-Step meeting attendance,
general medical, and mental health appointment adherence,
utilization of inpatient substance use treatment services,
inpatient readmissions, social functioning, number of psychiatric
hospitalization nights, length of living in the community without
rehospitalization, number of rehospitalizations, criminal charges,
and deaths. The range of follow-up length varied from 1 week
to 3 years following the intervention. Below we summarize the
review findings by study design type from the most to the least,
scientifically rigorous design types.
Randomized Controlled Trials
Bernstein et al. (2005) conducted the first RCT of a peer recovery
support intervention in a sample of 1,175 individuals with SUD
reporting past 90-day cocaine and/or heroin use who were
receiving general medical care from an urban hospital walk-in
clinic, but not SUD treatment. Participants engaged in one of
two interventions: either a brief, single session, structured peer
education session targeting drug use cessation, which included
written advice and a referral list as well as a “booster” telephone
call (experimental group), or written advice and referral list
for treatment only (control group). Compared to controls, at
6-month follow-up participants receiving a brief peer-support
intervention were more likely to be abstinent from cocaine,
and trended toward greater heroin, and combined cocaine and
heroin abstinence (p=0.05), with OR’s 1.51–1.57. This favorable
abstinence outcome, however, was not supported by bioassay
results; no significant between group differences were observed
for bioassayed drug use. Similarly, Addiction Severity Index
drug subscale and medical severity scores were not significantly
different, and no group differences were noted in detoxification
or treatment admissions among those who were abstinent. It
is possible that a brief, single-session peer interaction is not
sufficient to elicit statistically significant levels of behavior change
Frontiers in Psychology | 3June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
FIGURE 1 | Literature review diagram showing article review and selection.
in individuals with SUD. This does not necessarily preclude the
possibility that more intensive or sustained peer contact would
achieve this end.
In a demographically similar sample, and using a more
protracted treatment protocol, Rowe et al. (2007) compared the
effectiveness of clinician-delivered “Citizenship Training” (which
included twice-weekly 2-h classes over 8 weeks supporting
social participation and community integration) +peer support
combined with standard clinical treatment (experimental group),
with standard clinical treatment alone (control group), for
reducing alcohol and other drug use, and number of criminal
justice charges (N=228). Participants were adult outpatients
with severe mental illness who had criminal charges within the
2 years prior to study enrolment. Though having an SUD was not
required for study participation, the majority of study volunteers
had either a primary or secondary SUD diagnosis. Over the 4-
month study period participants attended an average of 66% of
Citizenship Training classes, and met once weekly with their
peer-mentor. A significant group ×time interaction showed
participants randomized to the peer support group showed
reduced alcohol use over 6- and 12-month follow-up as measured
by the Addiction Severity Index alcohol use subscale (d’s =
0.22 and 0.43, respectively), while controls demonstrated
increased drinking over the same periods. A similar group ×
time interaction was not reported for drug use measured by
the Addiction Severity Index drug use subscale, although from
baseline to 6-month follow-up the peer support group showed
reduction in drug use (d= −0.62), while the Citizenship Training
group showed an increase (d=0.27). From baseline to 12-month
follow-up, however, both groups showed reductions in drug use,
though the effect size of this reduction was notably larger for the
group receiving peer support (peer support group d= −0.64;
Citizenship Training d= −0.16). It is not clear, however, whether
these effects were driven by the Citizenship training itself, peer
support, or a combination of the two. Also, given only 31% of
the sample had alcohol use disorder, it is not clear how clinically
meaningful this reduction is. Both control and experimental
groups demonstrated significantly less non-alcohol drug use and
had fewer criminal justice charges over the 12-month study
period signaling that on these measures, Citizenship Training
+peer support did not perform better than standard clinical
treatment alone.
Three RCTs have also been conducted in which peer
volunteers from 12-Step groups were brought into the clinical
milieu to help connect patients receiving outpatient treatment for
SUD to 12-Step programs in the community. Timko et al. (2006)
Frontiers in Psychology | 4June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
developed and tested a brief, three-session, intensive referral
to 12-Step intervention for Department of Veterans Affairs
outpatients (N=345). Participants were randomly assigned
to a standard referral in which they were given a schedule
for local 12-step meetings and were encouraged to attend, or
intensive referral to 12-Step that included linking patients to 12-
Step volunteers and using journals to check meeting attendance.
For those receiving intensive referral, counselors arranged a
meeting between the patient and a participating member of a
local Alcoholics Anonymous or Narcotics Anonymous group by
calling the peer volunteer in-session to arrange for them to meet
patients before a 12-Step meeting so that they might attend the
meeting together. Intensive referral was associated with greater
likelihood of being involved with 12-Step groups and better
alcohol and other drug use outcomes over a six-month follow-
up period. Subsequently, Timko and Debenedetti (2007) followed
up with these participants at 1 year and found the benefits of
intensive referral were sustained. The intensive referral group
were more likely to attend at least one meeting per week (OR =
1.38), and had greater 12-Step group involvement (d=0.23), as
well as high rates of abstinence (OR =1.61).
Later, Timko et al. (2011) employed a very similar intervention
structure, but with a sample of dually-diagnosed individuals
seeking outpatient treatment at the Veteran’s Administration.
Participants were randomized either standard referral, or
four sessions of intensive referral to Double Trouble in
Recovery—a 12-Step program for individuals with SUD and
co-occurring psychiatric conditions. Intensive referral included
a peer volunteer from Double Trouble in Recovery joining
participants and their counselor in session. Peers gave a
brief personal history and arranged to meet participants
and attend a meeting together. At 6-month follow-up those
receiving intensive referral were more likely to have attended
a Double Trouble in Recovery meeting, and had attended
more meetings (d=0.89). Similarly, these participants were
also more likely to have attended other 12-Step program
meetings, and had greater frequency of attendance at these
meetings (d=0.25). They also had less past 30-day drug
use (d=0.30) and fewer psychiatric symptoms (d=0.28).
No differences were observed for alcohol use and notably
only 23% of patients in the intensive-referral group actually
attended a Double Trouble in Recovery meeting during the
6-month follow-up period compared to 13% in the standard
referral group, suggesting about one-fifth of participants
receiving intensive referral were driving the observed between
group differences.
Manning et al. (2012) sought to determine whether peer
referral to 12-Step meetings would increase 12-Step meeting
attendance among individuals with SUD undergoing inpatient
detoxification (N=151). Patients were randomized to either,
(1) introduction and referral to 12-Step by a peer who
shared their own recovery experience with the participant,
(2) introduction and referral to 12-Step by a doctor, or
(3) no introduction or referral (control group). Peers and
doctors were instructed to initiate and maintain an open
dialogue with participants about their beliefs, concerns, and
experiences with 12-Step meetings, and to address any concerns
or misconceptions that clients may have held about 12-
Step meetings. Together, peer and doctor referral to 12-
Step led to increased attendance at 12-Step meetings during
inpatient treatment (88 vs. 73%), though peer and doctor
groups had similar rates of 12-Step meeting attendance on
the inpatient unit (89 and 87%, respectively). Rates of post-
discharge meeting attendance, however, were significantly higher
in the peer referral group (64%; OR =3.6) compared to the
doctor referral (48%) or no referral groups (33%). Further,
participants who attended 12-Step meetings while inpatient
were three times as likely to have attended meetings post-
discharge than those who did not attend 12-Step meetings while
inpatient (59 vs. 20%), and post-discharge meeting attenders
reported significantly higher abstinence rates at 3-month follow-
up (60.8 vs. 39.2%). Abstinence rates at 3-month follow-
up, however, did not differ significantly across intervention
groups. Taken together, findings suggest introduction and
referral to 12-Step programs for individuals in inpatient
detoxification increases 12-Step meeting attendance both during
inpatient treatment and after discharge, and that meeting
attendance is associated with higher abstinence rates; it is not
necessarily important, however, that these referrals/introductions
be peer-delivered.
In contrast to the aforementioned studies, which utilized
either single session, peer-delivered intervention (Bernstein et al.,
2005) or peer support as an addendum to a professional-
delivered treatment (Rowe et al., 2007). Tracy et al. (2011)
compared a peer-driven treatment that included peer-led groups
as well as peer support, to a professional-delivered treatment
with peer support in a sample of 96 Veterans Administration
inpatients. Study groups included, (1) treatment as usual (TAU)
combined with peer-led groups and weekly peer mentorship,
(2) TAU combined with a dual recovery intervention involving
8 weeks of clinician-delivered individual and group relapse
prevention therapy in addition to peer-led groups and weekly
peer mentorship, and (3) TAU only. TAU consisted of standard
coping/skills training groups, medication management, and
social work support to handle basic needs during inpatient
stay. Substance misuse, psychiatric, and medication management
support services were also available. Peer mentors were referred
by their treating physician/clinician to a compensated work
therapy program, and screened by the program coordinator and
mentor supervisor from clinical record and interview. 88% of
study participants had an alcohol use disorder or other SUD,
in addition to psychiatric comorbidity. TAU combined with
peer-delivered treatment, and TAU combined with professional-
delivered treatment and peer support were both associated
with greater post-discharge, outpatient substance use treatment
attendance compared to TAU alone (51 and 52% SUD treatment
appointment adherence respectively among those receiving peer
ministrations vs. 38% for TAU). These two interventions were
also associated with greater general medical, and mental health
appointment adherence (43 and 48% appointment adherence
respectively among those receiving peer ministrations vs. 33%
for TAU), as well as greater inpatient substance use treatment
accessed (d’s =0.33 and 0.63 respectively vs. TAU only). Taken
together, findings suggest that at least in terms of treatment
Frontiers in Psychology | 5June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
adherence, compared with TAU alone, interventions including
peer support or peer delivered ministrations are superior.
Substance use outcomes were not reported.
Most recently, O’Connell et al. (2017) recruited 137 inpatients
with psychotic disorders and co-occurring problematic substance
use through substance dependence to receive either, (1) TAU
with skills training, (2) TAU with skills training +the “Engage
Program,” which included contact with a peer support while
inpatient, peer home visits after discharge, twice-weekly mutual
support groups accompanied by the peer, and social and
recreational outings, or (3) TAU only (not defined by the study’s
authors). Interventions were begun while participants were on
an inpatient unit, and continued for 3 months post-discharge.
At 3-month follow-up, participants receiving TAU with skills
training, and TAU with skills training +the “Engage Program”
fared better than those receiving TAU only in terms of reduced
alcohol use (d’s = −0.54 and 0.81 respectively vs. TAU only),
and alcohol use disorder symptom endorsement (d’s = −1.23
and 1.47 respectively vs. TAU only). Those in the Engage
Program also viewed getting help for their alcohol use problems
as being more important compared to those receiving TAU
only (d=0.69), though differences between those receiving
peer support and those receiving TAU with skills training were
not significantly different. Notably, Participants in the Engage
group had significantly greater increases in self-criticism from
baseline to 3 months compared to those receiving TAU (d=
0.43), which the authors posit may be a function of peer staff
holding up higher expectations for their clients than clinical
staff. Additionally, 6 months into the study, participants in the
Engage Program had greater duration of outpatient service use
compared to those in the TAU group (d=0.31). At 9-month
follow-up, skills training, and skills training with peer support
was associated with fewer positive psychotic symptoms and
greater functioning in comparison to TAU only, suggesting no
specific effect of peers on these measures at this measurement
time point. Participants in the peer support and skills training
only groups also had significantly fewer psychiatric hospital
readmissions from baseline at 6 and 12 months compared to
the TAU group, though the peer support and skills training
only groups were not significantly different from one another on
this measure.
Summary of Randomized Controlled Trial Evidence
Taken together, the RCTs reviewed here had a number of
strengths, including strong research designs, provision of
manualized treatment for the clinical components of studies
(Bernstein et al., 2005; Timko et al., 2006, 2011; Tracy et al., 2011;
O’Connell et al., 2017), and samples with diversity in terms of sex
and race. Notable limitations, however, include generally poorly
defined and non-manualized peer roles and procedures, although
some studies incorporated semi-structured scripts (Bernstein
et al., 2005) or manualized training protocols (Tracy et al., 2011)
for their peer workers, and combining of peer services with
clinician-delivered interventions without the necessary control
groups to allow discernment of the independent effects of peers
(Rowe et al., 2007; Tracy et al., 2011). Overall, positive effects
appeared small to moderate in magnitude, and null findings were
observed for many hypothesized treatment effects. It’s possible
too that the large numbers of measures assessed across these
studies could be leading to type I error. These findings, however,
should be taken in context; these studies typically reported
on novel interventions still under development, providing
treatment for individuals with complex clinical presentations
(i.e., co-occurring mental disorders in addition to SUD), high
addiction severity, and significant SUD related challenges such
as homelessness.
Quasi-Experimental Studies
Quasi-experimental studies addressing PRSS generally align with
findings from the aforementioned RCTs. In an early study
investigating the potential of PRSS, Sisson and Mallams (1981)
sought to increase the likelihood of participation in Alcoholics
Anonymous and Al-Anon meetings among a sample of adults
receiving outpatient treatment for alcohol use disorder (n=
16) and their spouses (n=4) in a sparsely populated, rural
area. Participants were randomly assigned to either a standard
referral procedure which involved receiving information about
Alcoholics Anonymous or Al-Anon, and providing information
concerning time, date, and location of weekly meetings with
encouragement to attend (control group), or to systematic
encouragement and connection to 12-Step groups that involved
a phone call being made in a counseling session to an Alcoholics
Anonymous or Al-Anon member, who had volunteered to
provide peer support. The 12-Step group member briefly talked
to participants about 12-Step meetings, offered to give a ride
to a meeting or meet them before a meeting, and followed up
with a call the night of the meeting to remind them about
it and to encourage them to attend (experimental group).
One hundred percent of the experimental group attended an
Alcoholics Anonymous or Al-Anon meeting within 1 week of
referral and continued to attend, whereas none of the control
group attended a meeting. The mean attendance rate over four-
week follow-up was 2.3 meetings for the experimental group and
zero for controls, and (d=2.74). It is possible that peer linkage
helped individuals surmount barriers to attending initial 12-Step
meetings due to factors like distance needed to travel to meetings
such rural areas.
In a similar study with a sample of patients hospitalized
for alcohol and other drug detoxification, Blondell et al. (2008)
utilized 12-Step group volunteers to visit patients undergoing
medical detoxification (n=19). During visits, which would
typically last between 30 and 60 min, peers would explain how
involvement in mutual-help programs was an essential part of
their recovery from SUD. The control group (n=80) consisted
of usual care in which mutual-help meetings were available
every evening, but attendance was not required. The authors
found that the brief, single-session peer-delivered counseling
intervention resulted in greater likelihood of completion of
medical detoxification and not leaving “against medical advice”
(88% completion vs. 74%). Although peer visits did not
result in statistically significant differences in mutual-help
meeting attendance following detoxification (p=0.05), observed
differences were clinically meaningful (90% attendance for those
receiving peer visits vs. 64% for those not). Similarly, likelihood
Frontiers in Psychology | 6June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
of abstinence from all substances seven days after discharge was
84% for those receiving peer visits vs. 59% for those not (p
=0.06), and initiation of professional aftercare treatment at 1-
week follow-up post detoxification discharge was 100% for those
receiving peer visits vs. 82% for those not (p=0.06). While
many detoxification sites invite 12-Step groups to bring meetings
into units, this work suggests the possibility of added benefit
to allowing 12-Step group members to meet individually with
patients to share their experience of recovery, and encourage and
support meeting attendance.
Work by Boisvert et al. (2008) indicates that PRSS may also
bolster patients’ perceived support. Using a sequential cohort
comparative design and a sample of adults with SUD and severe
mental illness living in permanent supportive housing (N=
19), the authors found that 10 individuals who participated in
a peer-driven program based on recovery community model
published by SAMHSA and did not relapse, reported increased
perceived emotional/informational (R2=0.39), tangible (R2
=0.24) and affectionate support (R2=0.24) from pre-
to post-intervention. Additionally, participants receiving the
peer-support recovery program had lower rates of return to
homelessness (85 vs. 33%) over a 6-month period, compared
to a sample of residents living in the permanent supportive
housing setting 6-months prior to instigation of the peer-support
program. Further, prior to institution of the peer program,
residents had a 24% chance of relapse to substance use, while
the risk for those residents participating in the program was 7%,
though it is not clear if this difference was statistically significant
and no demographic or clinical data were provided for this
comparison group.
Working in the Veteran’s Administration system, Smelson
et al. (2013) assessed a novel program referred to as Maintaining
Independence and Sobriety Through Systems Integration,
Outreach, and Networking (MISSION) for military veterans
with SUD and co-occurring mental disorders, as well as
experienced homelessness and current unemployment using a
quasi-experimental, intact group design (N=333). Over 12
months, MISSION provides temporary housing, and delivers
integrated mental health and SUD treatment delivered via Dual
Recovery Therapy (Ziedonis and Stern, 2001), case management,
and vocational and peer support. The manualized program is
delivered by a case manager and peer specialist team. Those
receiving MISSION had greater outpatient session attendance
within the 30 days before the 12-month follow up (d=1.25),
and a greater decline in the number of psychiatric hospitalization
nights compared to those receiving TAU only (d= −0.26).
Both groups, however, showed improvement on measures of
substance use and associated problems at 12 months, though
those receiving MISSION were less likely to drink to intoxication
(OR =0.29) and experience serious tension or anxiety (OR =
0.53). Given the broad treatment platform in this study, it is
impossible to separate out peer effects. The findings nevertheless
speak to the promise of integrating peer supports with clinician-
delivered treatments.
Most recently, in a large sample of parents or caregivers
referred by child protective services to a specialized SUD
outpatient treatment program (N=1,362), James et al. (2014)
found that peer contact was associated with faster outreach,
and shorter latency to initial clinical assessment (d=0.16),
as well as higher rates of any treatment service initiation
compared to no peer contact (96.9 vs. 89.9%). However, when the
authors used a more restrictive definition of service initiation—
limited to initiation of individual, group, or family counseling,
84.88 and 82.53% of individuals referred to the enhanced and
standard programs, respectively, initiated these services. Those
receiving PRSS were less likely to complete treatment (26.64
vs. 38.12%), however, among those completing treatment, the
average length of treatment was significantly greater for the
PRSS +TAU group than controls (d=0.35). Additionally,
participants who had received PRSS who discontinued treatment
remained in treatment longer than controls who discontinued
treatment (d=0.36). Groups, however, were not significantly
different in terms of total numbers making it to initial
assessment appointments, initiating counseling, or discontinuing
participation in treatment. Notably, relative treatment dropout
rates were very high for both the PRSS (56.9%) and control
groups (52.9%), though the difference was not statistically
significant (p>0.05). Also, effect sizes were generally small
suggesting the large sample size may have been driving observed
statistically significant effects.
Summary of Quasi-Experimental Evidence
Quasi-experimental studies to date provide further support
for the potential of PRSS for SUD. The quasi-experimental
literature, however, includes many of the limitations observed
for the RCT literature. For instance, peer roles were typically not
well defined, nor were peer training protocols well-articulated.
Further, positive findings were often small to moderate in size and
no studies included intent-to-treat design meaning participants
who dropped out of interventions or relapsed were not included
in many of the analyses. Although it is difficult to parse out the
independent effect of peers—because with the exception of Sisson
and Mallams (1981) and James et al. (2014) these studies lacked
the necessary control groups—overall these findings suggest
PRSS may have the ability to sure up treatment attendance
and help individuals engage with treatment. These findings also
speak to the versatility of PRSS by showing a diverse range
of residential treatment settings in which peer services might
be utilized.
Single- or Multi-Group Prospective or
Retrospective Studies
Single- or multi-group prospective or retrospective studies
addressing PRSS extend the case for more research on
PRSS. Boyd et al. (2005) piloted a 12-week peer-delivered
psychoeducation program for women with HIV living in
rural areas. Though no inferential analyses were conducted
due to the small sample size (N=13), results intimate
the authors’ brief peer-counseling intervention may increase
participants’ recognition that their alcohol and other drug
use is problematic, and increase the likelihood of steps being
taken to address their alcohol and other drug use. The
authors highlight the difficulty in identifying and retaining peer
counselors for a majority of the rural U.S. areas where this pilot
Frontiers in Psychology | 7June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
study was implemented, speaking to some of the real-world
challenges associated with implementation of PRSS, especially
in already underserved geographic areas. This observation
speaks to the potential utility of peer coaching via telemedicine
(Huskamp et al., 2018).
Using government public health, and Medicaid records,
Min et al. (2007) retrospectively assessed whether a long-
term, peer-mentorship intervention for individuals with SUD
and severe co-occurring mental illness has the capacity to
reduce rehospitalization rates (N=484). Survival analysis
results over a 3-year period indicate that peer-support program
participants had longer periods living in the community
without rehospitalization, and a lower overall number of
rehospitalizations, compared to a sample of comparable controls
not engaged in peer-mentorship.
Similarly, Andreas et al. (2010) shared preliminary findings
for the Peers Reach Out Supporting Peers to Embrace Recovery
(PROSPER) program, which includes peer-run groups, coaching,
workshops and seminars, social and recreational activities, and
community events (N=509). Peers work closely with program
staff and receive extensive training and supervision. Study
participants included women and men over the age of 18 who
had SUD and histories of incarceration. From baseline to 12-
month assessment the authors observed increases in self-efficacy,
perceived social support, and quality of life, as well as decreases
in perceived stress, though guilt- and shame-based emotions
increased over the same period of time.
Work by Armitage et al. (2010) suggests PRSS may also
be beneficial to individuals in sustained SUD remission. The
Recovery Association Project (RAP), which emphasizes active
citizenship and social engagement, is facilitated by individuals
in recovery from SUD who had completed at least 15 h each
of RAP leadership training (N=152). The authors found
retrospectively that 6 months following RAP participation,
86% of their clients reported no past 30-day alcohol or other
drugs use, and another 4% indicated reduced use. Further,
95% reported strong willingness to recommend the program to
others, 89% found services helpful, and 92% found provided
materials helpful.
Using a multi-group prospective design, Deering et al. (2011)
sought to better understand the effects of a peer-led, mobile
outreach program for female sex workers. Women were surveyed
every 6 months over 18 months (N=242). Women were
more likely to utilize the peer-led outreach service if they
were at higher risk due to factors such as seeing >10 clients
per week, working in isolated settings, injecting cocaine, or
injecting/smoking methamphetamine in past 6 months. Utilizers
of the peer-led service, however, were also more likely to access
the intervention’s drop-in center, and notably, after statistically
controlling for inter-individual differences, past 6-month use
of the peer-led outreach program was associated with a 4-fold
increase in the likelihood of participants utilizing detoxification
and/or inpatient SUD treatment.
In a retrospective single group study, Kelley et al. (2017)
explored the effects of the Transitional Recovery and
Culture Program, a Montana-based, community-driven,
PRSS intervention aimed at improving sobriety rates in a
collection of Native American communities in the region, and
increasing community awareness of substance use problems
and the need to support SUD recovery (N=224). The authors
found that participants completing 6-month follow-up (29%)
had significant reductions in past 30-day alcohol (d= −0.78)
and other drug use (d= −0.64). Participants were also more
likely to have attained housing and employment. Symptoms of
anxiety and depression, however, were not significantly changed.
The low follow-up rate (29%) for this study, however, suggests
the possibly of selection bias; i.e., individuals lost to follow-up
were doing worse and are not represented in the results, making
intervention look better than it actually was. As such, these
results should be interpreted with caution.
Most recently, Scott et al. (2018) piloted an intervention
designed to help link individuals actively using opioids to
detoxification and/or agonist medication treatment. Peers
approached individuals in urban areas identified as high-risk
for continued opioid use and overdose, engaged them in a
conversation about heroin, and explained they were recruiting
for a study that aimed to help people get into treatment. If
the individual expressed interest in the study, the peer outreach
worker then called study staff to phone-screened the prospective
participant for study eligibility. At the study office, participants
met with a treatment linkage manager who used an adapted
version of the Recovery Management Checkup protocol (Scott
and Dennis, 2010) to link individuals to detoxification and/or
methadone agonist medication therapy. Over the course of 8
weeks, peer outreach workers identified 88 individuals actively
engaged in opioid use. Seventy-two were screened as eligible, and
70 showed to the treatment linkage meeting. Of those showing
up to the treatment linkage meeting, eight went to detox, and
nearly all (96%) were admitted to methadone treatment, with a
median time from initial linkage meeting to treatment admission
of 2.6 days. The majority of participants were still in treatment
at 30 and 60 days post-intake (69 and 70%, respectively). This
study demonstrates the synergistic potential of integrating peer-
based approaches and evidence-based SUD interventions. While
peers were not necessarily providing treatment per se, they served
in this instance, as a critical link to treatment and were able
to accomplish in the field what may be difficult for a non-
peer provider.
Also interested in the benefits peers can confer for individuals
with opioid use disorder, Samuels et al. (2018) explored if
connecting individuals presenting to emergency department
(ED) for opioid overdose would benefit from PRSS provided
in the ED, in addition to provision of naloxone, and usual
care consisting of medical stabilization and provision of a list
of SUD treatment programs in printed discharge instructions
(N=151). Using ED electronic medical record review,
they contrasted this intervention to provision of naloxone
with written and video instructions on use +usual care,
and usual care only. Peers were employed by the partner
community-based peer recovery organization. Participants were
assigned to one of the three treatment groups based on
provider and patient discretion. Peers met with participants
in the ED and assessed their readiness to seek treatment,
identified overdose risk factors, and provided individualized
Frontiers in Psychology | 8June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
support and addiction treatment navigation, including linkage
to medication for opioid use disorder at the time of, and at
least 90 days after the ED visit. The authors did not find
significant differences between groups at 12-month follow-up via
electronic medical record review; groups were similar in terms
of proportion of participants initiating medication for opioid
use disorder, number of times returning to the same emergency
department for overdose, number of deaths, and median
time to death.
Summary of Single- or Multi-Group Prospective or
Retrospective Study Evidence
While the majority of these single- or multi-group prospective or
retrospective studies speak to the promise of PRSS, they should be
considered in the light of significant methodological limitations
associated with these research designs. Single-group prospective
and retrospective designs lack control groups; it is therefore
not possible to know if some of the positive findings presented
here reflected natural improvements in psychosocial functioning
commonly observed in SUD interventions. Relatedly, in multi-
group prospective and retrospective studies where comparison
groups are used, groups are not selected by random assignment.
As such there is risk for selection bias, although the majority
of studies reported here checked for demographic between-
group differences in order to mitigate this risk. Risk for
selection bias is further increased because these studies did
not use intent-to-treat analysis; it is thus possible that the
benefits conferred by these programs are inflated. Further, all
peer-based programs reported here included a wide range of
activities and types of support. It is therefore not possible
to parse out the unique effects of peers in the context of
these interventions.
Cross-Sectional Investigations
The cross-sectional literature tentatively speaks to the potential
of PRSS-based interventions in a range of treatment settings.
Sanders et al. (1998) sought to contrast client satisfaction
with peer-delivered SUD counseling, and counseling from
traditionally-trained addiction counselors (N=56). They found
that although there were no between-group differences in
overall treatment satisfaction, women receiving ongoing SUD
counseling from a peer-counselor were more likely to describe
their counselors as empathic, to identify them as the most helpful
aspect of the program, to utilize other clinic resources, and to
more strongly recommend the treatment program, compared
to clients receiving counseling from traditional providers. This
work speaks to the ability of peers to establish rapport in patients.
It does not however speak to quality of care or treatment
outcomes. It is unclear whether professional-delivered treatment
may benefit them more in terms of treatment outcomes, even
though patients may feel greater affinity for peer counselors.
One study has also assessed the motivation of individuals in
recovery from SUD to seek PRSS. Wanting to know more about
university students participating in peer-based college recovery
support services, Laudet et al. (2016) surveyed 486 students
engaged in 29 college recovery programs across the United States.
At the time of survey, students had been abstinent from alcohol
and other drugs a mean of 3 years. One third of the sample
reported they would not be in college were it not for a peer-based,
collegiate recovery program, and 20% would not be attending
their current university. Top reasons cited for joining collegiate
recovery programs were the need for same age peer recovery
support, and wanting to maintain their sobriety in the high-risk
college environment.
Although a strong theoretical case has been made for the
potential utility of PRSS in a range of SUD clinical and care
settings (e.g., White and Evans, 2014; Laudet et al., 2016), to date
PRSS research is limited for specific clinical SUD populations
for whom these services are most commonly provided (i.e.,
those in outpatient, residential and transitional care settings, and
recovery community centers). In their 2016 review of the PRSS
literature, Bassuk et al. noted open questions about the necessary
amount and intensity of PRSS interventions, and the optimal
contexts for provision of these services and the appropriate
skill levels for peers. Several years later, though a number of
recent studies have begun to inform these considerations, these
remain open questions. Moreover, additional work is needed
to parse out for whom and under what conditions these PRSS
interventions have most utility, and to determine how peers
should be trained, and what, if any certifications should be
required for peer work in order to inform the development
of “best practice” models. Further, research into potential cost-
benefits to healthcare systems is necessary. Although the existing
literature reviewed here reports mixed findings, positive findings
to date speak to the possibility of benefits associated with
adoption and implementation of PRSS. When placed in the
context of other research in the recovery supports arena (e.g.,
Humphreys and Moos, 2001, 2007), such entities hold promise
as cost-effective care models that can bridge gaps not covered by
traditional care.
In theory, peer supports such as recovery coaches may have
particular utility in hospital and clinical outpatient settings since
many individuals with SUD who are not yet engaged in treatment
present to these sites with SUD-related medical problems. Peers
are uniquely positioned to engage such individuals and help
connect them with SUD treatment, either in hospital systems,
or the community. Bernstein et al. (2005) showed that even a
single-session peer-led intervention for individuals presenting
to a hospital-based, walk-in clinic could result in significant
reductions in substance use at a 6-month follow-up. Though this
work is promising, more research is needed to determine how
effective peer-driven interventions may be. Hospital and medical
settings that have begun to utilize SUD peer supports should be
encouraged to monitor their programs and where possible report
their outcomes.
PRSS may be especially beneficial in substance detoxification
units, since successfully connecting individuals to care following
detoxification is a persistent and vexing problem for providers.
PRSS might also impact the culture of detoxification units by
offering a multiple pathways to recovery approach. Blondell
Frontiers in Psychology | 9June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
et al. (2008) found that detoxification patients receiving a
single peer counseling session were more likely to complete
medical detoxification and not leave detoxification “against
medical advice.” Though differences between participants
receiving a peer counseling session and controls were not
statistically significant on measures of attendance of mutual-help
group meetings during the first week following detoxification
discharge, remaining abstinent following discharge, and
initiating professional aftercare treatment, statistical trends
with clinically meaningful differences were observed suggesting
those receiving peer counseling fared better in a detoxification
setting already strongly encouraging 12-Step participation. These
observed trends may have been statistically significant were the
study better powered. Based on these findings, more work in this
area is justified. Peer supports could ultimately be a cost-effective
way to bridge the gap between detoxification and longer-term
SUD treatment by helping patients enter residential programs,
and/or engage with recovery programs in the community such
as mutual-help groups like Alcoholics Anonymous, Narcotics
Anonymous, Refuge Recovery, Rational Recovery, and/or
SMART Recovery.
The evidence reviewed here also suggests peer supports may
have the ability to improve outcomes for individuals engaged
in inpatient or outpatient psychiatric treatment for SUD and
co-occurring mental disorders. In such contexts peer supports
have been shown to reduce substance use (Rowe et al., 2007;
O’Connell et al., 2017), lead to better SUD and medical treatment
adherence (Tracy et al., 2011), get individuals to SUD treatment
faster following SUD treatment referral (James et al., 2014),
reduce the frequency of inpatient readmission (O’Connell et al.,
2017), and reduce criminal behavior recidivism (Rowe et al.,
2007). This body of work, however, reports a wide range
of PRSS outcomes, for which there are also many negative
findings showing treatment as usual performed equally well
as PRSS interventions. More work is needed to determine the
ways peer supports can be most effective in these treatment
contexts, and how, in the future, PRSS’ efforts might be
best focused.
Presently in the Unites States, state-to-state regulations vary
greatly in terms of training and credentialing requirements
for peer workers (London et al., 2018). More work is needed
to determine how peers should be trained, and what, if
any certifications should be required for peer work. Studies
reporting training procedures utilized a highly variable range
of training protocols for peers. Most of these studies report
providing some sort of supervision provided by licensed
clinicians, though the quantity and frequency of supervision
was typically not described. Future research will benefit from
more clearly articulating peer roles in published manuscripts
(Jack et al., 2018), and where possible, manualizing aspects
of peer interventions. This will help future studies replicate
findings, and also help educators and treatment providers
develop better training protocols for peer workers. Work is also
needed that identifies which peer roles are most helpful/effective
in different clinical, treatment, and recovery support contexts.
Further, it is important that future research distinguishes
between paid peer workers such as recovery coaches who are
generally expected to have formal training and certification
(e.g., Tracy et al., 2011; O’Connell et al., 2017), and untrained,
volunteer peer supports who may facilitate brief interventions
akin to 12-step calls made by members of mutual-help groups
(e.g., Sisson and Mallams, 1981; Blondell et al., 2008).
Community-based SUD programs also utilize PRSS.
Research summarized in this review suggests peer recovery
supports integrated into community outreach programs
may increase individuals’ self-awareness of problematic
substance use (Boyd et al., 2005), and lead to reductions
in alcohol and other drug use (Kelley et al., 2017). Such
programs may also lead to greater utilization of detoxification
programs and residential SUD treatment among those needing
treatment (Deering et al., 2011), and reduce rehospitalization
rates following treatment (Min et al., 2007). Findings from
these preliminary cross-sectional, and prospective and
retrospective studies indicate more comprehensive RCTs
are warranted on this topic, and suggest that marginalized
and/or stigmatized populations may particularly benefit from
peer-driven initiatives.
Relatedly, peers may also have potential to bolster harm
reduction programs. Ashford et al. (2018), for instance, found
peers could be successfully utilized to engage individuals who are
at risk of diseases such as hepatitis-C and HIV, and overdose in
the context of an urban needle exchange program. In light of
the current opioid crisis, such ministrations are much needed
and could enhance existing efforts to curb the prodigious disease
burden of opioid misuse.
Assessment of Potential Bias
The findings reviewed in the present paper should be tempered
by the fact the discussed RCTs did not use an intent-to-treat
design, potentially introducing sample bias into the results.
Additionally, to date, all RCTs studying PRSS have recruited
participants with fairly severe SUD and co-occurring mental
illness, and major impairment in psychosocial functioning. It
is therefore not clear how these results might generalize to
samples of individuals with less severe SUD presentations, and
those without psychiatric comorbidity. The vast majority of SUD
treatment in the US is level-I outpatient treatment, yet to our
knowledge there are no studies that have examined the utility
of providing peer supports/recovery coaches in these settings. It
should also be highlighted that, by nature, much of the non-RCT
research presented here is based on convenience sampling, and
survey analysis. More RCTs are needed on this topic to validate,
and expand upon reported findings.
This comprehensive, systematic review of the existing PRSS
literature speaks to both the potential of peer supports across a
number of SUD treatment settings, as well as the great amount
of work yet needed to establish the efficacy and effectiveness
of such ministrations. Importantly, many ethical and practical
challenges remain for this novel class of interventions for
SUD. For instance, individuals providing peer support face
boundary issues as their work typically lies at the intersection
Frontiers in Psychology | 10 June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
of purely-peer, and purely-clinical support roles (Jack et al.,
2018). Their work lacks the clarity of the professional treatment
realm with its clear roles, work schedules, and expectations,
and marked differentiation between paid professional staff and
clients, as well as the mutual-help 12-Step tradition with its
own well-articulated, and long-standing peer-support traditions.
Regardless, work to date makes the case for further exploration
PRSS in a range of SUD-related contexts. Peer support specialists’
roles will, no doubt, increasingly become more clearly defined
as peer-supports are integrated more and more into the spectrum
of SUD care.
JK, BH, and BB conceived the project. LH, CV, and AA conducted
literature search. DE and JK wrote manuscript. LH, CV, AA, BB,
BH, and CW provided revisions and edited the manuscript.
The Supplementary Material for this article can be found
online at:
Andreas, D., Ja, D. Y., and Wilson, S. (2010). Peers reach out supporting peers
to embrace recovery (PROSPER): a center for substance abuse treatment
recovery community services program. Alcohol. Treat. Q. 28, 326–338.
doi: 10.1080/07347324.2010.488538
Armitage, E. V., Lyons, H., and Moore, T. L. (2010). Recovery association
project (RAP), Portland, Oregon. Alcohol. Treat. Q. 28, 339–357.
doi: 10.1080/07347324.2010.488539
Ashford, R. D., Curtis, B., and Brown, A. M. (2018). Peer-delivered harm reduction
and recovery support services: initial evaluation from a hybrid recovery
community drop-in center and syringe exchange program. Harm Reduct. J.
15:52. doi: 10.1186/s12954-018-0258-2
Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., and Laudet, A. (2016).
Peer-delivered recovery support services for addictions in the United States: a
systematic review. J. Subst. Abuse Treat. 63, 1–9. doi: 10.1016/j.jsat.2016.01.003
Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S.,
and Hingson, R. (2005). Brief motivational intervention at a clinic
visit reduces cocaine and heroin use. Drug Alcohol Depend. 77, 49–59.
doi: 10.1016/j.drugalcdep.2004.07.006
Blondell, R. D., Behrens, T., Smith, S. J., Greene, B. J., and Servoss, T. J. (2008).
Peer support during inpatient detoxification and aftercare outcomes. Addict.
Dis. Their Treat. 7, 77–86. doi: 10.1097/ADT.0b013e31804eff1b
Boisvert, R. A., Martin, L. M., Grosek, M., and Clarie, A. J. (2008). Effectiveness of
a peer-support community in addiction recovery: participation as intervention.
Occup. Ther. Int. 15, 205–220. doi: 10.1002/oti.257
Bora, R., Leaning, S., Moores, A., and Roberts, G. (2010). Life coaching for mental
health recovery: the emerging practice of recovery coaching. Adv. Psychiatr.
Treatment 16, 459–467. doi: 10.1192/apt.bp.108.006536
Boyd, M. R., Moneyham, L., Murdaugh, C., Phillips, K. D., Tavakoli, A.,
Jackwon, K., et al. (2005). A peer-based substance abuse intervention
for HIV+rural women: a pilot study. Arch. Psychiatr. Nurs. 19, 10–17.
doi: 10.1016/j.apnu.2004.11.002
Cicchetti, A. (2010). Review of Peer-based addiction recovery support: history,
theory, practice, and scientific evaluation. J. Groups Addict. Recov. 5, 330–332.
doi: 10.1080/1556035X.2010.523380
Corrigan, P. W., Kraus, D. J., Pickett, S. A., Schmidt, A., Stellon, E., Hantke, E.,
et al. (2017). Using peer navigators to address the integrated health care needs
of homeless African Americans with serious mental illness. Psychiatr. Serv. 68,
264–270. doi: 10.1176/
Cunningham, J. A., and McCambridge, J. (2012). Is alcohol dependence
best viewed as a chronic relapsing disorder? Addiction 107, 6–12.
doi: 10.1111/j.1360-0443.2011.03583.x
Deering, K. N., Kerr, T., Tyndall, M. W., Montaner, J. S. G., Gibson, K., Irons,
L., et al. (2011). A peer-led mobile outreach program and increased utilization
of detoxification and residential drug treatment among female sex workers
who use drugs in a Canadian setting. Drug Alcohol Depend. 113, 46–54.
doi: 10.1016/j.drugalcdep.2010.07.007
Dennis, M., Scott, C. K., and Funk, R. (2003). An experimental
evaluation of recovery management checkups (RMC) for people with
chronic substance use disorders. Eval. Program Plann. 26, 339–352.
doi: 10.1016/S0149-7189(03)00037-5
Freeman, H. P. (2012). The origin, evolution, and principles of
patient navigation. Cancer Epidemiol. Biomark. Prev. 21, 1614–1617.
doi: 10.1158/1055-9965.EPI-12-0982
Giese-Davis, J., Bliss-Isberg, C., Carson, K., Star, P., Donaghy, J., Cordova, M. J.,
et al. (2006). The effect of peer counseling on quality of life following diagnosis
of breast cancer: an observational study. Psychooncology. 15, 1014–1022.
doi: 10.1002/pon.1037
Humphreys, K., and Moos, R. (2001). Can encouraging substance abuse
patients to participate in self-help groups reduce demand for health
care? A quasi-experimental study. Alcohol. Clin. Exp. Res. 25, 711–716.
doi: 10.1111/j.1530-0277.2001.tb02271.x
Humphreys, K., and Moos, R. (2007). Encouraging posttreatment self-help
group involvement to reduce demand for continuing care services: two-
year clinical and utilization outcomes. Alcohol. Clini. Exp. Res. 31, 64–68.
doi: 10.1111/j.1530-0277.2006.00273.x
Huskamp, H. A., Busch, A. B., Souza, J., Uscher-Pines, L., Rose, S., Wilcock, A.,
et al. (2018). How is telemedicine being used in opioid and other substance use
disorder treatment? Health Aff. 37, 1940–1947. doi: 10.1377/hlthaff.2018.05134
Jack, H. E., Oller, D., Kelly, J., Magidson, J. F., and Wakeman, S. E.
(2018). Addressing substance use disorder in primary care: the role,
integration, and impact of recovery coaches. Substance Abuse 39, 307–314.
doi: 10.1080/08897077.2017.1389802
James, S., Rivera, R., and Shafer, M. S. (2014). Effects of peer recovery coaches on
substance abuse treatment engagement among child welfare-involved parents.
J. Family Strengths 14:6.
Kelley, A., Bingham, D., Brown, E., and Pepion, L. (2017). Assessing the impact of
American Indian peer recovery support on substance use and health. J. Groups
Add. Recov. 12, 296–308. doi: 10.1080/1556035X.2017.1337531
Kelly, J. F., Bergman, B., Hoeppner, B. B., Vilsaint, C. L., and White, W. L. (2017).
Prevalence and pathways of recovery from drug and alcohol problems in the
United States population: implications for practice, research, and policy. Drug
Alcohol Depend. 181, 162–169. doi: 10.1016/j.drugalcdep.2017.09.028
Laudet, A. B., Harris, K., Kimball, T., Winters, K. C., and Moberg, D. P. (2016).
In college and in recovery: reasons for joining a collegiate recovery program. J
Am. Coll. Health 64, 238–246. doi: 10.1080/07448481.2015.1117464
Laudet, A. B., and Humphreys, K. (2013). Promoting recovery in an evolving
policy context: what do we know and what do we need to know about
recovery support services? J. Subst. Abuse Treat. 45, 126–133. doi: 10.1016/j.jsat.
London, K., Mccaffrey, M., Mcdowell, L., Maughan, M., and Tourish, J. (2018).
Recovery Coaches in Opioid Use Disorder Care. Boston, MA: University of
Massachusetts Medical School.
Manning, V., Best, D., Faulkner, N., Titherington, E., Morinan, A., Keaney, F.,
et al. (2012). Does active referral by a doctor or 12-Step peer improve 12-
Step meeting attendance? Results from a pilot randomised control trial. Drug
Alcohol Dep. 126, 131–137. doi: 10.1016/j.drugalcdep.2012.05.004
Mclellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G.,
et al. (1992). Addiction severity index. J. Subst. Abuse Treat. 9, 199–213.
doi: 10.1016/0740-5472(92)90062-S
McLellan, A. T., Lewis, D. C., O’brien, C. P., and Kleber, H. D. (2000). Drug
dependence, a chronic medical illness. J. Am. Medical Assoc. 284, 1689–1695.
doi: 10.1001/jama.284.13.1689
Frontiers in Psychology | 11 June 2019 | Volume 10 | Article 1052
Eddie et al. Systematic Review of Peer Support
Min, S.-Y., Whitecraft, J., Rothbard, A. B., and Salzer, M. S. (2007). Peer
support for persons with co-occurring disorders and community tenure:
a survival analysis. Psychiatr. Rehabil. J. 30, 207–213. doi: 10.2975/30.3.20
O’Connell, M. J., Flanagan, E. H., Delphin-Rittmon, M. E., and Davidson,
L. (2017). Enhancing outcomes for persons with co-occurring disorders
through skills training and peer recovery support. J. Mental Health 10, 1–6.
doi: 10.1080/09638237.2017.1294733
Office of the Surgeon General (2016). Facing Addiction in America: The Surgeon
General’s Report on Alcohol, Drugs, and Health. Washington, DC: U.S.
Department of Health and Human Services.
Powell, J. (2012). Recovery coaching with homeless African Americans
with substance use disorders. Alcohol. Treat. Q. 30, 364–366.
doi: 10.1080/07347324.2012.691345
Reif, S., Braude, L., Lyman, D. R., Dougherty, R. H., Daniels, A. S.,
Ghose, S. S., et al. (2014). Peer recovery support for individuals with
substance use disorders: assessing the evidence. Psychiatr. Serv. 65, 853–861.
doi: 10.1176/
Robinson-White, S., Conroy, B., Slavish, K. H., and Rosenzweig, M. (2010). Patient
navigation in breast cancer: a systematic review. Cancer Nurs. 33, 127–140.
doi: 10.1097/NCC.0b013e3181c40401
Rowe, M., Bellamy, C., Baranoski, M., Wieland, M., O’connell, M. J., Benedict,
P. et al. (2007). A peer-support, group intervention to reduce substance use
and criminality among persons with severe mental illness. Psychiatr. Serv. 58,
955–961. doi: 10.1176/ps.2007.58.7.955
SAMHSA (2009). What are Peer Recovery Support Services?. Rockville,
MD:Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.
SAMHSA (2015). Core Competencies for Peer Workers in Behavioral
Health Services. Washington, DC: Substance Abuse and Mental Health
Services Administration.
Samuels, E. A., Bernstein, S. L., Marshall, B. D. L., Krieger, M., Baird, J., and Mello,
M. J. (2018). Peer navigation and take-home naloxone for opioid overdose
emergency department patients: preliminary patient outcomes. J. Subst. Abuse
Treat. 94, 29–34. doi: 10.1016/j.jsat.2018.07.013
Sanders, L., Trinh, C., Sherman, B., and Banks, S. (1998). Assessment of
client satisfaction in a peer counseling substance abuse treatment program
for pregnant and postpartum women. Eval. Program Plann. 21, 287–296.
doi: 10.1016/S0149-7189(98)00018-4
Scott, C. K., and Dennis, M. L. (2009). Results from two randomized
clinical trials evaluating the impact of quarterly recovery management
checkups with adult chronic substance users. Addiction 104, 959–971.
doi: 10.1111/j.1360-0443.2009.02525.x
Scott, C. K., and Dennis, M. L. (2010). “Recovery management checkups with adult
chronic substance users,” in Addiction Recovery Management: Theory, Research,
and Practice, eds J.F. Kelly and W.L. White. (New York, NY: Springer), 87–102.
doi: 10.1007/978-1-60327-960-4_6
Scott, C. K., Grella, C. E., Nicholson, L., and Dennis, M. L. (2018).
Opioid recovery initiation: pilot test of a peer outreach and modified
recovery management checkup intervention for out-of-treatment
opioid users. J. Subst. Abuse Treat. 86, 30–35. doi: 10.1016/j.jsat.
Sisson, R. W., and Mallams, J. H. (1981). The use of systematic encouragement
and community access procedures to increase attendance at Alcoholic
Anonymous and Al-Anon meetings. Am. J. Drug Alcohol Abuse 8, 371–376.
doi: 10.3109/00952998109009560
Smelson, D. A., Kline, A., Kuhn, J., Rodrigues, S., O’connor, K., Fisher,
W., et al. (2013). A wraparound treatment engagement intervention for
homeless veterans with co-occurring disorders. Psychol. Serv. 10, 161–167.
doi: 10.1037/a0030948
Timko, C., and Debenedetti, A. (2007). A randomized controlled trial of intensive
referral to 12-step self-help groups: one-year outcomes. Drug Alcohol Depend.
90, 270–279. doi: 10.1016/j.drugalcdep.2007.04.007
Timko, C., Debenedetti, A., and Billow, R. (2006). Intensive referral to 12-Step
self-help groups and 6-month substance use disorder outcomes. Addiction 101,
678–688. doi: 10.1111/j.1360-0443.2006.01391.x
Timko, C., Sutkowi, A., Cronkite, R. C., Makin-Byrd, K., and Moos, R. H. (2011).
Intensive referral to 12-step dual-focused mutual-help groups. Drug Alcohol
Depend. 118, 194–201. doi: 10.1016/j.drugalcdep.2011.03.019
Tracy, K., Burton, M., Nich, C., and Rounsaville, B. (2011). Utilizing peer
mentorship to engage high recidivism substance-abusing patients in treatment.
Am. J. Drug Alcohol Abuse 37, 525–531. doi: 10.3109/00952990.2011.600385
Valentine, P. (2010). “Peer-based recovery support services within a recovery
community organization: The CCAR experience,” in Addiction Recovery
Management, eds J.F. Kelly and W.L. White. (New York, NY: Springer),
259–279. doi: 10.1007/978-1-60327-960-4_14
White, W. L. (2009). Peer-based addiction recovery support: History, theory,
practice, and scientific evaluation. Counselor 10, 54–59.
White, W. L. (2010). Nonclinical addiction recovery support services: history,
rationale, models, potentials, and pitfalls. Alcohol. Treat. Q. 28, 256–272.
doi: 10.1080/07347324.2010.488527
White, W. L. (2011). Review of Treating substance use disorders
with adaptive continuing care. Addiction 106, 453–453.
doi: 10.1111/j.1360-0443.2010.03288.x
White, W. L., and Evans, A. C. (2014). The recovery agenda: the shared role of
peers and professionals. Public Health Rev. 35:4. doi: 10.1007/BF03391703
White, W. L., and Kelly, J. F. (2011). Alcohol/drug/substance “abuse”: The history
and (hopeful) demise of a pernicious label. Alcohol. Treat. Q. 29, 317–321.
doi: 10.1080/07347324.2011.587731
Ziedonis, D. M., and Stern, R. (2001). Dual recovery therapy for
schizophrenia and substance abuse. Psychiatr. Ann. 31, 255–264.
doi: 10.3928/0048-5713-20010401-09
Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2019 Eddie, Hoffman, Vilsaint, Abry, Bergman, Hoeppner, Weinstein
and Kelly. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (CC BY). The use, distribution or reproduction in
other forums is permitted, provided the original author(s) and the copyright owner(s)
are credited and that the original publication in this journal is cited, in accordance
with accepted academic practice. No use, distribution or reproduction is permitted
which does not comply with these terms.
Frontiers in Psychology | 12 June 2019 | Volume 10 | Article 1052
... Though empirical support for PRC services is growing (Eddie et al., 2019), most services emphasize substance use cessation as a primary goal of service engagement (Paquette et al., 2022). The use of PRCs in novel "hybrid" recovery and harm reduction programs indicates PRCs may be well situated to deliver harm reduction services (Ashford et al., 2018). ...
... PRCs play a unique and integral role in the substance use service system. By drawing on their lived experience in substance use recovery, PRCs can quickly build trust and rapport with people with SUDs (Solomon, 2004) and facilitate treatment engagement, retention, and client satisfaction (Eddie et al., 2019). However, many PRCs have personal and professional experience in abstinence-based treatment and recovery programs. ...
Peer recovery coaches (PRCs), direct service providers with lived experience in recovery, are a growing sector of the substance use workforce. As rates of cannabis use increase nationwide, including among treatment-seeking populations, many PRCs will work with clients who wish to use cannabis for medical or recreational purposes. This study explores how PRCs perceive the use of cannabis among clients in treatment or recovery services. Semi-structured phone interviews were completed with 28 PRCs in Michigan. Inductive thematic analysis was used to document PRCs’ perceptions of client cannabis use, including overall trends, potential benefits, and concerns. While participants indicated a desire to support clients’ autonomy, and many were able to identify potential benefits of cannabis use, they also expressed concerns about the quality of clients’ recovery and difficulties managing personal biases. Findings highlight key areas for training and technical assistance to assist PRCs in their work with clients who use cannabis.
... Converging data suggests that PRC contact is associated with positive SUD behavior change including increased treatment attendance, abstinence rates, decreased rates of recurrence of substance use and decreased stigma. Recoverees report satisfaction with PRC support and describe peer coaching as helpful for promoting behavior change [13][14][15]. SUD PRCs could potentially be leveraged to assist with tobacco treatment to help individuals with SUD quit smoking. However, no work has examined SUD PRC's tobacco smoking rates or reported on their attitudes regarding integrating tobacco treatment coaching into their SUD recovery coaching. ...
... Overall, the survey responses indicate that peer coaches view tobacco treatment as an important goal to be supported when identified by the patient. This is congruent with the overall framework of the recovery coaching model [14,31], which is based on supporting the recoveree's self-identified goals, rather than a coach or clinician imposing goals or specific treatments. Importantly, PRCs viewed tobacco as harmful and were interested in learning more about how to support tobacco cessation in SUD recovery. ...
Full-text available
Background Individuals with substance use disorder (SUD) have high prevalence of cigarette smoking and difficulty quitting. Peer recovery coaches (PRCs; individuals with lived SUD experience) facilitate SUD behavior change in recoverees but it is unknown if/how they address tobacco treatment in SUD recovery coaching. We assessed PRC’s tobacco-related practices and attitudes about tobacco treatment in SUD recovery. Methods The Tobacco use In Peer-recovery Study (TIPS) was a cross-sectional mixed-methods pilot survey (January–March 2022) of the 26 PRCs employed by a Massachusetts-based healthcare system’s 12 SUD treatment clinics/programs. PRCs completed a quantitative survey (n = 23/26; 88%) and a telephone-based qualitative interview (n = 20/26; 77%). Results One-third of PRCs reported current smoking, 50% reported former smoking, and 18% never smoked. Among PRCs, 61% reported accompanying recoverees outdoors to smoke, 26% smoked with recoverees, 17% had provided cigarettes to recoverees, 32% used smoking to help build peer-relationships, and 74% rated smoking as socially acceptable in SUD treatment. PRCs reported regularly talking to recoverees about tobacco treatment (65%), believed they should have a role in helping recoverees quit smoking (52%), and were interested in tobacco treatment training (65%). A majority of both nonsmoking and current smoking PRCs (73% vs. 57%) regularly talked to recoverees about quitting smoking. Conclusion PRCs’ attitudes about integrating tobacco treatment into SUD recovery coaching were generally positive and PRCs reported they could have a role in helping recoverees with tobacco treatment. Barriers to integrating tobacco treatment into SUD recovery include use of cigarettes as a peer-recovery tool and high prevalence and social acceptability of smoking in SUD recovery.
... One of the most valuable, yet underutilized, resources identified by participants was peer-based recovery support, which aims to engage clients through individual support and health care navigation. Peer mentors are those with lived experience who function as mentors or recovery advocates within a coordinated recovery plan (23,24). Examples of peer services include legal services, child care, employment coaching, and service guidance (24). ...
Objective: The authors aimed to uncover factors that affect engagement in substance use disorder treatment among Medicaid beneficiaries in New York State. Methods: The authors conducted 40 semistructured interviews with clients, plan administrators, health care providers, and policy leaders directly involved with substance use care in New York State. Data were analyzed with thematic analysis. Results: Main themes resulting from analysis of the 40 interviews showed that most stakeholders agreed that a need exists to better integrate psychosocial services into behavioral health care systems; that systemic stigma, stigma from providers, and lack of cultural responsiveness in the substance use care system hinder engagement in and provision of high-quality care; and that rural health care networks with coordinated models benefit clients' engagement in care. Conclusions: Stakeholders involved in care for substance use disorder perceived a lack of integration of resources to meet clients' social needs, the presence of stigma, and low levels of cultural and linguistic capacity as key factors contributing to low engagement in and low quality of care for substance use disorder. Future interventions should address social needs within the therapeutic regimen and modify curricula in clinical training to reduce stigma and increase cultural competence.
Purpose Peer Support Specialists (PSS) play an integral role in substance use disorder treatment and aftercare services. PSS training programs vary in format and need to be evaluated for continued improvement. The purpose of this study was to gather feedback about course delivery and instruction from PSS trainees in a PSS training program in Alabama. Design/methodology/approach Focus groups were conducted with 15 PSS trainees after they completed two training courses delivered in an online university format. There were four men and 11 women. Four were black, 10 were white and one was Hispanic/Latinx. Participants ranged in age from 20 to 70. Findings Through content analysis of focus group content, four themes emerged: (1) issues with online navigation, (2) desire for an orientation to university-level education, (3) instructor qualities (e.g. approachability and availability) and (4) course structure considerations (e.g. balance between online and in-person learning, more frequent class meetings). Originality/value To the best of the authors’ knowledge, this study is the first to evaluate a new PSS training program in Alabama. Findings help inform future PSS training programs and assist in the development of best practices in PSS training.
Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].
The COVID-19 pandemic has placed an unprecedented burden on patients, health care providers, and communities and has been particularly challenging for medically underserved populations impacted by the social determinants of health, as well as people with co-occurring mental health and substance use risks. This case study examines outcomes and lessons learned from a multisite low-threshold medication-assisted treatment (MAT) program at a federally qualified health center in partnership with a large suburban public university in New York to integrate and train Health Resources & Services Administration Behavioral Health Workforce Education and Training-funded graduate student trainees in social work and nursing in screening, brief intervention, and referral to treatment and patient care coordination, including social determinants of health and medical and behavioral comorbidities. The MAT program for the treatment of opioid use disorder has a low threshold for entry that is accessible and affordable, reduces barriers to care, and uses a harm reduction approach. Outcome data showed an average 70% retention rate in the MAT program and reductions in substance use. And, while more than 73% of patients reported being somewhat or definitely impacted by the pandemic, most patients endorsed the effectiveness of telemedicine and telebehavioral health, such that 86% indicated the pandemic did not affect the quality of their health care. The main implementation lessons learned were the importance of increasing the capacity of primary care and health care centers to deliver integrated care, using cross-disciplinary practicum experiences to enhance trainee competencies, and addressing the social determinants of health among populations with social vulnerabilities and chronic medical conditions.
This handbook is currently in development, with individual articles publishing online in advance of print publication. At this time, we cannot add information about unpublished articles in this handbook, however the table of contents will continue to grow as additional articles pass through the review process and are added to the site. Please note that the online publication date for this handbook is the date that the first article in the title was published online. For more information, please read the site FAQs.
Canadian women with alcohol use disorder have limited access to anti-craving medication, despite its effectiveness in reducing alcohol use. This article describes the results of a pilot program developed to improve access to integrated medical assessment and management of anti-craving medication and traumainformed relapse prevention counselling in a community setting.
Objectives: Patients with opioid use disorder (OUD) are increasingly being hospitalized for acute medical illnesses. Despite initiation of medications for OUD (MOUDs), many discontinue treatment after discharge. To evaluate whether a psychosocial intervention can improve MOUD retention after hospitalization, we conducted a pilot randomized controlled trial of a peer recovery coach intervention. Methods: An existing peer recovery coach intervention was adapted for this trial. Hospitalized adults with OUD receiving MOUD treatment were randomized to receive either a recovery coach intervention or treatment-as-usual. For those in the intervention arm, the coach guided the participant to complete a relapse prevention plan, maintained contact throughout the 6-month follow-up period, encouraged MOUD continuation, and helped to identify community resources. Those receiving treatment-as-usual were discharged with a referral to outpatient treatment. Primary outcome was retention in MOUD treatment at 6 months. Secondary outcomes were the proportion of participants readmitted to the hospital and the number of days until treatment discontinuation and to hospital readmission. Results: Twenty-five individuals who provided consent and randomized to the recovery coach intervention (n = 13) or treatment-as-usual (n = 12) were included in the analysis. No significant differences were found in the proportion of participants retained in MOUD treatment at 6 months (38.5% vs 41.7%, P = 0.87), proportion of participants readmitted at 6 months (46.2% vs 41.2%, P = 0.82), or the time to treatment discontinuation (log-rank P = 0.92) or readmission (log-rank P = 0.85). Conclusions: This pilot trial failed to demonstrate that a recovery coach intervention improved MOUD treatment retention compared with treatment-as-usual among hospitalized individuals with OUD.
Full-text available
Background Recovery from substance use disorder (SUD) is often considered at odds with harm reduction strategies. More recently, harm reduction has been categorized as both a pathway to recovery and a series of services to reduce the harmful consequences of substance use. Peer recovery support services (PRSS) are effective in improving SUD outcomes, as well as improving the engagement and effectiveness of harm reduction programs. Methods This study provides an initial evaluation of a hybrid recovery community organization providing PRSS as well as peer-based harm reduction services via a syringe exchange program. Administrative data collected during normal operations of the Missouri Network for Opiate Reform and Recovery were analyzed using Pearson chi-square tests and Monte Carlo chi-square tests. Results Intravenous substance-using participants (N = 417) had an average of 2.14 engagements (SD = 2.59) with the program. Over the evaluation period, a range of 5345–8995 sterile syringes were provided, with a range of 600–1530 used syringes collected. Participant housing status, criminal justice status, and previous health diagnosis were all significantly related to whether they had multiple engagements. Conclusions Results suggest that recovery community organizations are well situated and staffed to also provide harm reduction services, such as syringe exchange programs. Given the relationship between engagement and participant housing, criminal justice status, and previous health diagnosis, recommendations for service delivery include additional education and outreach for homeless, justice-involved, LatinX, and LGBTQ+ identifying individuals.
Full-text available
Peer Recovery Support (PRS) is emerging as a key intervention for communities and individuals as they address high rates of substance abuse and limited recovery resources. American Indian populations were among the first people to use concepts of PRS through abstinence-based revitalization movements and ceremonies. The present study examined the impact of PRS on substance use, emotional and psychological problems, and social connections among urban and reservation American Indian peers involved in a 3-year PRS program. A total of 224 individuals, 110 male and 114 female completed baseline GPRA. Of these, 65 peers completed baseline and 6-month follow-up GPRAs. Involvement in PRS decreased substance use significantly among peers. Peer attendance at voluntary self-help groups and support from family and friends increased as a result of PRS.
An extensive report on the impacts recovery coach services can have on Opioid Use Disorder care in Massachusetts accompanied by two tools to assist in understanding how to develop such services. The report defines what a recovery coach is, delves into the role experts believe they could play in the recovery process and ultimately how they could change overall health outcomes. Along with the report, the team built a recovery coach Impact Estimator Tool which allows users to calculate the caseload, budgetary, financial, and clinical impact policy makers need before making the decision to invest in new forms of intervention. Implementing a new form of health care intervention requires research and planning. Finally, they created a Compendium of Recovery Coach Certification Requirements by State, which provides recovery coach certification information for 48 states and the District of Columbia. Client/Partner: RIZE Massachusetts
Only a small proportion of people with a substance use disorder (SUD) receive treatment. The shortage of SUD treatment providers, particularly in rural areas, is an important driver of this treatment gap. Telemedicine could be a means of expanding access to treatment. However, several key regulatory and reimbursement barriers to greater use of telemedicine for SUD (tele-SUD) exist, and both Congress and the states are considering or have recently passed legislation to address them. To inform these efforts, we describe how tele-SUD is being used. Using claims data for 2010-17 from a large commercial insurer, we identified characteristics of tele-SUD users and examined how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the study period, we found low use rates overall, particularly relative to the growth in telemental health. Tele-SUD is primarily used to complement in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, low rates of tele-SUD use represent a missed opportunity. As tele-SUD becomes more available, it will be important to monitor closely which tele-SUD delivery models are being used and their impact on access and outcomes.
Background U.S. opioid overdose deaths have increased five-fold since 1999. In 2014, two Rhode Island emergency departments (EDs) began providing take-home naloxone and peer recovery coach consultation to patients identified at risk of opioid overdose. Similar programs have been initiated throughout the country, but patient outcomes of ED naloxone distribution and recovery coach consultation have yet to be evaluated. Methods This is an observational, retrospective cohort study of ED patients discharged after a non-fatal opioid overdose in the six months after implementation of an ED naloxone distribution and recovery coach consultation program, September 2014 to February 2015. By provider and patient discretion, patients received either: usual care, take-home naloxone, or a recovery coach with take-home naloxone. Primary outcomes one year from index ED visit were initiation of medication for opioid use disorder (OUD), repeat ED visit for opioid overdose, and all-cause mortality. Results 151 adults met study inclusion criteria. Sixty (39.7%) received usual care, 26 (17.2%) received take-home naloxone alone, and 72 (47.7%) received take-home naloxone and a peer recovery coach. Less than a third (28.5% 48/151) initiated medication for OUD. Median time to new initiation of medication for OUD was shorter among those who got a recovery coach (81.5 days vs 139 days usual care). Thirty (19.9%) were treated in the ED for a repeat opioid overdose. Seven (4.6%) died within one year of initial ED visit. A smaller proportion of deaths occurred among those receiving services. Conclusion Preliminary patient outcomes demonstrate a high frequency of death and repeat overdose one-year following an ED visit for opioid overdose. A minority initiate medication for OUD. Among those who got a recovery coach and naloxone, median.
Background: Alcohol and other drug (AOD) problems confer a global, prodigious burden of disease, disability, and premature mortality. Even so, little is known regarding how, and by what means, individuals successfully resolve AOD problems. Greater knowledge would inform policy and guide service provision. Method: Probability-based survey of US adult population estimating: 1) AOD problem resolution prevalence; 2) lifetime use of "assisted" (i.e., treatment/medication, recovery services/mutual help) vs. "unassisted" resolution pathways; 3) correlates of assisted pathway use. Participants (response=63.4% of 39,809) responding "yes" to, "Did you use to have a problem with alcohol or drugs but no longer do?" assessed on substance use, clinical histories, problem resolution. Results: Weighted prevalence of problem resolution was 9.1%, with 46% self-identifying as "in recovery"; 53.9% reported "assisted" pathway use. Most utilized support was mutual-help (45.1%,SE=1.6), followed by treatment (27.6%,SE=1.4), and emerging recovery support services (21.8%,SE=1.4), including recovery community centers (6.2%,SE=0.9). Strongest correlates of "assisted" pathway use were lifetime AOD diagnosis (AOR=10.8[7.42-15.74], model R2=0.13), drug court involvement (AOR=8.1[5.2-12.6], model R2=0.10), and, inversely, absence of lifetime psychiatric diagnosis (AOR=0.3[0.2-0.3], model R2=0.10). Compared to those with primary alcohol problems, those with primary cannabis problems were less likely (AOR=0.7[0.5-0.9]) and those with opioid problems were more likely (AOR=2.2[1.4-3.4]) to use assisted pathways. Indices related to severity were related to assisted pathways (R2<0.03). Conclusions: Tens of millions of Americans have successfully resolved an AOD problem using a variety of traditional and non-traditional means. Findings suggest a need for a broadening of the menu of self-change and community-based options that can facilitate and support long-term AOD problem resolution.
Background: Only 10% of people with substance use disorder (SUD) receive treatment, partially due to inadequate access to specialty SUD care and limited management within primary care. "Recovery coaches" (RCs), peers sharing the lived experience of addiction and recovery, are increasingly being integrated into primary care to help reach and treat people experiencing SUD, yet little is known about how their role should be defined or about their clinical integration and impact. Methods: In order to explore patient and RC perspectives on the RC role, we conducted semi-structured interviews with RCs (n = 5) and their patients (n = 16). Maximum variation sampling was used to select patients who displayed diversity across gender, RC, housing status, and number of contacts with an RC. We sampled until no new concepts emerged from additional interviews, and we used a semi-structured interview guide for data collection and recorded all interviews. To analyze interview transcripts, we employed the constant comparative method to assign inductively developed codes. Two coders separately coded all transcripts and reconciled code assignments. Results: Four core RC activities were identified: system navigation, supporting behavior change, harm reduction, and relationship building. Across these activities, benefits of the RC role emerged, including accessibility, shared experiences, motivation of behavior change, and links to social services. Challenges of the RC model were also evident: patient discomfort with asking for help, lack of clarity in RC role, and tension within the care team. Conclusions: These findings shed light on RCs in primary care. Many patients and coaches perceived that RCs play a valuable role within primary care, providing both tangible system navigation and intangible, social support that promote recovery and might not otherwise be available. Enhanced communication between RCs and health center leadership in defining the RC role may help resolve ambiguity and related tensions between RCs and care team members.
Background: “Recovery supports”, often provided by persons in recovery themselves, have emerged over the last decade as important components of recovery-oriented systems of care for persons with substance use disorders. Aims: This study assesses the benefit of adding peer recovery supports to the care of adults with co-occurring psychosis and substance use. Method: 137 adults with both disorders who had at least one prior admission within the past year were recruited during an index hospitalization into a randomized trial of standard care vs skills training with and without a peer-led social engagement program. Participants were assessed at admission and at three and nine months post-discharge on symptoms, functioning, substance use, and other factors. Results: At three months, skills training was effective in reducing alcohol use and symptoms, with the addition of peer-led support resulting in higher levels of relatedness, self-criticism, and outpatient service use. At nine months, skills training was effective in decreasing symptoms and inpatient readmissions and increasing functioning, with the addition of peer support resulting in reduced alcohol use. Conclusions: Adding peer-led support may increase engagement in care over the short term and reduce substance use over the longer-term for adults with co-occurring disorders.