Peers have been involved in alcohol and drug use disorder treatment for decades. They started as volunteers who had personally experienced addiction and later were in recovery, helping new patients learn the 12 Steps and cope with life's challenges. More recently, peers have started to gain a professional aura, with credentialing and insurance reimbursement available.
In particular, peers are being used to help on the front end of the opioid crisis. Their work can begin immediately after someone has been rescued from an overdose, to help the individual get through the next few hours and days and in many cases to help engage the person in treatment. This is a desperately needed function, not only for humane purposes (people recovering from a naloxone rescue are confused, sick and unable to think clearly about what has just happened to them), but also because there simply is not enough professional staff to go around.
Addiction Professional spoke with several experts in the recovery movement to examine the current status of peers.
“Peer support is the process of giving and receiving non-clinical assistance so that people can achieve long-term recovery,” says Tom Coderre, senior advisor for behavioral health at the Altarum Institute, a health systems research and consulting organization. (It was announced late this week that Coderre has been hired by the Rhode Island governor's office to coordinate addiction- and opioid crisis-related responses.)
Coderre, who worked on recovery issues as senior advisor to the assistant secretary at the Substance Abuse and Mental Health Services Administration (SAMHSA) from 2014-2017, and before that as national field director for Faces & Voices of Recovery, emphasizes that a peer is not the same as a treatment professional. In fact, the person who is being assisted ultimately might not want to go to treatment, but it is the peer’s job to help the person follow through on the best path to recovery for that individual.
For peers to be most effective in responding to the opioid overdose epidemic, they need to be in places where people show up, says Coderre. “That’s why you’re seeing them in police departments,” he says, with first responders often being the ones providing the dose of naloxone that rescues people.
In Rhode Island, the most active peer program in the country has a foothold in emergency departments, and also in outreach. “They don’t wait for people to show up,” Coderre says of the Anchor ED program.
Training of peers
There are “thousands” of peers working through recovery community organizations (RCOs), says Patty McCarthy Metcalf, executive director of Faces & Voices of Recovery. About 100 of the RCOs are part of Faces & Voices. The model is for the RCO to provide training to peers, and for peers to work through the RCO. The RCO itself may have a contract with an emergency department, drug court, police department or other organizations, with the peers assigned by the RCO.
The peer has an experiential knowledge of addiction. But some organizations want peers to be in recovery for a set period of time before working with clients. Two years generally has been the standard, with this originally having been based on when it was believed to be personally safe for a person to share publicly that he/she was in recovery.
“It’s a state-by-state decision in terms of recruiting peers to participate in the training of a recovery support worker,” Metcalf says of the sobriety period.
She adds that despite the dire need for more assistance to combat the opioid crisis, she would not recommend relaxing the two-year sobriety period “because we need to protect the integrity of peer services. And we need to build capacity and infrastructure to meet the demand.”
A new profession
Peers are not sponsors, as in Alcoholics Anonymous (AA), and they are not counselors—or in fact any type of clinical professional. But the precise scope of what they do is still being worked out, and depends largely on where they are working.
Rachel Witmer, assistant director of the International Certification and Reciprocity Consortium (IC&RC), which offers a peer recovery credential, explains that many issues with peers involve the newness of the work. Definitions vary from state to state and organization to organization. “What Faces & Voices calls a recovery coach, some people call a peer recovery specialist,” Witmer says.
In some jurisdictions, the peers must themselves be in recovery from a substance use disorder. In others, a peer can be a family member or friend of someone with a substance use disorder, Witmer says.
Even though the title and credential are new, the presence of peers is as old as the drug and alcohol treatment field itself, says Witmer. “Peers were very much about the origins of treatment before it was more regulated,” she says. “Now they’re cycling back in.” But because the concept of peers as professionals is so new, there are still problems defining the scope of their work, she says.
The purpose of a credential is to develop expertise in a field, says Witmer. “Both a credential and a license are indicators of a certain amount of experience and training,” she says. The IC&RC peer recovery credential is developed to include basic concepts for both substance use and mental health disorders. “It’s a combined credential,” Witmer explains. “It’s pliable.” There are now about 2,000 IC&RC-certified peers in the U.S.