Peer recovery support services (PRSS) for substance use disorder (SUD) have expanded over the past two decades, and the most recent National Drug Control Strategy recommends continuous development of the PRSS workforce (e.g., peers) [1]. PRSS interventions are also a current research priority of the National Institute on Drug Abuse [2], with several systematic reviews providing support for peer effectiveness related to such outcomes as decreased substance use, increased rates of abstinence-based recovery, strengthened treatment retention, improved provider-participant relationships, and increased treatment satisfaction [3–7]. However, studies suggest workforce-related challenges associated with peer roles, including a lack of clarity and high potential for burnout and vicarious trauma exposure [8, 9]. When considering workforce outcomes for peers, it is important to remember that many peers are, themselves, living in recovery or successfully managing their substance use through harm reduction strategies. While previous studies have tended to focus on those certified peer workers or peer recovery coaches who are in active recovery, they have neglected those who might be actively using drugs but are engaged in harm reduction service environments [10–12]. Overall, the field must develop a stronger understanding of the impact this work has on all peers’ professional and personal lives, and how the impact might vary by service setting context.
The PRSS workforce comprises both certified and non-certified peers who work in paid or volunteer positions to deliver a range of support along the continuum from harm reduction to abstinence-focused recovery [13]. It is important to note that people with lived experience have been involved in supporting those who use substances since the beginning of mutual-aid groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, Medication Assisted Recovery Anonymous). However, while peers are involved in sponsorship activities through these mutual support groups, positions of this sort should not be considered PRSS because they exist outside a formal paid or volunteer work environment [14]. People with lived experience have also been highly represented among treatment professionals like addiction counselors [13, 15] and, while such experience may be helpful for their work, they do not interact with participants in a peer capacity. The development of PRSS as a profession can be traced to 1999, when Georgia became the first state to allow peer support as a billable provider type for both mental and behavioral health [15]. As of 2019, 39 US states offered reimbursement for peer services, with training and certification requirements that typically include a specified recovery time, a criminal background check, varied training and exams, and continuing education or recertification [15, 16]. Various professional organizations and state-level boards approve these certifications, with as many as 45 distinct categories of certified peers eligible for Medicaid reimbursement [5, 16]. This lack of standardization for PRSS certification has generated confusion regarding certified peers’ minimal required training and education, role, and scope of work [17].
Understanding workforce outcomes for PRSS is essential for supporting this growing field and ensuring peers’ continued wellness and professional growth. These outcomes encompass a wide variety of factors related to peer employment experiences that include burnout, job satisfaction, role clarity, secondary trauma, turnover, and absent/presenteeism [18–20]. The relationship between workplace context and workforce outcomes is well-supported within health professional literature. For example, burnout among health care workers is associated with perceptions of inequity within their organization, perceived job support, supervisory support, and workload [21, 22]. Previous reviews have noted those in the PRSS workforce have high burnout potential due to emotionally laborious conditions rooted in role ambiguity, limited resources, difficulties establishing boundaries, and vicarious trauma exposure [8, 15]. These PRSS outcomes may be moderated by individual characteristics such as coping skills and personal recovery orientation (e.g., abstinence-only vs. harm reduction), but may also be influenced by workplace factors like belongingness or supervisory support [23–25]. Likewise, it is worthwhile to understand the extent to which peers’ well-being both mediates and is mediated by workforce outcomes [26].
The COVID-19 pandemic likely exacerbated factors that can lead to negative peer workforce outcomes. With the sharp increase in drug overdose deaths that started during the pandemic [27], peers report greater stress than ever in their roles [28]. Research notes a high potential for ‘dual trauma’ during this time, as peers faced pandemic stressors in their personal lives and recovery while simultaneously supporting a population at high risk for adversity and death [25]. These compounding factors make it critical to better understand how peer workplace conditions may contribute to negative outcomes currently associated with this workforce.
The aim of this scoping review is to explore the nature and extent of research focusing on PRSS workplace contexts that either support or interfere with peer work. Questions guiding this review include: 1) What is known about workforce-related outcomes for peers working in the substance use field? 2) What is known about how the structure of work impacts these outcomes? and 3) How do these outcomes differ by service setting type? This effort builds on prior published reviews of the PRSS experience or effectiveness by targeting how the context of a workplace impacts PRSS outcomes and how these outcomes might vary by workplace type (e.g., clinical, harm reduction settings). Additionally, we will explore individual-level characteristics of peers (e.g., demographics, training, attitudes) that may moderate workforce outcomes. Finally, workforce outcomes will be explored as potential mediators of peers’ personal recovery outcomes. A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and Joanna Briggs Institute (JBI) Evidence Synthesis was conducted and no current or underway scoping reviews on this topic were identified.