Commentary on Chambers et al.: Investigating the use of peer support services in substance use disorders treatment

Substance use disorders (SUD), in particular opioid use disorder, are a health care crisis in the United States. Nearly 50 million individuals in the United States experienced a SUD in 2023 and more than 80% of those individuals did not receive any SUD treatment [1]. The increase in fentanyl in the illicit drug supply has increased substance-related overdose considerably. The age-adjusted rate of drug overdose deaths increased from 8.2 deaths per 100 000 standard population in 2002 to 32.6 in 2022 [2]. Engaging and retaining people in the SUD continuum of care is challenging, yet essential to addressing this problem.

Compounding this problem is the longstanding shortage of individuals working in the SUD treatment field. In 2013, the Department of Health and Human Services commissioned a report on Substance Use and Mental Health Workforce Issues, which noted the growing workforce crisis in the addictions field because of high turnover rates, worker shortages, aging workforce, stigma and inadequate compensation [3]. Although some progress has been made, with the overdose crisis, access to mental health and addiction services has fallen further behind the needs [4].

Over the past 10 years, peer recovery support specialists (PRSS) have been an increasingly important and valuable addition to the SUD treatment workforce, providing the unique perspective of ‘lived experience’, linkage to community resources and serving as role models in recovery. PRSS are part of the movement toward a ‘recovery-oriented’ model of care focused on helping people get and stay engaged in the continuum of care until achieving sustained recovery. In general, PRSS provide more active support as compared to more traditional approaches, with frequent contact, guidance and outreach beyond medical settings. Although there have been a number of studies with generally positive findings focused on outcomes of PRSS interventions, most studies suffer from lack of a well-described intervention, inadequate sample size and/or adequate comparison groups [5].

Chambers et al. [6] describe a study that addresses many of the shortcomings of previous work. The study's findings are valuable in supporting the work of PRSS in the emergency room despite no evidence that intervention from a PRSS was more effective in preventing non-fatal overdose than a licensed clinical social worker. Study limitations include being potentially underpowered to detect differences between active treatments, lack of a non-treatment control group and lack of monitoring for intervention fidelity.

Like most good science, this study fills an important knowledge gap, but also leads to new questions. There is some suggestion that PRSS outreach may be particularly valuable to individuals from marginalized groups or from low resource areas, such as rural populations [7]. A comparison of characteristics of responders would be valuable in refining the best use of peer services. In addition, it has been suggested that the context in which the peers are working, whether they have direct patient access, how quickly/often they are called in intervene and whether they are physically located in the emergency room can all be important. Future research should describe and examine these elements of emergency room-based peer support programs for opioid overdose survivors, so that the relationship between programmatic elements and outcomes can be examined. Studies should also examine peer level interactions to better understand behaviours associated with better patient outcomes and help in defining peer practice and competence [8].

Finally, well-controlled studies need to be conducted exploring PRSS in contexts beyond the emergency room. There are a number of emerging roles for peer support in both mental health and SUDs [9]. In a conceptual paper using a multidimensional framework of the SUD care continuum, Stanlovic and Davidson [10] explored possible roles of PRSS and their potential to improve engagement and retention in care by targeting specific barriers to successful transitioning from one stage of the continuum to the next. This provides an excellent framework for further exploration of PRSS as an integrated part SUD care, an important step toward workforce development and improving health outcomes in SUDs.

Kathleen T. Brady: Conceptualization; writing—original draft.

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