Field leans on peers, but roles remain ill-defined

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.

Credentialing, for the most part, is used to establish reimbursement for peers. “This is a growing trend,” says Coderre. Ten years ago, reimbursement was rare, mostly coming from grants. “Now we’re actually seeing insurance companies, and Medicaid, reimburse for peer services,” he says.

Coderre believes licensing is not a good idea for peers, however. “My worry is that if you license peers, you start to take them away from the non-professional experiential model and you put them more into a professional class, and that defeats the entire purpose of what a peer is supposed to do,” he says.

Professional considerations

Peers should be paid salaries, not just a stipend, says Metcalf. “They’re not volunteers in RCOs,” she says. “They’re moving into the workforce, and they go through just as much training as a community health worker.”

In RCOs, peers are paid at least $15 an hour, says Metcalf. They may be full- or part-time, depending on the funding source. They may have the title of certified recovery coach, or recovery support specialist, she says.

But the definition of their role remains blurry at times. In some cases, treatment programs send peers—sometimes graduates of the programs—into hospital emergency departments to help steer patients back to the program. “That’s not the role of the peer,” says Metcalf, adding that this practice is unethical.

“The peer has to work with clients on all the options—whether it’s residential, outpatient, all of that is information that the peer worker explores” with the patient, Metcalf says. The peer worker then helps to engage the patient in whatever path the patient chooses, she says. “The RCOs don’t have an obligation to send people to a particular treatment program,” she says.

She adds, “Recovery support workers help people with the things that sponsors don’t. If I’m a recovery coach, I would look at things like cleaning up your criminal record, getting a job, looking for education if you need it, cleaning up your family relationships. The peer can say, ‘It was hard for me to get jobs because of my criminal record,’” and thus can empathize, she says.

When peers help engage people who have been rescued from an overdose, the message they convey is one of hope, says Metcalf. The patient needs to have a relationship with someone who is “not an authority or a treatment provider, but someone who can sit with them while they’re going through this experience,” she says. “They can say, ‘I’m with you, I overdosed four times, now I’m four years in recovery. Life will get better.’”

In general, first responders and even health care workers often are judgmental. The patient may need support, even if he or she has decided to go to treatment. For instance, there might be a wait of three days before admission. At that point the peer might say, “Let’s talk about what you’re going to do for the next three days.”

Building the peer workforce

In 2007, when state Medicaid directors were first told that peer support is an evidence-based practice for both substance use and mental health disorders, it was asked why this wasn't made a reimbursable service. This is an even more pressing question now, says Metcalf. “This is the time to do it—it’s an all-hands-on-deck moment,” she says.

One of the more controversial suggestions is for money for peers to come from the treatment side of the equation, even though funding for treatment is already strained. “We aren’t pointing fingers at treatment—treatment programs are our allies,” says Metcalf. But the problem is that eventually, treatment ends, and that’s where recovery support starts.

Metcalf says an infrastructure for peer support can be put in place in every state, in one of two ways. One is by ensuring that Medicaid will reimburse peer recovery services. But Faces & Voices would prefer a second option: a 20% set-aside in the federal Substance Abuse Prevention and Treatment Block Grant, administered by SAMHSA. But with 20% of this grant already set aside for prevention, an additional 20% would take a huge bite out of treatment.

“In no way do we want to take away money from treatment or prevention,” says Metcalf. “It’s time to put more money [overall] into the block grant.”

Peers in MAT

One of the best peer programs in the addiction field is MARS (Medication Assisted Recovery Services), a peer-initiated program sponsored by the National Alliance for Medication Assisted Recovery. Founded in 2005 with a SAMHSA grant and run out of the Albert Einstein College of Medicine, MARS trains peers who are in medication-assisted treatment with methadone to help others access treatment.

But there is what Coderre calls the “eternal stigma” of addiction, which is heightened in people treated with methadone. In this situation, peers are even more important, as medication-assisted treatment has been shown in research to be the most effective type of care for opioid use disorders.

“People need to tell their stories of how they are in recovery using medications,” says Coderre. “We rarely hear those stories.”

Last fall, an initiative funded by the Office of National Drug Control Policy (ONDCP) released a $2 million grant for an effort that will fund nine programs. One gives $135,000 to The Providence Center, which operates the Anchor ED program in Rhode Island, for implementing Safe Stations, a program in which fire department personnel will respond to people with opioid problems who walk in to fire stations. The project will support on-call recovery coaches to provide peer-based recovery support services. Coderre hopes such programs will continue to surface in 2018.

Alison Knopf is a freelance writer based in New York.

The basics of the peer recovery credential

Credentialing is needed in most states in order for a peer support worker to be paid. The International Certification and Reciprocity Consortium (IC&RC) offers a peer recovery credential, now available in 26 states. Individual state boards can determine the length of sober time required.

Here are the minimum requirements for the credential:

• Education: High school diploma or jurisdictionally certified high school equivalency.

• Education: 46 hours specific to a number of domains, with 10 hours each in the three domains of Advocacy, Mentoring and Education, and Recovery/Wellness Support and 16 hours in the domain of Ethical Responsibility.

• Experience: 500 hours of volunteer or paid work experience specific to the domains.

• Supervision: 25 hours of supervision specific to the domains. Supervision must be provided by an organization’s documented and qualified supervisory staff per job description.

• Examination: Applicants must pass the IC&RC Peer Recovery Examination.

• Code of Ethics: The applicant must sign a code of ethics statement or affirmation that the applicant has read and will abide by the code of ethics.

• Recertification: 20 hours of continuing education earned every two years, including six hours in ethics.

Metcalf: Assign roles with care

When Faces & Voices of Recovery's Patty McCarthy Metcalf hears about programs in police departments that are enrolling peers to help with the overdose epidemic, such as the growing Police Assisted Addiction Recovery Initiative that started in Gloucester, Mass., she is supportive in part. For example, when there is a structure, it works, she says.

“But peers need to be with other peers,” Metcalf says. “It’s tokenism if you put [only] one peer in an environment” such as a police department, she says. Another potential problem is “role drift,” in which peers end up being assigned other roles that are not intended for them.

Ultimately, using peers the wrong way, for the wrong purposes, will destroy the integrity of peer recovery, says Metcalf. “Our whole movement is in jeopardy,” she says.