The need for a robust workforce that can effectively work with individuals living with substance use disorder has never been greater than it is today. Across the United States, billions of dollars are allocated to addressing substance use disorders; however, one of the major barriers is — who will do the work? I focus much of my attention on the peer specialist and the role they play in the addiction recovery space. My colleague Dr. Fred Rottnek, professor and the program director of the new Addiction Medicine Fellowship at Saint Louis University (SLU), is also sounding the alarm for the development of physicians, nurses, and other professionals who can answer the call. In this article, I will discuss some challenges to professional development and highlight examples of how SLU is forming collaborations to promote training and professionalism among health care workers.
Addiction Medicine requires specialization due to many complexities of daily care. Under the newly created Accreditation Council for Graduate Medical Education (ACGME), the addiction medicine subspecialty focuses on the prevention, screening, diagnosis, treatment, and recovery of unhealthy substance use, substance use disorders (SUDs), and other addictive behaviors. Saint Louis University developed the fellowship not only in response to the current opioid epidemic but to also address the often-neglected training needs of physicians around SUDs and chronic pain. Addiction physicians provide care to patients across the lifespan, who have different degrees of disease severity. Care and prevention services provided by physicians, and interprofessional teams who work in diverse settings, including clinical medicine, public health, education, and research.
SLU’s fellowship is the first and only addiction medicine fellowship in the state of Missouri. (Together with the new University of Nebraska’s recently approved fellowship, we are the only two fellowships in SAMHSA’s Region VII — Missouri, Iowa, Nebraska, and Kansas). SLU’s program is the only one in the nation with core faculty and core rotations in Family Medicine, Psychiatry, and Maternal-Fetal Medicine. Emphasis on inpatient services will be patient stabilization and facilitated referral to ambulatory and community-based treatment and recovery support. St. Louis regional institutions for core rotations include SSM Health St. Mary’s Hospital and Saint Louis University Hospital, the WISH Center, Family Care Health Center, and Assisted Recovery Centers of America.
An exciting element of training is SLU’s program is the inclusion of peer workers with other health professionals in both classroom settings and community agency settings. In the classroom, peers, graduate students, and fellows will share their scope and training and practice. In the community, the same groups will develop the teamwork skills to provide safe, effective care with the patient at the center of the team.
The ARCHway Institute is partnering with Saint Louis University to provide peers for these interdisciplinary teams. The ARCHway Institute is a St. Louis-based non-profit agency currently working in seven states. ARCHway focuses on education and the care of caregivers of those affected by substance use disorders and co-occurring mental illness. ARCHway also supports the development of peer support specialists as members of recovery and treatment teams.
“ARCHway peers are excited to be learning alongside graduate students and fellows while also sharing their lived experience and their knowledge of working in the treatment field.” Emily Jung, a peer in recovery and the Education and Awareness Coordinator for ARCHway, continued, “These early conversations are helping to build strong working relationships between peers and clinicians moving forward. We all have a great deal to learn from each other.”
Peer support workers, or recovery coaches, should be the lead on interdisciplinary teams working to address substance use disorder. Workforce development with well-trained physicians and peer workers is how the United States is going to impact the opioid crisis in the most substantial way. Peer workers have the lived experiences and innate credibility to start the conversations and set the tone for effective team-based connection and care.
In a few small regions, the role of peer support workers is well-supported. In the majority of the country, however, there is a massive opportunity for growth. After quite a few conversations, there seems to be a need for a few more pieces that highlight a few various aspects of how we move forward in improving the system, which supports the peer workers who are truly giving life to those struggling with addiction.
There is a variety of training in which certified peer workers participate nationally, to receive a credential of ‘Certified Peer Specialist.’ The fundamental training helps a peer to learn what to say in the most general of situations. This training includes how to tell your own story, how to empathize with a person with whom you are working, and how to identify red flags for compromise of health and well-being.
Beyond that, peers learn the real skills that they need to work within clinical teams and within other team settings. This critical skill set is left to the agency, which might hire them; however, it creates a situation where if hired, they will need to learn on the job, and quickly, to sustain the workflow. The technical skills like how to work within an electronic medical record system, charting, billings, etc. are needed, but not taught.
Moreover, teaching supervisors how to best support peer workers, once hired, is critical. Supervisors often need additional support in learning how to supervise efficiently effectively. (Shameless plug! Jenna Nesbitt and I will be presenting in April regarding this topic. You should check it out!)
It is not uncommon for organizations and supervisors to not understand the best way to utilize peer support workers, which results in the peer not being used appropriately. Peer workers bring a unique skill set and mission to the team and patient, and their skills should focus on the primary mission. Although a peer worker is flexible and can do a vast array of tasks, their primary goal, and for most desire, is to work with active users desiring something different. This desire, however, is often lost to the inertia of the day-to-day business of organizations and agencies.
MO-PROS, a peer-driven coalition in the state of Missouri, sees these challenges to the sustainability and growth of peer specialists in the workforce. This coalition is comprised of peer support specialists in the states with a variety of work experience in treatment, including outreach work, inpatient and outpatient settings, housing, etc. They acknowledge that if peers are not given more training initially and to develop professionally, the workforce of peers will not grow and will instead diminish. However, they personally know the impact that peers have played in their own recovery, and they’ve experienced making a difference in the recovery of those they work with, so they are advocating for this development.
It is a well-known challenge that non-profit organizations rarely carve out time or money for professional development. If it is something that is being addressed, often, it is to meet an obligation to funders or other regulatory bodies. The higher the level of license, the more that a person can build professional development into their employee benefits package. That translates into peer support workers being left to scrape together training or education opportunities on their own. One easy change that can occur at the funder level is for funders and philanthropic organizations to allow professional development and training to be built into grant requests and Grant awards. To go a step further, not only can they allow for it, but they should require it.
Pathways to excel
Pathways into the workforce start with a foot in the door. As the industry strives to incorporate peer workers and recovery coaches, their value as individuals and as workers has to be recognized. Meaningful pathways must be developed to allow for upward mobility. Although an individual may initially want to work within the addiction space, there may come a time where they need to transition out of that organization or out of that population. This means creating a universal baseline of accepted knowledge that makes peer workers competitive across all the various sectors i.e., mental health, substance use, criminal justice. Hiring peers as supervisors is an effective way to ensure peer roles remain peer oriented and optimized for success. Successful peers should also be considered for other leadership and administrative roles as they demonstrate their effectiveness. So we want to ensure that peers are provided with a base of general and technical knowledge that allows them to shift over into a different demographic or population.
It is not uncommon for an individual who is new to recovery to get really excited and want to give back. It is the thought process of making amends to the community to themselves to their families etc. It is also not uncommon that individuals they had been caught up in an extensive drug history might have an academic or educational background that is not that of individuals who are licensed social workers or therapists etc. so I would argue that if we are serious about the role that peer workers and recovery coaches play then it is up to the industry to incorporate these individuals into the interdisciplinary teams and into the treatment team model. That would mean providing educational opportunities for technical educational opportunities supervision and feedback. Feedback often comes in the aftermath of a situation when it is far too late.
A lot to prove
As a person who has had personal challenges with employment as a result of addiction, I can tell you that when I moved into social services, I jumped on the first chance I could to find meaningful employment. As a result of my substance use, I felt like nobody would take a chance on me, and I felt like I had to take whatever people were willing to give me. Many peer support workers and recovery coaches feel this way too.
Often peer workers are made to feel as if they should be thankful for whatever is given to them, and they are but that is not the point. Peer workers generally work harder than other employees who do not have substance use histories due to their passion, this also creates great risk of compassion fatigue. This attitude of having something to prove can be a detriment to the peer, and it can also be taken advantage of from an organizational or agency standpoint. If you are a supervisor and you have one of these peers under your supervision, it can be hard to throttle them back and to build self-care into their responsibilities. When we are asking more-more-more, it is not uncommon that the peers will respond until there is no more to give.
Peer workers and those with lived experience want to do the work that they are passionate about while also earning a salary that is in line with the value-added to the workforce. Moreover, peer workers and those with lived experience need to be involved with every aspect of an organization, not just the ones that meet the criteria for a grant application. It is about meaningful involvement and engagement on every level.
Special thanks to Dr. Fred Rottnek, Emily Jung, ARCHway Institute and Jenna Nesbitt for contributing to this piece and providing your editorial eye.