Introduction

Although there was a promising decline in overdose (OD) deaths in 2018 [1], the downward trend has reversed and the United States experienced an increase in OD deaths, from 65,000 in 2018 to over 100,000 deaths in 2021 [2]. Among people who inject drugs in North America, approximately 44.5% will experience a non-fatal OD in their lifetime [3] and many will be seen in the emergency department (ED). Surviving an OD increases the risk for experiencing a subsequent fatal or nonfatal OD [4]. Non-fatal drug-related visits to the ED have also increased dramatically since 2008 [5]. People who experience a non-fatal OD are less likely to engage with the healthcare system for routine medical care but more likely to visit the ED [6], and PWUD have higher rates of ED visits and hospitalization overall, compared to their non-drug-using peers. In a Canadian study, the odds of having two or more ED visits within a year were higher among PWUD who endorsed greater social and behavioral health needs, including receiving disability or income assistance and having mental health comorbidities [7]. Therefore, when someone presents to the ED for an OD or a drug-related concern, it is an opportunity to engage them in harm reduction services and link them to substance use disorder (SUD) treatment and other services, if appropriate. The ED has been identified as a crucial point of contact [8], described as both a “teachable” [9] and “reachable” moment [10] for PWUD.

Peer recovery-based support services are a strategy for boosting the recovery capital of people who use drugs (PWUD) while also addressing social needs such as housing, social connectivity, and employment [11, 12]. Peer support was first introduced in the mental health system as a method of person-centered, collaborative recovery [13]. Variations of the model have since expanded into substance use including smoking cessation [14], alcohol education [15], and most recently, post-opioid OD support in the ED [16]. Utilizing peer support in the ED following a drug related visit is a promising method of engaging PWUD and has garnered national attention [11].

A certified peer recovery support specialist (CPRSS) is someone with lived experience in successful recovery from substance use, mental health and/or other co-occurring challenges [17]. While certifications requirements vary by state, other qualifications include a high school diploma, GED, or higher; specialized training in delivering peer services (including multiple pathways to recovery, ethics, motivational interviewing, advocacy, crisis management, education, recovery capital, etc.); completing an internship, supervised experience hours, and examination; and agreement with a code of ethics [17, 18]. CPRSSs have been shown to empower clients, reduce hospitalizations, and make linkages to other resources [13]. CPRSSs may play a role in reducing the stigma associated with methadone treatment and improve retention for SUD treatment [19]. Moreover, interaction with a CPRSS in the outpatient setting has been associated with increased buprenorphine treatment engagement and opioid abstinence [20].

Some studies have examined the qualities that make CPRSSs effective in medical settings outside of the ED [19, 21–24]. Lennox et al., (2021) identified three characteristics of an effective peer worker in a hospital setting (but not specifically the ED): intrinsic qualities (such as being reliable, open-minded, respectful, adaptable, empathetic, sociable, and a good listener), contributions of shared experiences (acknowledging a past experience with substance use allowed the patient to feel more comfortable and understood), and personal stability (defined as an individual’s substance use pattern, mental health support, housing stability, and access to social supports). However, the ED is a unique clinical care environment in some ways that might require setting-specific adaptations. What is not known are the individual, organizational, and system level dynamics that allow for integration of CPRSS in the ED with the ultimate goal of improving patient outcomes.

In part because CPRSS models have been determined to be feasible and acceptable to health care providers working in settings such as the ED [8, 11, 25–28], CPRSS models have been rapidly implemented across the United States in hospital and community settings in response to the escalating opioid OD crisis [11, 19, 20, 27, 29]. It has also been shown that people who use opioids are open to and welcome engagement with a CPRSS in a setting such as the ED [16, 19]. Three perceived positive characteristics of a CPRSS identified by people who use opioids are the ability to offer empathy, encouragement, and hope during an ED intervention immediately following an OD [16]. Stewart, et al. (2021), identified five key features of ED-based interventions for OUD: patient identification; treatment approaches; program structure; relationship with community treatment programs; and program financing, sustainability, and maturity. Peer support services were described as “a key part” of these interventions, however a discussion on the characteristics of the peers themselves was missing [8]. Other studies point to what makes an effective workflow for CPRSS in the ED but not the unique characteristics of the people that make these interventions work [11]. Although these studies provide useful information on the need to and process for engaging CPRSSs in the ED, a formal investigation of the unique conditions of the ED and the qualities that enable CPRSSs to deliver an intervention in an ED is lacking.

The ED is a unique setting within the healthcare continuum. The ED is a fast-paced, unpredictable, and often overcrowded setting designed for acute clinical care [30, 31]. Staff are often under the pressure of budgetary constraints while also being asked to assume an increasing patient to provider ratio and greater responsibility [32]. ED staff are trained to attend to patients based on acuity, first caring for those with life threatening conditions. Although the immediate response to an OD or other substance use-related concern can be acute care, the underlying SUD is a chronic condition, requiring longer-term interventions including medications (e.g., to treat opioid use disorder), longer-term rehabilitation, social support, mental health referrals, and employment or housing assistance, all of which CPRSSs can facilitate [33].

Finally, all EDs have a unique culture [34] and generally operate under strict policies and protocols (e.g., restricted access areas, security, and parking) within a fairly hierarchical organizational structure [35]. This environment may demand unique characteristics and skills of the CPRSSs that are not necessary in other intervention settings such as in primary care offices, SUD treatment facilities, or in less-structured harm reduction-oriented settings.

Addressing the spectrum of SUDs and their health consequences requires a robust workforce of substance use and mental health professionals, of which CPRSS are one component. Although the evidence for peer-based interventions is accumulating [11, 12], less information exists about the unique characteristics and special skills that CPRSSs bring to their work in the ED. This study describes CPRSSs experiences in a ED-based intervention for people with SUD and characterizes the qualities of CPRSSs that they identified as important for their work.

Material and methods

Results

All participants (n = 14) were CPRSSs ranging in age from 26 to 62 years old. The majority of participants were white (64%), female (71%) and had worked in SUD treatment for an average of approximately 6 years (Table 1). Most participants had also worked as a peer in other settings including homeless encampments, areas where people use substances outdoors, SUD treatment facilities, and behavioral health agencies.

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Table 1. Participant demographics (n = 14).

https://doi.org/10.1371/journal.pone.0289920.t001

In the sections that follow, we discuss three primary aspects of doing CPRSS work in the ED (Table 2). First, we discuss the approach that CPRSSs take and the orientation they have to their work. Second, we describe the inherent qualities that the CPRSSs identified as being important for their work, in general. Finally, we will discuss context specific hard and soft skills that our participants believe are essential for doing CPRSS work in the ED, specifically.

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Table 2. Categories related to certified peer recovery support specialist work in general, and in an emergency department setting, specifically.

https://doi.org/10.1371/journal.pone.0289920.t002

Discussion

ED-based CPRSS-delivered interventions for PWUD are being rapidly scaled up across the US, and evidence regarding their effectiveness is beginning to accumulate [29]. Our findings contribute to this growing body of literature by highlighting the nuances that shape how CPRSSs do their work in an ED setting compared to other settings such as general medical, inpatient hospitals, or community-based services. We found that CPRSSs consider this work a higher calling that they are driven to do. There are inherent qualities that they possess no matter what setting they are working in, and there are context-specific hard and soft skills that CPRSSs employ when working in an ED setting.

Participants in our study described that their approach to their work is shaped by an inherent sense of purpose and passion, often derived from their own experiences as people in recovery from SUDs. A “sense of purpose” and other reinforcers (such as employment, financial rewards, social support, and enjoyable experiences) have been proposed as critical components of sustained recovery from SUD and other challenges [41, 42]. In fact, the act of helping others or giving back as an act of service is foundational to some recovery pathways, including those that adhere to 12-step principles. Our findings suggest that working as a CPRSS can provide such reinforcement to some people (through providing a sense of purpose and meaningful employment), which could both improve patient outcomes and help sustain long-term recovery for the CPRSSs themselves. However, it is also important to recognize that CPRSSs may experience negative individual level dynamics such as occupational stress, burnout, compassion fatigue, and vicarious trauma through their work. Ensuring that organizations employing and supporting CPRSSs have high-quality, recovery-centered supervision is critical to improve training, retention, and quality of services delivered.

The ED is a unique context for providing interventions, and our participants suggested that both global and specific skills are required of CPRSSs in this setting. Soft skills, sometimes referred to as personality traits, are more challenging to assess than hard skills (like knowledge of the healthcare system), however are often equally as valued in the workplace [43]. The degree to which they can be learned versus are innate lies on a spectrum [43]. Globally, CPRSSs must have good rapport building skills, strong listening skills, and a non-judgmental attitude. These findings map well onto the IC&RC CPRSS certification Domains: (1) Advocacy, (2) Mentoring and Education, (3) Recovery and Wellness Support, and (4) Ethical Responsibility [44]. The value of a shared lived experience, of having “walked in their shoes”, was also identified as a critical component that distinguished CPRSSs from other providers of behavioral or social support, similar to findings from other research [41]. One unique finding from our study is that participants were not unanimous in their assessment of which experiences must be shared. While some people thought that a history of having a shared drug of choice was essential, others disagreed. The degree to which, and on what attributes, peers and patients should be similar in their lived experiences is an area for future research.

Additionally, working with both patients and professionals from a variety of disciplinary backgrounds and specialized training such as nurses, social workers, physician assistants, and medical doctors placed CPRSSs in the position of having to “code switch” as a way of engaging in ingroup identification, identity management, and distancing behaviors. Turner et al. (1987) [45] describes ingroup identification as an important component of social cohesion. Ingroup solidarity is associated with a high degree of commitment to their group and a strong sense of identity [46]. Scholars have noted that individuals in recovery often draw on organizational narratives that place an emphasis on treatment services for PWUDs as a technique to manage one’s own stigmatized identity [47, 48]. Based on the narratives that discussed the precarity of managing one’s identity within this setting by switching communication styles as well as the heavy emphasis on connecting individuals to detox, treatment, and formalized services rather than offering harm reduction strategies, further research could focus on the relationship between self-identity, cohesion in the recovery community, and whether the CPRSS’s recovery journey influences the services to which ED patients are connected.

Experiences of the CPRSS in our study were both similar to and different from the perspectives of ED staff. In line with other research among ED clinicians examining feasibility and acceptability of ED-based intervention programs [28], participants spoke of the potential benefits to the patients (by adding additional resources) and ED staff (by freeing up clinical resources and reducing their workload) conferred by adding a CPRSS program to the ED.

Other research has suggested that medical professionals on the front lines of the opioid OD epidemic are experiencing challenges including inadequate knowledge and training about SUDs, limited resources, and negative emotions directed at patients with SUDs [49]. As identified by our participants, these conditions can be exacerbated by high turnover of clinical staff, especially when understaffed hospitals rely on temporary travel nurses or other health care professionals [50]. According to our findings, integrating CPRSSs into the ED may help to develop best practices and provide expertise about SUDs that was otherwise lacking in the ED, thereby supplementing, and providing education for the clinical staff.

In research with patients, CPRSSs have been described as potential patient advocates who can help buffer the more negative experiences with some ED clinicians [16]. Furthermore, the unique attributes identified by our participants may help with the specific challenges of working with a patient who has just overdosed. For example, based on their shared lived experience, CPRSSs may be able to empathize with that patient better than a clinician who does not have the experience of overdosing. Additionally, the CPRSS can exercise their best judgement on what type of support to provide and to what depth. Knowing that the time immediately following an OD can be emotionally and physically challenging and that all patients are at different levels of willingness to change their behavior, the CPRSS may act as a confidant by primarily listening and sharing their story. Or they may provide referrals, complete paperwork, and drive the patient to their next stage of care. Although integrating a CPRSS program into an ED could help mitigate some challenges associated with caring for patients with SUD, care must be taken to ensure that the emotional burden is not shifted entirely to CPRSSs, which could jeopardize their own wellbeing. This reinforces our previous recommendation to ensure that CPRSSs have access to quality peer supervision that is recovery-focused and adequately addresses individual needs.

Future research

As the field moves forward with research on the effectiveness of ED-based CPRSS programs, there is a need to more precisely understand the essential elements of an intervention in the ED including dose, provider, and desired outcomes [11]. Related to dose, questions remain related to how long the CPRSS needs to meet with the patient while in the ED and how frequently post-discharge to be most effective. In terms of the intervention provider, a recent study found high rates of linkage to SUD treatment within 30 days from an ED-intervention, and found no difference based on whether the intervention was delivered by a CPRSS or a social worker [29]. However, more qualitative research is needed to understand the experiences of providing and receiving ED-based interventions from CPRSSs compared to other providers, which can inform more robust outcomes analysis. Future research can focus on the patient perspective after meeting with a CPRSS including how that experience impacted their time in the ED, subsequent substance use, and other outcomes. Further, given the well-documented increase in burnout among emergency medical providers associated with the opioid epidemic, research should examine the impact of providing these services on CPRSSs’ wellbeing. Lastly, by definition, CPRSSs are in recovery from substance use, mental health, or co-occurring disorders. Although this quality is considered essential, it may also create barriers to engagement in other harm reduction-oriented services that do not prioritize abstinence. There is a risk that peers could perpetuate SUD stigmatization of clients whose behaviors and priorities around substance use do not match their own [19].

Limitations

This study is not without limitations, largely related to generalizability and transferability. First, we used convenience sampling to recruit participants and were unable to contact all the eligible CPRSSs, which could introduce selection bias. Due to turnover within the organizations we were unable to reach some participants and cannot assess differences between our sample and non-respondents. Second, this study was conducted within two hospital systems in Nevada, a large, mostly rural Western state, and findings may differ from research in more urban areas with a more robust health care infrastructure. Third, the intervention and data collection began during the COVID-19 pandemic, which resulted in significant challenges to implementing the program in the EDs and may have resulted in fewer peers participating in this study. Fourth, the CPRSSs in Nevada are employed by a community-based organization (not the hospitals) with a harm reduction orientation. While there are benefits to the CPRSSs being employed by a harm reduction, community-based organization, our findings may differ from the experiences of peers employed by the hospitals or health care system.

Conclusion

ED-based interventions for people with SUD are rapidly scaling up across the US in response to an unprecedented number of opioid OD deaths. Although evidence for the effectiveness of peer-based programs exists in other settings, the ED is unique and may require some special adaptations and qualities to ensure program success. We found that CPRSSs working in the ED setting identified some global qualities, such as relationship building, communication skills, and shared lived experiences, but also some context-specific attributes that CPRSSs perceive as important for their work with PWUD. CPRSSs represent promising agents for the delivery of effective SUD interventions. Understanding what barriers exist at recruiting, training, and retaining this workforce is an important next step in delivering ED-based interventions with the ultimate goal of improving outcomes for PWUD.

Acknowledgments

This research would not be possible without the community-based organizations that employ peer recovery support specialists. Special thank you to Trac B and all the peers who took the time to talk with us. Thank you to Robert Harding for assistance with data collection. Lastly, we sincerely appreciate all the valuable feedback from the reviewers which helped us to improve the quality of the manuscript.