Expert Recommendations for Peer Practice within Abstinence-Oriented Systems

Background and Purpose: Peer workers are nonclinical service providers with lived experience of recovery who often practice within systems that are grounded in abstinence-only philosophy. Although national guidelines recommend that peers be trained to support multiple recovery pathways, peers have expressed ambivalence about using harm reduction strategies, particularly when they perceive such strategies as conflicting with system-level policies or client goals. To inform the development of best-practice guidelines, this study explored expert recommendations for peer practice in contexts where abstinence is expected or preferred.

Methods: A national panel of experts in peer recovery support services (N=72) was surveyed using real-time Delphi software. The sample included certified peers (66.7%), peer supervisors (57.1%), service recipients (33.3%), and researchers (20.6%). Most identified as in recovery (85.7%), and many worked for harm reduction organizations (74.2%). Three items solicited expert recommendations as to whether peers should provide education about safer drug use when (a) working within abstinence-only treatment or recovery programs, (b) supporting clients who are court-mandated to be abstinent, and (c) serving clients whose goal is abstinence. Recommendations were provided on a 5-point scale, supported with open-ended comments. Qualitative data were independently coded by three members of the research team following Braun and Clark’s (2023) framework for reflexive thematic analysis.

Results: Experts most frequently emphasized the need for nuance (38.0%); however, many recommended that peers always provide information about safer drug use (33.1%), and a minority indicated harm reduction strategies would never be appropriate in these contexts (4.3%). Rationales were organized within four overarching themes: (1) pragmatism, (2) elevation, (3) self-determination, and (4) compliance. Experts were pragmatic (1), noting substance use may occur despite policy mandates or stated goals and citing evidence of the increased risk of overdose following periods of abstinence. Education about safer use was described as an evidence-based practice and an essential component of safety planning. Experts called for elevating professional ethics above institutional policies (2), which may undermine the integrity of the peer-to-peer relationship. Self-determination was a prominent theme (3); experts emphasized peers’ responsibility to provide information about multiple recovery pathways, including harm reduction. Some suggested that information about safer drug use be delivered judiciously to avoid harming clients seeking abstinence. Others recommended compliance with system-level policy (4), discussing integrity as a form of recovery capital, the need for balanced information about the risks associated with policy violations, and concerns for peers’ job security. Generally, recommendations that peers always provide information about safer drug use were associated with calls for pragmatism and elevation; recommendations that peers never do so within abstinence-only systems were tied to compliance concerns; and recommendations for nuance suggested consideration of context, with a focus on client self-determination.

Conclusions and Implications: Findings provide direction for the training and supervision of peer workers and highlight the need for guidance that reconciles professional ethics with institutional constraints. Though many experts suggested peers operate pragmatically, structural changes, such as clear policies, quality supervision, and labor protections, may be necessary to empower peers to provide evidence-based, client-centered support.