Understanding recovery experiences and occupational support needs among substance use peer workers: a qualitative systematic review protocol

Abstract

Introduction

The USA is facing a substance use workforce crisis, due in part to a shortage of providers. Substance use peer workers (PWs) fill a critical gap in the care continuum and are a growing sector of the workforce. In their daily work of providing non-clinical services to highly vulnerable people who use drugs, PWs are repeatedly exposed to stress, trauma and loss, which can adversely affect their well-being and recovery. This review aims to synthesise available evidence on PWs’ experiences working in the field, its impact on their recovery and their occupational support needs.

Methods and analysis

We will conduct a qualitative systematic review using the PRISMA flow diagram to illustrate article identification and screening. We will search six databases (Academic Search Complete, APA PsycInfo, CINAHL, MEDLINE, SocINDEX, PubMed) for English-language peer-reviewed scientific literature published between January 1, 2000, and August 13, 2025. Eligible articles must primarily focus on PWs’ perspectives and experiences related to working in the field and the impact of this work on their recovery. Article screening and data extraction will be conducted independently by two trained research assistants and supervised by a third researcher who will resolve any disagreements. We will use a thematic synthesis approach to synthesise findings of included articles and report synthesised findings in accordance with Enhancing Transparency in Reporting the Synthesis of Qualitative Findings guidelines. We will assess article quality using the CASP Qualitative Checklist and assess our confidence in individual review findings using the GRADE-CERQual approach.

Ethics and dissemination

Ethics approval is not required, as the research only involves published work. Findings will be disseminated via peer-reviewed publication, conference presentations and online via social media.

PROSPERO registration number

CRD420251105491

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review excludes research conducted outside of the USA and published in languages other than English, which may limit generalisability to other regions.

• Included studies may reflect publication bias due to this review’s focus on peer-reviewed literature and exclusion of grey literature.

• This review searches six interdisciplinary databases and conducts a supplementary search in Google Scholar to capture relevant articles.

• This review synthesises original empirical qualitative and mixed methods studies with a robust qualitative component using thematic synthesis approach is used to generate analytical themes.

• Confidence in review findings will be assessed using the GRADE-CERQual approach.

Introduction

The substance use crisis in the USA is at its worst.¹,³ Though there have been unprecedented investments in the substance use care continuum, the substance use workforce has not kept pace with the increased need for services,⁴ thus impacting the availability and accessibility of services for people with substance use problems.

Substance use peer workers (PWs) are a growing sector of the substance use workforce. PWs are helping professionals with lived experience of substance use and recovery who provide a wide range of non-clinical services to people who use drugs, including system navigation, linkage to resources and psychosocial support,⁵,⁸ as well as other frontline duties, such as street outreach and reversing overdoses in the field.⁸ PWs work in various organisational settings, have diverse job titles and possess varying levels of professional training and experience.^{5 7 9 10} Both the National Institutes of Health and the Substance Abuse and Mental Health Services Administration recognise PWs as vital to the workforce due to their unique ability to promote the recovery process through their lived/living experience.¹¹,¹⁴

PWs are often asked, above other substance use professionals, to intervene in high-stress emergencies and crisis de-escalation, which repeatedly exposes them to direct and indirect forms of trauma, including witnessing or learning of a client’s relapse, overdose or death.^{8 15 16} This stress is amplified for PWs who may deeply relate through their own personal recovery journey,^{8 15 16} leaving PWs potentially burdened with guilt, grief and fear of further loss.¹⁵ These role-related stressors are exacerbated by organisational stressors (eg, stigma associated with the peer label, job insecurity due to funding instability) and systemic stressors (eg, housing insecurity, harm reduction policy environment).⁸¹⁶,¹⁸

Chronic stress and exposure to environments can trigger substance use craving and contribute to negative mental, social and emotional health outcomes, such as psychological distress and secondary traumatic stress,^{15 17 19 20} as well as overdose-related compassion fatigue and burnout.^{21 22} This is particularly concerning, as PWs often lack access to necessary mental health resources, which may be a driver of significant unmet mental health needs. Further, chronic work-related stress can jeopardise recovery outcomes for PWs and result in a relapse to substance use.¹⁷

To date, the bulk of research on PWs has focused on understanding their role, job characteristics, effectiveness and employment outcomes.²³,²⁵ Research has increasingly focused on understanding PWs’ experiences working in the field, resulting in a primarily qualitative body of literature, which has yet to be systematically examined. A recent systematic review synthesised available evidence regarding the experiences of peer workers working at the intersections of substance use and homelessness²⁶; however, this review focused on how peer workers manage the process of providing peer support to people experiencing the same challenges. Thus, a gap remains in our collective understanding of how PWs’ recovery journeys and outcomes are impacted by their professional role as a peer worker. Synthesising extant research on PWs’ work experiences and its implications for their recovery will reveal important insights for research, policy and practice necessary for sustaining this critical sector of the substance use workforce.

Objectives

The primary objective of this qualitative systematic review is to synthesise available evidence on the perspectives and experiences of substance use peer workers (PWs) related to working in the field and the impact of this work on their recovery. Using the PICo tool for formulating qualitative systematic review questions,²⁷ the population is adult peer workers (aged 18+), the phenomenon of interest is their perspectives and experiences working in the field and its impact on their recovery, and the context is any setting that includes a peer worker role in the field of substance use in the USA. Thus, our research questions are as follows:

1. What are substance use PWs perspectives and experiences related to being a person with lived/living experience with substance use and working in the substance use field?

2. How does being a substance use PW impact one’s recovery?

3. What are the occupational support needs of substance use PWs to reduce relapse risk?

Review methods and analysis

Design

This study design is informed by Kolaski et al.’s Guidance to Best Tools and Practices for Systematic Reviews.²⁸ Accordingly, due to this review’s focus on the meaningfulness and impact of substance use PWs experiences, perspectives and priorities related to the impact of their work as a peer on their personal recovery, this review is considered a qualitative systematic review. As such, we will use the Cochrane Qualitative Evidence Synthesis²⁸ for methodological guidance. The study protocol is reported in accordance with PRISMA-P guidelines²⁹ (see online supplemental file 1). We have registered this protocol on the International Prospective Register of Systematic Reviews (PROSPERO) Database (#1105491).

Patient and public involvement

There is no planned patient or public involvement in the design, conduct, or reporting of this qualitative systematic review.

Eligibility criteria

Eligible articles will be those written in English with the full text available published in peer-reviewed journals between January 1, 2000, and August 13, 2025. Due to different global requirements in substance use peer worker certification and healthcare system infrastructure, our search will include only studies conducted in the USA.

Articles must report original empirical studies with a qualitative design, such as phenomenology, grounded theory, ethnography, action research or descriptive qualitative studies. Mixed methods studies will be eligible for inclusion only if qualitative findings are distinctly reported with sufficient detail (eg, themes, participant quotes, analytic methods). Only the qualitative components of these studies will be included and appraised.

A preliminary search indicated grey literature was unlikely to yield data suitable for synthesis (eg, participant quotes, rich narrative detail). Thus, grey literature (eg, agency reports) will be excluded from this review due to concerns related to (1) relevance to research questions, (2) lack of data (ie, participant quotes) needed for extraction for thematic synthesis and (3) lack of methodological fit needed for critical appraisal. We acknowledge that excluding grey literature may introduce some bias and will reflect on the implications of this in the final manuscript.

Study samples must be substance use PWs. For the purpose of this review, we define substance use PWs as individuals who have lived/living experience with substance use disorder and who work in the field of substance use. Due to the ambiguity of nomenclature, different titles for substance use PWs will be considered, including but not limited to Peer Recovery Support Specialists, recovery coaches and harm reduction workers. The primary topic of the article must focus on substance use PWs’ perspectives, experiences and/or the impact of peer work on PWs’ substance use recovery. Additional details about eligibility criteria are provided in table 1.

Table 1. Eligibility criteria.

	Inclusion criteria	Exclusion criteria
Language	Articles written in English	Articles that are not available in English
Study limits	Studies published between 1 January 2000 and 13 August 2025	Studies published before 1 January 2000 and 13 August 2025
Study sample	Individuals who have lived experience with substance use disorder AND work in the field of substance use	Individuals who do not have lived experience with substance use disorder Individuals who work in another field (eg, mental health)
Concept/topic	Studies that discuss the perspectives, experiences and/or impact of peer work on workers’ personal recovery	Studies that focus on medications or treatments for substance use disorders
Study design and source	Research was conducted in the USA Full-text articles Original empirical studies with a qualitative design Original mixed methods studies with a distinct qualitative component reported in sufficient detail	Research was conducted outside of the USA Articles that lack full text availability Studies with a quantitative design Dissertations, books, conceptual papers, agency reports, opinion papers, abstracts, conference proceedings, posters and preprints

Information sources and search strategy

This search strategy was developed in collaboration with a university librarian with expertise in behavioural sciences. While peer support has long been a core aspect of the substance use and recovery field, recovery coaching did not gain formal recognition and develop as a distinct profession until the early 2000s; thus, date limiters will be set to 1 January 2000 through 13 August 2025 to capture the full body of literature on the topic. The search will be conducted in English. To identify relevant scientific literature, the following six databases will be used to search for peer-reviewed articles: (a) Academic Search Complete, (b) APA PsycInfo, (c) CINAHL, (d) MEDLINE, (e) SocINDEX and (f) PubMed. These databases were selected due to their coverage of a wide range of relevant interdisciplinary literature, including psychology, medicine, nursing, allied health, sociology and life sciences. Search terms will be related to peer workers (eg, “peer recovery coach,” “peer specialist”) and recovery (eg, “recovery,” “personal recovery”). Specific search strings are provided in online supplemental file 2. We will conduct a supplemental search in Google Scholar to capture relevant articles that are not otherwise indexed in our chosen databases. We will record the results of each database search.

Data management and selection process

We will use Covidence³⁰ systematic review software to manage the search. Screening will be conducted by two trained research assistants and supervised by a doctoral-level researcher who will act as a third reviewer in the case of discrepancies. After conducting the database searches, we will import articles into Covidence and remove duplicates. We will use a two-step screening process to identify the final set of included articles: First, we will conduct title and abstract screening of all articles, in which articles that are not relevant will be excluded. Then, we will conduct a full-text review of articles that meet initial eligibility criteria. Search results will be presented in full in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.³¹

Data collection process and data items

Data extraction will be managed in Covidence. Data extraction will be conducted by two trained research assistants and supervised by a doctoral-level researcher who will act as a third reviewer in the case of discrepancies. The following descriptive information will be extracted for context: (a) bibliographic information, (b) study design, including study research objectives, sample size and sample characteristics and (c) key definitions of peer workers and recovery. These definitions must be explicitly stated by study authors. If a definition is not provided, we will not infer one and instead record the lack of definition. To answer this study’s research questions, we will extract results related to the impact of peer work on personal recovery, including illustrations of findings and research priorities. Additional details of the categories and fields used for data extraction are provided in table 2.

Table 2. Data extraction categories and fields.

Category	Fields
Publication details	(a) Publication title, (b) authors, (c) journal and (d) publication date
Study design	(a) Study methodology, (b) research objectives, (c) study location and workplace context and (d) sample size and characteristics
Key definitions	(a) Definition of peer worker and (b) definition of recovery
Results	(a) Key findings related to the impact of peer work on personal recovery, (b) illustrations of findings and (c) occupational support needs
Research priorities	Key insights on future directions or research priorities related to peer workers’ occupational well-being

Quality appraisal

We will assess the quality of all included studies using the Critical Appraisal Skills Programme (CASP) Checklist,³² a validated and widely recognised tool for assessing the quality of qualitative studies. The CASP Checklist is a 10-item tool that appraises: research aims, methodology, design, recruitment, data collection, reflexivity, ethical issues, analysis, findings and value. In terms of scoring, each domain is rated as ‘yes,’ ‘no’ or ‘can’t tell’ (as opposed to a numerical score) and accompanied by a narrative justification. No articles will be excluded solely based on their quality. Quality appraisal will be conducted independently by two trained research assistants and supervised by a doctoral-level researcher who will act as a third reviewer in the case of discrepancies.

Data synthesis

We will use Thomas and Harden’s³³ thematic synthesis approach to synthesise qualitative findings of included studies. This analytical method follows three stages: line-by-line open coding, developing descriptive themes and generating analytical themes.

Open coding will be conducted by two trained research assistants using Dedoose. Coding will be supervised by a doctoral-level researcher who will act as a third reviewer in the case of coding discrepancies. The two research assistants will then group codes into descriptive themes and offer an initial interpretation of findings to the team. The final stage of thematic synthesis aims to generate new analytic themes that ‘go beyond’ the content of the original studies and offer new interpretive constructs, explanations or hypotheses.³³ The full research team will participate in this process. Team members will independently, then collectively, interpret descriptive themes and generate inferences. The team will regularly meet to develop and refine analytical themes that directly address the aims of our review until consensus is reached.

We will report synthesis findings according to Enhancing Transparency in Reporting the Synthesis of Qualitative Findings guidelines³⁴ and present findings in a Summary of Qualitative Findings tables and Evidence Profiles. Further, overarching results will be summarised in tables, conceptual diagrams and quotes to illustrate themes.

Meta-bias assessment

We will consider forms of bias during our critical appraisal (using the CASP Checklist) and confidence assessments (GRADE-CERQual approach; described below) processes. We are aware that the body of included studies may reflect publication bias due to this review’s focus on peer-reviewed literature and exclusion of grey literature and will discuss these limitations in the final manuscript.

Confidence in cumulative evidence

We will employ the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to transparently assess our confidence in individual review findings.³⁵ The GRADE-CERQual approach assesses confidence in the evidence across four domains: methodological limitations, coherence of review findings, adequacy of data contributing to a finding and relevance of included studies to the review question(s). Two trained research assistants will make judgments about overall confidence in the evidence supporting the review finding according to GRADE-CERQual criteria (ie, high, moderate, low or very low). All findings will start as high confidence and be graded down if important concerns are present within a domain. A doctoral-level researcher will supervise this process, and the final assessment of confidence will be based on consensus among the review team. We will use the GRADE-CERQual Interactive Summary of Qualitative Findings (iSoQ) online tool³⁶ to assist in applying and managing the CERQual approach.

Discussion

 Substance use PWs are an imperative sector of the substance use workforce,¹¹,¹⁴ especially amid the current workforce crisis.⁴ Substance use PWs are regularly exposed to occupational stressors that can adversely affect their well-being and jeopardise their recovery journeys and outcomes.^{15 17 19 20} This systematic review will enhance the fields’ understanding of substance use PWs’ experiences working in the field, its impact on their recovery and their occupational support needs. The main outcomes of this review will be the key themes or concepts identified in the included studies as described by participants themselves (first-order interpretations) and studies’ authors (second-order interpretations) as they relate to recovery and occupational support needs.

 However, this review is not without limitations. First, this review excludes research conducted outside of the USA due to different global requirements in substance use peer worker certification and healthcare system infrastructure. Second, this review excludes articles published in languages other than English due to the research team possessing proficiency only in English and translation of non-English articles being beyond the scope of available resources. These limitations may limit the generalisability of this review’s findings to other regions. Third, this review’s focus on peer-reviewed literature and exclusion of grey literature may introduce publication bias.

 Nevertheless, this review possesses several strengths. To identify all potentially relevant literature, six databases spanning psychology, sociology, biomedical and life sciences and nursing and allied health disciplines will be searched. Additionally, a supplemental search in Google Scholar is incorporated in the search strategy to capture any relevant articles that are not otherwise indexed in the chosen databases. Further, this review synthesises original empirical qualitative articles and mixed methods studies with a qualitative component reported in sufficient detail using a thematic synthesis approach to generate analytical themes. Moreover, confidence in review findings will be transparently and independently assessed by two independent team members using the CERQual approach, with a final assessment of confidence based on consensus.

 Synthesising extant research on PWs’ work experiences and its implications for their recovery will reveal important insights for research, policy and practice necessary for sustaining this critical sector of the substance use workforce. Review findings will potentially benefit policymakers and leaders of substance use organisations that employ peer workers by providing a synthesised evidence base to inform peer professional development programming and staff well-being initiatives, as well as service design and delivery. Findings will also benefit substance use researchers by highlighting gaps in research and informing future research priorities.

Ethics and dissemination

Given that this research will only involve published work and is not associated with individual participant data, ethics approval is not necessary. Review findings will be disseminated via publication in peer-reviewed journals, presentations at academic conferences and online via social media.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.