The Evolution of Peer Services Across Systems:Navigating the Three Waves of the Opioid Epidemic

The history of the opioid epidemic is often told in three waves: the rise of prescription pills, the shift to heroin, and the current lethal dominance of fentanyl and synthetics. But there is a parallel history that is rarely told with the same clarity—the evolution of the workforce that rose to meet it.

As the epidemic mutated from a prescription problem to a public health catastrophe, the role of the peer support specialist has evolved from outsider advocate to essential system integrator. Yet, this evolution has not been seamless. While every wave of the crisis generated innovative peer-led responses, these innovations often failed to scale quickly enough to meet the need.

Today, we face a paradox: we have more “islands of excellence”—innovative programs in hospitals, courts, and child welfare systems—than ever before. Yet, we also face systemic inertia. Many communities are fighting a third-wave fire with first-wave infrastructure. To understand where we must go, we must look at how the role of the peer has shifted—and sometimes struggled to adapt—through each phase of this crisis.

1. Prescription Opioids (Late 1990s–2010): The Era of Advocacy & Infrastructure

During the first wave, driven by the aggressive marketing and misuse of prescription opioids, the crisis was often cloaked in the legitimacy of a prescription bottle. While millions of Americans were suffering, the broader healthcare system frequently framed addiction as a private medical issue or a moral failing rather than a systemic public health crisis.

In this era, peer support specialists were often viewed as outsiders. Because the formal healthcare system had not yet recognized the value of lived experience, the recovery community had to build its own lifeboats. This period saw the rise of the New Recovery Advocacy Movement and the formalization of Recovery Community Organizations (RCOs).

The innovation of this era was the RCO itself—an independent, non-clinical hub where recovery was centered on community connection rather than medical treatment. However, the challenge that began here continues today: chronic underfunding. As noted in the position paper “Unlocking the Potential of Recovery Community Organizations and Peer Recovery Support Services,” RCOs were established as the gold standard for fidelity, yet they remain chronically underfunded.

To survive, many RCOs rely on a “braided funding” strategy—patching together federal block grants, opioid settlement funds, and local contracts. While resourceful, this strategy has severe limits. It creates a heavy administrative burden, requiring RCOs to manage conflicting reporting requirements for every dollar, distracting them from their core mission of support.

2. The Heroin Surge (2010–2013): The Era of Access & the Fight for Fidelity

As the crackdown on pill mills increased heroin use, the crisis moved to the streets. Emergency departments (EDs) became the revolving door for overdoses, creating a desperate need for a new approach.

The innovation of this wave was the warm handoff. Peer support specialists extended their reach from the community into the clinic (EDs, treatment centers) to bridge the gap between overdose and treatment. Recognizing this value, and given the opportunity by the Centers for Medicare and Medicaid Services, states began to expand Medicaid reimbursement for Peer Recovery Support Services (PRSS), creating the first major boom in the workforce.

However, this expansion set the stage for the current fight for fidelity. In the rush to bill Medicaid, reimbursement rates were often set too low to support a living wage. In my research for Critical Public Health, “The Wages of Peer Recovery Workers,” we found that while the number of peer jobs exploded, many were precarious positions characterized by high turnover and burnout.

Crucially, this period revealed that funding without fidelity is a trap. Many of these new roles were located in non-peer-run, clinical settings that lacked a culture of recovery. Without supervisors experienced in recovery, peer roles became confused, and career ladders remained non-existent. This proliferation of sites lacking fidelity threatens the PRSS model itself. If services are delivered without the core values of mutual support, we cannot expect them to yield the same life-saving outcomes.

3. Synthetic Opioids (2013–Present): The Era of Integration & Standardization

We are now in the third wave, defined by fentanyl and synthetics. The lethality of the drug supply means the window to intervene is minutes, not years. The crisis is no longer just medical; it is entangled with housing instability, child welfare, and the criminal legal system.

The role of the peer support specialist has had to evolve again, moving toward deep integration. Some peers are now embedded in systems unrelated to recovery per se, where they are working as parent partners in child welfare cases, deflecting arrests alongside police, and supporting retention in primary care clinics.

Yet, this integration carries three major risks that threaten the soul of the profession:

Clinical Drift
As peers are absorbed into rigid systems like courts and hospitals, they are often pressured to act as junior case managers, losing the mutual, non-hierarchical connection that makes them effective.

Standardization vs. Fragmentation
While demand has skyrocketed, certification standards remain a patchwork. We currently navigate 50 different state certifications with varying requirements. The release of the SAMHSA National Model Standards for Peer Support Certification in 2023 was a critical step toward fixing this, but adoption remains slow. Without a unified standard, we risk a workforce that is “certified” in name but inconsistent in skill.

The Threat of Private Equity
A new and concerning trend is the entry of private equity firms into the addiction treatment space. These firms now own a significant portion of treatment facilities and often prioritize short-term profit over long-term recovery. The playbook for private equity involves aggressive cost-cutting and poses a direct threat to the peer workforce, viewing PRSS as a billable commodity rather than a human relationship. The recovery community should not ignore this threat.

The Path Forward: Scaling with Fidelity

As we look to the future, the question is not if we should use peer support specialists, but how. We have learned that simply placing a peer in a hospital or court is not enough if the environment is not built to support them.

To overcome the inertia of the past and fully address the third wave, we must shift our policy approach:

Contracting for Fidelity
Rather than hiring peers directly as low-wage employees, health and legal systems should contract directly with RCOs to provide these services. While Faces & Voices of Recovery’s position paper calls for new reimbursement approaches to solve the funding crisis, direct contracting is the practical mechanism to achieve this. It ensures peers are supervised by other peers and remain embedded in the recovery community.

Regulations for Non-Peer-Run Organizations
As PRSS expands into clinical and commercial settings (including those owned by private equity), we need guardrails. Regulations must ensure fidelity to the peer model even when the provider is not an RCO. As detailed in my recent paper for CAMHPRO, Strengthening Peer Support Services Through Improved Regulations in California, establishing clear regulatory standards is essential to protect the integrity of the service and the safety of the workforce.

Strategic Alliances
Advocacy must broaden by partnering with stakeholders in public health and the mental health Consumer-Survivor Movement. Though the New Recovery Advocacy and Consumer-Survivor Movements have historically run in parallel, they share mutual policy goals regarding the peer workforce, reimbursement sufficiency, and model fidelity. A united front can amplify demands for sustainable funding and standards.

Evidence of Fidelity’s Impact
The field urgently needs a well-designed study that measures the impact of model fidelity on PRSS outcomes. Data must demonstrate that peer services delivered by a CAPRSS-accredited program or organization yield better results than those delivered in low-fidelity settings.

The evolution of peer services has been a story of resilience and adaptation. Innovations have emerged at every wave. Now, the task is to ensure these innovations are not just isolated success stories, but the standard of care for every community.

Authored By

Kenneth D. Smith, Ph.D.