Peer supports may facilitate re-integration and substance use disorder recovery following incarceration

Rates of substance use disorder are high among incarcerated individuals and there are insufficient supports in place to facilitate effective community re-integration following incarceration. In this study, researchers described and pilot tested an innovative peer support intervention for individuals with substance use disorder following release from incarceration. The results provide insights into interventions that might improve outcomes for these individuals post-incarceration, but research with more rigorous tests of their effectiveness are needed to inform practice and policy.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Incarceration rates in the US are the highest worldwide, and the prevalence of substance use disorder among incarcerated and recently released individuals is exceptionally high.

Readjustment to community life following incarceration is a challenge for many individuals with substance use disorder and may require social support as well as assistance with housing, employment, education, and accessing other community supports to promote readjustment and recovery. Peer support specialists who are trained to provide support; mentoring; and employment, housing, and treatment planning assistance might provide added value to individuals post-incarceration and provide care that complements existing services (e.g., outpatient treatment, case management). While peer support models are being delivered in both community and clinical care systems across the U.S., there are few studies that evaluate the effectiveness of peer supports in the context of outpatient substance use treatment and case management. Also, while these models are promising, existing studies have generally not been designed to examine whether these services improve substance use and other recovery outcomes. This study provided outcome data of a pilot randomized clinical trial, comparing their peer support and voucher program to treatment as usual within an outpatient clinic offering outpatient substance use disorder treatment and case management. This study provides an important building block toward developing a better understanding of the value of peer supports in the recovery process, both overall and for individuals post-incarceration specifically.

HOW WAS THIS STUDY CONDUCTED?

This study was a randomized pilot trial of 100 previously incarcerated individuals comparing substance use treatment as usual or treatment as usual plus a peer support intervention on recovery outcomes including self-efficacy, treatment motivation, and substance use. Eligibility specified individuals over 18, current substance use disorder diagnosis (how diagnosis was determined is not reported in the study), at least 1 felony or 5 misdemeanors, and release from prison or jail within 3 months of study enrollment. Recruitment into the study took place within the Public Advocates in Community Re-Entry (PACE) program, a non-profit and community-based program for previously incarcerated individuals in Indiana, and spanned October 2017-December 2018. The researchers conducted interviews with clients at baseline (i.e., the day participants first enrolled in services at PACE, which could have been at any point from one day to three months after release), and again at 6- and 12-months following baseline. Participants in the study received $60 for each interview (up to $180 total) and were entered into a raffle for 1 of 2 $100 gift cards at each assessment wave.

The peer support intervention – Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT) – is based on a peer service model and designed to pair peer support workers, who are current or former clients of the PACE program, with a current client to support recovery and facilitate community reintegration following incarceration.

The peer support workers were certified by the state as “peer recovery coaches” to provide mentoring, facilitate support groups, and provide employment and housing assistance. The peer support intervention also engaged participants with recovery-oriented treatment planning consistent with client goals and provided vouchers to pay for recovery-oriented services. Clients assigned to the SUPPORT treatment condition received 12 months of individualized peer support and $700 in vouchers to cover an undefined group of “recovery support services” that were not covered by the program including housing, employment, treatment, transportation, childcare, education, or after care planning services.

Clients in the treatment as usual condition had access to the same standard of care that all individuals receive in the PACE program, including substance use counseling and case management services, but did not receive individualized peer support or vouchers.

In this pilot study, the researchers measured several outcomes that they considered to be mechanisms of action of their intervention, and primary study outcomes. The mechanisms of interest in this study included self-determination, treatment motivation, and general self-efficacy. Their primary outcomes included self-reported substance use and abstinence (e.g., nicotine, alcohol, sedatives, tranquilizers, opioids, stimulants, cannabis, hallucinogens, inhalants), motivation to change substance use behavior, and quality of life.

Participants in the study were 39 (SD = 10.4) on average, predominantly male (58%) and white (60%), followed by black (36%) and multiracial (4%). Participants were also predominantly straight/heterosexual (92%) with 8% reporting gay/lesbian, bisexual, or “unsure” identities. The vast majority (88%) were unemployed, 35% reported completing a college education, 45% held high school diplomas or equivalencies, and 20% reported lower than a high school education. The authors did not report on the types of substance use disorders or other relevant psychiatric or medical diagnoses of their sample.

WHAT DID THIS STUDY FIND?

Attrition rates among the participants in the study was high, with over half leaving the study before 6 months, and more than 2 out of 3 leaving before 12 months.

A total of 77 out of 100 participants left the study. Three participants died during the study period and the remainder were recorded as “lost to follow up,” which included re-incarcerated or leaving the program. Participants with higher treatment motivation and who had longer delays between their release from incarceration and treatment admission were less likely to drop out. That is, counter to what might be expected, shorter time lags between release and treatment admission were associated with a higher likelihood of dropout. All data from 6-month and 12-month follow-ups summarized below reflect just the sub-set of 23 individuals who completed these assessments.

The authors noted improvements on self-reported substance use but no significant differences between treatment groups.

Total abstinence from alcohol and other drugs increased in the peer support groups from 70% to 84%, but decreased in treatment as usual from 74% to 59% between baseline and the 6-month follow-up. While these, of course, reflect descriptive differences, they were not statistically significant. Participants in both groups maintained high rates of abstinence but reported decreases between the 6-month and 12-month follow-ups (down to 77% for SUPPORT and 59% of individuals in the treatment as usual condition).

Both groups generally improved on other recovery-related measures, with inconsistent differences between groups.

The peer support group reported positive changes in self-efficacy (their confidence in their ability to accomplish things they set out to do) whereas participants in the treatment as usual group reported positive changes in their perceived choices, or their feelings about the degree to which they have choices about how to behave. The two groups were statistically similar, however, on each of these outcomes at both follow-ups.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

The authors describe outcomes of a pilot randomized clinical trial evaluating changes in substance use and other recovery-related outcomes among recently incarcerated individuals engaged in a substance use treatment and case management program. Half of participants were assigned to receive individualized peer support and vouchers for 12 months in addition to treatment as usual, whereas the remainder of participants only received treatment as usual.

While the authors reported that individuals in both groups reported similar improvements on substance use and recovery-related outcomes (e.g., self-efficacy) over time, follow-up rates were 28% and 37% in the SUPPORT and treatment as usual conditions, respectively, and the improvements reported only included individuals who completed follow-ups.

It is possible individuals dropped out of the study because they were not doing as well, making it difficult to determine how the sample overall, and for each group, fared over the 1-year follow-up period. As such, while the peer support intervention described here remains a promising approach to assist individuals with substance use disorder after incarceration, more research is needed to examine the effectiveness of this and other similar peer support interventions. While the authors did not report feasibility and acceptability data from the participants, the study helps support proof-of-concept and is a demonstration of the implementation of a peer support and voucher intervention for individuals with substance use disorder recently released from incarceration.

As mentioned above, there was a very high level of drop out from the study, suggesting that greater attention may be needed to keep similar clients and participants engaged in treatment and research, respectively. The authors further found that dropout was highest among individuals with lower levels of treatment motivation and who initiated treatment sooner rather than later following their release from incarceration. The latter and somewhat counter-intuitive finding might relate to the possibility that the participants who were most likely to stay in the study and in treatment had less immediate need for treatment following their release, were more stable by the time they entered treatment, or had more support and resources available to them after their release from incarceration. If so, these individuals might have characteristics or resources that promote treatment engagement and study continuation relative to those who started treatment earlier. In contrast, individuals who started treatment earlier might have been more severe, may have required more intensive treatment or resources, and might also have more closely resembled those who never sought treatment in the first place (e.g., higher level of ambivalence).

LIMITATIONS

The authors described their study as a pilot study but also reported recruiting 20 more participants than was required based on their power calculations. However, the high level of attrition in the study limited the number of participants included in analyses, potentially making it more difficult to detect a difference between groups (i.e., statistical power). Indeed, their subsequent power analysis suggested that they were underpowered in the current study.
While high attrition is understandable given the study design and population, the fact that less than 1 in 3 completed the 12 month follow up may severely limit any conclusions drawn from the study.
The authors did not define what was meant by vouchers or report what recovery-oriented services entailed. Further, since clients in the peer support intervention condition received both peer support and vouchers, it is hard to know which of these or if both of them accounted for the results of the study.
Participants were eligible within a 3-month window following their release. The time lag between release and treatment orientation was a predictor of dropout, which might suggest cohort effects between those who sought treatment earlier vs. later following their release. However, the authors did not report on characteristics of these different groups to be able to test for any differences by time since release.

BOTTOM LINE

Outpatient treatment, case management, and potentially peer support represent promising intervention strategies for individuals with substance use disorder in the weeks and months following release from incarceration. While receiving additional peer support on top of outpatient treatment, descriptively, was associated with improved substance use outcomes, the high drop-out rates from the study make it too difficult to draw conclusions. While interventions that leverage peer recovery support specialists are promising, more effort and support is needed to increase sustained treatment and research participation in the future to reduce attrition and increase the rigor of tests of their effectiveness. This study provides important information on the challenges of studying this population that can inform future research.

For individuals and families seeking recovery: Individuals face a variety of stressors as they re-adjust to daily living following release from incarceration. Common obstacles pertain to employment, housing, medical and mental health concerns, lack of finances or social supports, and limited means of accessing effective treatments. For individuals and families, substance use disorder treatment and case management that helps to improve housing, employment, education, and recovery prospects appears to be highly beneficial. While peer recovery supports are promising, more research is needed before we can confidently say these services are likely to help.
For treatment professionals and treatment systems: Clients face a variety of obstacles as they readjust to life following release from incarceration and may need added support and assistance to obtain and maintain housing, employment, training, and to achieve and maintain substance use disorder recovery. The authors of this study describe outpatient treatment and case management options that may be efficacious, as well as a model for delivering a peer support intervention to supplement usual care. While participants in both conditions in this study improved similarly, there may be benefit from implementing peer support specialists to supplement usual care, given peers’ ability to lead by example, provide information, and to support clients in recovery beyond that which is typically provided in outpatient care clinics.
For scientists: The authors of this study did not detect significant between group differences which might relate to insufficient statistical power. Prior to the execution of the study, the authors projected they needed 80 participants to achieve 80% power. They later indicated they may have been underpowered (largely due to high levels of attrition) and estimated that 304 participants would be needed to detect between-group differences. Replication of this kind and magnitude could be beneficial to evaluate the statistical significance of their results, which included small and moderate effect size differences between groups in the absence of statistical significance. As the authors point out, there is a dearth of rigorous research on this topic; replication may benefit from careful attention to research design, with preference for randomized clinical trials to evaluate the efficacy of peer support interventions. Future research might also benefit from examining the use of peer recovery support specialists specifically to facilitate adherence to medications for substance use disorder (e.g., buprenorphine). Despite the obvious limitations of the findings, this study nonetheless provides important information on the challenges of studying this population that can inform future research protocols.
For policy makers: The number of individuals incarcerated in the U.S. is higher than anywhere else in the world, and rates of substance use disorder and substance-related deaths among incarcerated and recently released individuals are exceptionally high. Engaging these individuals in therapy, offering case management, and potentially peer support may provide critical support during the post-incarceration readjustment phase. However, research in this area remains underdeveloped and increased funding and support could increase the development, implementation, and evaluation of novel intervention strategies to engage these individuals in care and retain them in treatment to facilitate readjustment and recovery from substance use disorder.

CITATIONS

Ray, B., Watson, D. P., Xu, H., Salyers, M. P., Victor, G., Sightes, E., Bailey, K., Taylor, L. R., & Bo, N. (2021). Peer recovery services for persons returning from prison: Pilot randomized clinical trial investigation of SUPPORT. Journal of substance abuse treatment, 126, 108339. DOI: 10.1016/j.jsat.2021.108339