Dissertations & Theses (Open Access)

Date of Award

Spring 5-2023

Degree Name

Doctor of Philosophy (PhD)


H. Shelton Brown, III

Second Advisor

Sheryl A. McCurdy


The infrastructure for addressing problematic substance use and substance use disorder (SUD) across the US has shortages in many areas, and suffered additional challenges during the COVID-19 pandemic. One method to address shortages in SUD care infrastructure relatively quickly is to expand the peer workforce delivering peer recovery support services (PRSS). This workforce has expanded to cover most US states over the past two decades, but gaps in the evidence base for peer workforce development and economic evaluations of PRSS have persisted. To address these gaps, three studies were undertaken with the following aims: (1) Conducted a systematic review of the PRSS literature with a focus on the workforce development and economic evaluation gaps, (2) Assessed whether any personal history or psychosocial variables were associated with peer worker training stage completion likelihood, and (3) Analyzed the cost-effectiveness of long-term, post-treatment PRSS and created a cost-effectiveness calculator based off of that analysis. While workforce development and economic evaluation research gaps persist for PRSS, sufficient potential economic evaluation parameters currently exist in the peer-reviewed and grey literature to model the efficiency of certain forms of PRSS, and some aspects of peer workforce characteristics and peer workforce needs are in the literature. More research is needed on the potential relationship between peer worker site tenure, job satisfaction, and participant outcomes. Peer worker trainees in Texas are diverse, and both past support from a peer worker and criminal legal system involvement were significantly associated with greater training stage completion likelihood. Long-term PRSS is cost-effective to all willingness to pay thresholds and in terms of both quality-adjusted life years added and number of people in recovery at three years, and under a wide variety of conditions. Peer worker pay and service utilization have little impact on overall cost-effectiveness, so there is no efficiency justification for holding peer worker pay low nor limiting services. A pilot cost-effectiveness calculator for PRSS and bystander naloxone distribution was created and is currently in use at https://web.sph.uth.edu/cea/. The research conducted in this dissertation lays important foundation for future work on PRSS workforce development and economic evaluation of peer-driven substance use interventions.