Author: Nigel Brunsdon

These are some of the thorniest issues faced when hiring peers:

• Special accommodations for people who use drugs (PWUD) – ideally, allow people who use drugs to adjust their work schedules and responsibilities to their needs as much as possible.
• Workplace disciplinary issues – issues should be documented and handled exactly like any other employee subject to progressive disciplinary action.
• Professional boundaries – because they are from the community, peers occasionally struggle to maintain professional boundaries so it’s important to concretely discuss the differences in responsibility between being a community member or friend and being a professional. This includes, but is not limited to, participant confidentiality and employee safety.
• Drug-free workplace – many organizations must sign “drug-free workplace” pledges established in the 1980s. No one who signs these pledges is required to drug-test employees.

Despite stereotypes, people who use drugs, sex workers, and other people who are marginalized come from many walks of life and have many patterns of behavior. Many of the considerations here come from leaders managing chaotic employees – an important source of wisdom for all employers, but please remember that not every person using drugs is chaotic.

• Expect to train peers personally, informally, and in short doses – be prepared to offer training in chunks that are ninety minutes or less and refer to the person’s lived experience.
• Expect to train everyone – peers may be experts in drug use but they may have things to learn about biowaste safety, de-escalation, how your program works, and even safer injection – expect to train all workers in the basics.
• Be open to learning– the peers are already experts and will also have things to teach.
• Have varying levels of involvement or employment – the most successful peer programs have levels of employment that allow people to stay employed even when their drug use is more chaotic. For example, an organization may have regular schedules for folks who can keep up with them and relief slots on the schedule for folks who are new or more chaotically using.
• Employee expectations apply to everyone – create and enforce the same reasonable and compassionate policies for all employees. These policies should relate to behavior, but not drug use per se.
• Do NOT create policies that set peers up for failure – some peers may not be familiar with “professional cultural expectations”, such as perfect punctuality and what “workplace appropriate” attire or humor might be. Therefore setting up cultural expectations when they are not essential for your program creates situations where peers who are doing good work might “fail” anyway.
• Train for redundancy – SSPs should cross-train all staff in multiple areas. This is especially true if you are hiring folks who may be in chaotic use.
• Work to people’s strengths – observe people, figure out what they are good at, and put them there. For example, if you have someone who is great with the public but weaker on paperwork and someone else who is great on paperwork but finds direct contact with the public challenging, put those people in appropriate roles that will play to their strengths.
• Work with people’s schedules – one of the biggest barriers peer employees and volunteers face is the expectation they will be at a place at a given time, especially in the morning. As possible, work with peers who have scheduling issues to find a schedule they can succeed in.
• Increase responsibility incrementally – drop-in shifts, fewer initial hours, and “piece work” are great ways to start having people gradually take on responsibility.
• Allow people to come and go – another thing the best peer programs have in common is that they are flexible and understanding, allowing more chaotic peers to increase or decrease their responsibilities as necessary.
• Pay people in a way that works for them – peers and other people with less stability often do not have access to bank accounts. In order to cash a check, someone without a bank account has to pay a check cashing business up to 12% of the check’s value in fees. These businesses exploit poor people, and iIt would be unethical for an SSP to put an employee in a position to lose some of the money they have earned in this way. Because of this, organizations must be prepared to pay employees in cash or by cash app if an employee needs it.
• Consider piece work – instead of requiring hourly work and paying an hourly rate, organizations may consider paying by the job instead. This may mean deciding on the value of an activity (say one SSP shift or 50 kits packed) and paying accordingly.
• Hold people with love no matter what – one of the most important things about employing peers is that no matter what, they should be treated with dignity and compassion in every circumstance, even those where discipline, terminating employment, or severing a relationship is necessary.

There are many things to consider before you hire anyone, but the following were cited by many leaders as important to consider before hiring peers:

• Start internally – if you are an organization hiring peers for the first time it is ideal to start by considering the structural barriers to employment for peers and the internalized stigma that current staff may hold toward peers.
• Confront stigma – regardless of where you are in the process to create the environment necessary for peers to be successful, it is essential that organizations confront and deconstruct stereotypes and stigma that people may have toward the people served by the SSP. Like any kind of self-examination, working through this is sometimes painful and difficult but always powerful and important if you’re truly making a commitment to the peers you are hiring. Make no mistake – stereotypes about people who use drugs, sex workers, unhoused people, and folks suffering mental illness are incredibly pervasive and we cannot help but internalize them. So the work of confronting stigma includes peers themselves.
• Define your terms – make sure you are clear about who you are defining as a “peer” and that the peers you hire are actually from the community (rather than just “reflecting” it- they are not the same).
• Check your insurance – if you’re offering health insurance make sure your insurance covers substance use disorder treatment, medication assisted treatment, and a robust mental health care package.
• Look for reliability and enthusiasm – reliability and enthusiasm were cited by leaders as the most important traits to look for in all SSP employees, especially peers who may not have formal work experience.
• Don’t tokenize peers – hire peers on the strength of their individual character and because you think they can do the job effectively, not because they check a box on your grant report or harm reduction to-do list.

There are many reasons why programs have historically been resistant to peer involvement. Sadly, one of the main reasons is stigma, and the regulations that have resulted from stigma, about people who use drugs and other peers. Traditional stereotypes about people who use drugs, especially those using chaotically or those using so-called “hard” drugs like opioids and stimulants, are that they are unreliable, untrustworthy, and incapable. Similar unfair stigma exists about sex workers (lazy, untrustworthy, unreliable, dishonest), folks suffering mental illness (incapable, frightening, dangerous, completely irrational) and the unhoused (lazy, dishonest, dirty, pathetic).

As with every group that unfair stereotypes have been applied to, the fact is that none of these things are true about every individual in any group even though there may be individuals in every group who exhibit these traits. Importantly, the evidence is clear – peer-involved programs reach more people more effectively than those who are only staffed by so-called “professionals”.

The stigma around drug use is so strong that it is often made into workplace policy banning “drug use” and calling for invasive practices such as drug testing.

Here are a few important reasons why employing peers is critical, especially for programs that are not created by people who use drugs:

• Peers are experts – this is, by far, the most important reason to hire peers and put them in decision making roles. They are experts on using drugs, doing sex work, navigating being unhoused and/or mental illness. It is universally true that people who have personal experience understand things more clearly than those who only know about them in the abstract. This is especially true when talking about highly stigmatized activities.
• They have authority – peers often have a moral and expert authority that people who are naïve to those experiences can never have.
• It helps address structural violence – many marginalized people face the structural violence caused by poverty and other structures of inequality, alongside stereotypes about who they are and what they are capable of. This creates a vicious cycle in which people will not hire marginalized or criminalized people, which only perpetuates the cycle of poverty and criminality. Giving people work and legitimate sources of income is an incredibly concrete thing SSPs can do to address that structural violence, one employee at a time.
• It shows the community you’re committed – hiring people from the community shows that an organization is authentically committed to being a part of that community.
• Provides people with skills and experience – because many of the people served by harm reduction programs have been criminalized, they may have little or no experience in the mainstream workforce. Harm reduction work can be a meaningful step toward sustainable employment and economic empowerment.
• Strengthens community – harm reduction organizations thrive best when they are a part of, and form their own, communities. Making the people of the community a working part of an organization builds the program into the very fabric of the community.
• Gives peers esteem and a path to belonging – working to help others is a way for people to build a sense of belonging and esteem, both of which are deeply undermined by the stigma of being a marginalized person.

Peers are people who are actively using drugs, doing sex work, living unhoused, and/or with mental illness. Having peers volunteer, work for, and run harm reduction organizations is critical to ensure that (following the Principles of Harm Reduction) “drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.” and to “affirm drug users themselves as the primary agents of reducing the harms of their drug use”.

Moreover, more than 30 years of HIV prevention and other public health practice clearly demonstrates that programs with peer involvement have better outcomes than those that don’t.

The following four articles in this section discuss why and how to involve peers in your program and addresses many of the top issues that programs and peers face regarding hiring and retaining peers.

Volunteers, even those with lived experience using drugs, always need training. Volunteer training in harm reduction varies from very minimal (less than 5 hours) to very long (120 hours) and there are many ways to provide training at an SSP. The bare-bones minimum basics that every SSP must train all staff on includes:

• Universal Precautions and site safety
• De-escalation
• Program policies and procedures
• Participant privacy and confidentiality

It should be emphasized that this is the very minimum that SSP personnel should have. Just doing the bare minimum is usually inadequate. Most people, even those with lived experience, will need further training in:

• Harm Reduction
• Outreach
• Models of Behavior Change
• Cultural Competency for SSP Participants
• Safer Drug Use
• Overdose Prevention and Response
• Safer Sex Work
• Trauma
  And more…

Training can be achieved in a variety of ways including relying on national or regional technical assistance providers, hiring outside trainers, or creating and providing training “in-house”.

Deciding how volunteers will be recruited and vetted should be part of any volunteer plan. The population served by the SSP is the most obvious group to include in any recruitment plan for an SSP. Others in communities frequently looking for volunteer opportunities are college and university students (especially students in social services and medicine) and retirees. These communities often have flexible schedules and are either looking to launch careers or give back to their communities. In addition, members of participants’ communities, socially conscious faith communities, and folks who have changed their previously chaotic relationships with drugs are also excellent people to recruit as volunteers.

SSPs should consider having regular open house or tour events so potential volunteers and other community members can see the organization in action and get a sense of whether it is a good fit for them. Some programs allow potential volunteers to “shadow” during shifts, while other SSPs don’t feel comfortable having “tourists” on site. Whatever you decide for your program, do at least have a conversation about participant confidentiality with anyone who visits your program and will encounter participants – including potential volunteers and funders.

Recruitment does not stop when organizations have people in the door. It is equally important to vet potential volunteers to make sure they have the temperament and capacity to treat SSP participants with the dignity, compassion, and respect that every SSP participant should expect at harm reduction programs.

To vet volunteers, consider having both a written application and an interview process that allows you and the candidate to get a good sense of each other. Many folks recruiting volunteers feel awkward vetting people who are willing to work for free, which is understandable under the idea that “beggars can’t be choosers”. To overcome this awkwardness, always remember that vetting volunteers is a way of ensuring a good cultural fit and protecting your participants and work environment.

For permanent volunteers, who are almost like staff, ask for a commitment of at least a year. SSPs serve highly criminalized populations, so they rely heavily on the goodwill and trust of community members. That trust is built through relationships and takes time. Remember, you are asking your volunteers to make a promise to your community, don’t be shy about the expectation that they commit to that community.

Volunteers are in many ways the lifeblood of harm reduction programs, representing a large portion of the total syringe access workforce. These volunteers can be peripheral, such as volunteers providing help with activities like kit making and paperwork, or they can help in more central, direct service roles providing syringe access and other harm reduction services on the ground.

Every SSP should consider taking advantage of the potential that volunteers represent for the expansion and sustainability of their agency. Many SSPs “start from the middle” with volunteers because they are volunteer initiatives to begin with. so “creating a volunteer plan” can seem redundant.

However, even if you are a volunteer yourself, creating a volunteer plan can help you get a sense of what your program needs, and what your responsibilities and challenges are with regard to taking on more volunteers. The most successful volunteer programs must decide:

• What you need volunteers for – Decide what tasks and/or jobs can be done by volunteers and how many volunteers you would ideally like to have.
• What training and support your volunteers will need – Assume that your volunteers will be coming to you with little or no experience doing the work your program does and plan on training them accordingly. Experience with drug use or lifestyle is not the only training needed to provide harm reduction services. In the same vein, just because someone has an academic or professional background related to harm reduction does not mean they automatically know what it is like to use drugs or live as a person who uses drugs.
• What you are offering for your volunteers in return for their help – It goes without saying that volunteers won’t be paid in cash, but successful programs also understand that everyone needs to be appreciated and they find ways to compensate volunteers through occasional gifts, volunteer appreciation days, opportunities to attend conferences, professional support (such as training and professional and academic recommendations) and, paid work if the option arises.
• What your expectations are for your volunteers – Finally, you must set clear expectations and boundaries for volunteers including commitment, attendance, behavior, training, and so on.

Volunteers in harm reduction programs fall into three broad categories: short-term, permanent, and secondary.

• Short-term volunteers – Short-term volunteer positions don’t usually include participant contact because SSPs participants do best in programs where they are able to develop relationships with SSP staff. Examples of short-term volunteers include folks who volunteer for events and kit making.
• Permanent volunteers – these are long-term volunteers who have contact with participants. SSP volunteers may run shifts, do testing, provide naloxone training, or any other service the organization provides that they are trained to do.
• Secondary or community volunteers – these are SSP participants who provide secondary access to harm reduction supplies (taking syringes, kits, naloxone, or information to their friends), and they should be considered an essential part of your capacity to reach the most secluded participants in the community.

Volunteers are a commitment and will take time to develop and support, but the reward is an enthusiastic pool of passionate community members who can help take responsibility for ensuring your participants are provided with the best possible services, allow staff to focus on other program and service areas, and increase your community footprint and brand by acting as ambassadors for your organization.

In harm reduction, peer volunteers are often seen as ideal because community members can relate to them and they provide another way for people to work on their own needs while providing for others. They have essential lived experience and tend to be less judgmental and stigmatizing towards participants. People from outside the community, as long as they approach participants with respect and compassion, can offer a different perspective and represent a particular kind of privacy to some participants because they are not from the community. Many of the strongest programs in harm reduction have drawn significant strength from diversity so it is best to have a wide volunteer base, which should always include peers.

There are some ethically challenging or particularly difficult issues that have emerged at SSPs over the years. These issues have been the subject of a good deal of debate and a variety of responses. Your organization should always place your values and the lived experience of the people you serve first regarding all policy decisions, especially those that have multiple conflicting responses that are compassionate and reasonable. Some particularly difficult issues are:

Bathrooms/ On-Site Drug Use – Bathrooms have always been an issue in SSPs because of their potential use as sites for injection drug use. On the one hand, withholding such an essential facility – especially from populations who may not otherwise have access to restrooms is clearly unethical for any agency providing public health services. At the same time, many SSPs cannot allow the drug use that may take place inside bathrooms because of laws, leases, insurance, etc. A common approach for SSPs with bathrooms is to have a policy opposing using drugs on site while simultaneously preparing for the possibility that participants may not follow it. Organizations prepare by having a lock on the bathroom that can be opened from the outside, strict time limits on (and/or monitoring of) restroom use, a sharps container, excellent lighting, available surfaces to cleanly set up a shot, and naloxone (and people prepared to administer it) on-site. Things that have proven less functional for managing this possibility including threatening participants with law enforcement and installing black lights or cameras.

Weapons at Site – Another possible issue at SSP sites is weapons. The fact of the matter is that it is not unusual for SSP participants to carry weapons occasionally. It would be unrealistic for SSPs to entirely ban weapons, but it is also true that weapons create a less trustworthy and community-oriented environment and are uncomfortable for some people to be around. To address this, many programs have adopted “don’t ask/don’t tell” policies, or policies that require weapons not to be visible.

Children at Site – Another contentious issue for SSPs is the presence of children, on site or during home delivery. This is difficult because under many state laws, parental drug use may be assumed to be parental neglect and must be reported by certain types of service providers to child welfare authorities. However, the mere USE of substances is NOT grounds for abuse or neglect – rather one needs evidence of neglect outside of mere substance use (i.e. bruises, scars, harms, etc). Reporting parents to the authorities can lead to children being taken away and to parental incarceration, outcomes that evidence shows is not beneficial for children or families. To avoid the issue of mandatory reporting, some SSPs have chosen to ban all children from their sites. However, this can have the potential consequence of further marginalizing and endangering critically vulnerable populations including very young people who use drugs and/or caregivers. Other organizations have learned that SSP workers are not mandated reporters, which means they do not have to report parents who are people who use drugs. (Some professionals, like therapists, are mandatory reporters and should advise participants, especially those they may be required to report, of their legal obligations.) When SSPs are intentional about avoiding mandatory reporting, parent and underage participants should be told that they are not in danger of being reported and asked if they need any extra services, referrals, or support.

Involving Law Enforcement – Another issue SSPs face is whether or not to involve law enforcement in escalated situations involving SSP workers. Because calling the police would seriously undermine community credibility, and because the communities served by SSPs are more likely to experience violence or murder at the hands of police, it is inadvisable for SSPs to call the police under almost any circumstances except for the most extreme. Instead, SSPs have developed a variety of ways of de-escalating situations to avoid needing to call the police. These include planning program details such as use of space, transparency, and service provision with a focus on creating community trust and goodwill. Other important strategies include training personnel in identifying agitation, de-escalation techniques, and empowering participants to help ensure sites are kept safe for everyone.

Many of the essential policies that SSPs will use, such as workplace theft and sexual harassment policies, are generic to NPOs and can be copied directly from a trustworthy source like a reputable organization or legal resource. Other policies are either, in whole or in part, unique to harm reduction and/or essential to SSP service provision. These include policies for:

Diversity, Equity and Inclusion (DEI) – although most nonprofits have some form of DEI policy, harm reduction programs have some specific issues with regard to these policies. An SSP’s DEI policy should include provisions regarding the marginalized folks who they serve including people who use drugs, sex workers, people with a history of incarceration, and unhoused people.

Participant Definition – every SSP must define who is eligible to be a participant in their program. This includes defining both communities that they serve, as well as limitations on who they serve (if there are any). Because discrimination is fundamentally wrong, as well as illegal, the default for every SSP is to serve anyone who identifies as a person who uses drugs or needs SSP services. However, some programs have chosen to concentrate on a subset of the population who may have particular needs (e.g. people who use stimulants) and/or those who may experience particular marginalization (e.g. youth and/or transwomen). In those cases, service limitations must be clearly stated and publicized.

Participant Privacy – because the populations served by SSPs are heavily policed and criminalized, they have a healthy and rational distrust of authority. Because of this distrust, every SSP must define how much information they will collect and/or share with outside entities about the people they serve. The default for harm reduction programs has been to try and maintain, at best, participant anonymity (collecting no unique identifying information) or, at least, confidentiality (collecting the least information possible about individual program participants often in the form of “unique identifiers” created using formulas developed by the programs). An example of a unique identifier is “the person’s initials, date of birth, and the first letter of their mother’s first name” – information that could not be used to identify the person but will still be unique to them and allow programs to track individual program participants they have reached. Whatever decisions the program makes regarding these issues, it is necessary for the reputation of the SSP and their ability to provide effective services that the privacy policy is transparent to program participants and followed by all staff.

Communications – it is essential for SSPs to develop a plan for communications – both with other stakeholders and community members but, most importantly, with participants. This should include both who should do the communication and how it should be done. Having a plan in place avoids a variety of potential conflicts.

Universal Precautions and Sharps Handling – because SSPs all provide some form of sharps handling and bio-waste disposal it should go without saying that every SSP, by law, must have clear, written policies regarding handling biohazardous waste and potential needle stick injuries. Programs should follow the universal precaution guidelines established by the CDC and OSHA. SSPs may need to adapt those precautions to accommodate the circumstances of their work because many SSPs literally “meet people where they are at”: offering mobile exchange from RVs, cars, bikes, or on foot. In such cases, SSPs should consult appropriate professionals to ensure their programs have the best practices possible. Programs should also anticipate the potential of needlestick injury and routinely have a “post-exposure-prophylaxis” protocol in place – in other words: what happens when someone gets stuck and needs/wants medication to prevent possible infection.

Gifts to Staff – it is not uncommon for SSP participants to want to give staff gifts. This should be banned or discouraged to prevent favoritism, or even the appearance of favoritism.

De-escalation – conflict is common wherever there are humans. Calling law enforcement often escalates issues and can ruin the reputation of the SSP as a safe place for highly criminalized populations. It can also have unintended, and deadly, consequences for participants. Therefore, it is imperative that SSPs have a de-escalation policy in place that includes training for staff, volunteers, and even participants where appropriate.

Participant Treatment, Rights, and Grievance Procedure – another fundamental policy that every SSP should have is a set of participant rights and expectations about the services they receive and a formal mechanism for grievances to be levied and addressed.

Supply and Service Limitations and Procedures – another essential policy for SSPs to have in place, especially smaller or more modest programs without unlimited funds, regards service and/or supply limitations. It is common for programs to experience supply shortages or need to limit services for a period of time for a variety of reasons. When these interruptions happen, they can cause chaos, confusion, and even community-wide loss of reputation if participants feel that they are being treated arbitrarily or unfairly. To avoid this, it is important for SSPs to decide on a policy ahead of time about how to deal with limitations that includes how to best (and most transparently) communicate about limitations to participants.