“An Emotional Roller-Coaster:" Stressors Faced by Peer Workers in Overdose Response Settings

Background Experiential workers or ‘peers’ (workers with past or present drug use experience) are at the forefront of overdose response initiatives and their role is essential in creating safe spaces for people who use drugs (PWUD). Working in overdose response settings has benets for experiential workers but is also stressful, with lasting emotional and mental health effects. Yet, little is known about the stressors experiential workers face and what interventions can be implemented to support them in their roles. This project used a community-based mixed methods research design. Eight experiential worker-led focus groups (n = 31) were conducted between November 2018 and March 2019 to assess needs of experiential workers. The transcripts were thematically coded and analyzed using interpretative description. These results informed a survey which was conducted (n = 50) in September 2019 to acquire quantitative data on experiential workers’ perception of health, quality of life, working conditions and stressors. Frequency distributions were used to describe characteristics of participants. X 2 distribution values with Yates correction were conducted to check for association between variables. Five themes emerged from the focus groups that point to stressors felt by experiential workers: (1) Financial insecurity; (2) lack of respect and recognition at work; (3) poor living conditions; (4) inability to access and/or refer individuals to resources; and (5) constant exposure to death and trauma. Consistent with this, the top four factors that survey participants picked as one of the “top three stressors” included nancial situation, work situation, housing, and caring for others. these

Several studies have found that individuals without lived or living experience of substance use often have negative attitudes towards PWUD [31][32][33]. These stigmatizing attitudes permeate into workplaces and lead to inequity and differential treatment of experiential workers. A recent study based in Vancouver, BC found that experiential workers often receive minimal nancial compensations for their work, have precarious work arrangements and lack job security [11].
This, coupled with the stress of the work itself can contribute to burnout [11,34].
Yet, while other front-line workers engaged in overdose response (i.e. paramedics, nurses, or other rst responders) have access to counselling, training and support through their employers [35,36], experiential workers often lack such supports. It is important, therefore, to understand the stressors faced by experiential workers and design holistic support interventions to ameliorate the negative emotional and mental health effects of working in these stressful environments.
The overall aim of our research project, titled Peer-2-Peer Project, is to identify and implement supports designed for and by experiential workers in overdose response settings. This paper highlights the stressors faced by experiential workers, both within their work environment and in their daily lives. This understanding will lay the foundation to identify and implement suitable supports developed for and by experiential workers.

Methods
The research was based at two organizations, located in four urban cities that spanned three of the ve BC health regions: 1) Solid Outreach -an experiential worker-led organization in Vancouver Island that educates, advocates and provides services for individuals that use substances [37], and 2) RainCity Housinga not-for-pro t, housing-rst organization in Vancouver Coastal and Fraser regions that provides housing and support services for people living with mental health, substance use, and other challenges [38].
This project used a community-based research design and the research team consists of both academic researchers as well as experiential research assistants (ERAs). The ERAs were recruited by managers of the pilot organizations, and trained in research methods. Initially, ve ERAs were recruited; more ERAs were added to the team and some disengaged from the project at various times, due to competing priorities or personal circumstances.
A sequential mixed-methods design was used for data collection. Experiential workers were invited to participate in qualitative focus groups and this constituted the rst phase of data collection. The results of the focus group informed the quantitative survey which was administered to experiential workers as the second phase of data collection.

Phase 1 -Qualitative Focus Groups
Focus groups were conducted at the four urban centres where pilot sites are located from November 2018 to March 2019. An additional focus group was conducted at an emergency shelter with an OPS in Vancouver Island, to encourage a diversity in experiential worker perspectives. Purposeful sampling (by ERAs or organizational managers) was used to identify and recruit participants with in-depth knowledge about experiential work from different positions, circumstances and perspectives [39,40]. The inclusion criteria for participants were (1) working, formally or informally, in overdose response settings, (2) identifying as an experiential worker (3) being over the age of 18, (4) being able to complete a brief demographic questionnaire and a focus group interview in English.
The purpose of the focus groups was to identify the positive aspects, stressors and challenges faced by experiential workers in their jobs, and explore their support needs. Conversations were directed by a semi-structured focus group guide, which was developed based on the research objectives, preliminary discussions with ERAs and literature review. Focus groups started with a brief description of the project and the goals of the focus group. Informed consent was then obtained and participants were asked to complete a one-page demographic questionnaire. The focus groups were conducted by two members of the research team: an ERA who facilitated the focus group, and an academic researcher who took eld notes and provided logistical support. Each focus group lasted approximately one hour. Focus groups were audio-taped and each participant received $25 CAD in cash and food. The audio recordings were transcribed verbatim by an external transcriber and the transcripts and eld notes were de-identi ed. Demographic identi ers are not associated with quotes to protect experiential workers from being recognized.
We used thematic analysis to identify, organize, and report themes, which aligned with the applied focus of our study [41,42]. A participatory coding process was used to sort the quotes into relevant codes that helped surface the underlying meanings behind the quotes [43]. A coding framework was developed with input from ERAs and inputted into NVivo (QSR International, version 12) where data analysis progressed in an iterative and re exive manner. We speci cally drew on interpretive description to generate practical and applied knowledge from the data, situating ndings within the real-world context [43]. Quotes were extracted from NVivo for each identi ed theme and brought to ERAs for data validation. ERAs were also responsible for selecting quotes most re ective of their experience for presentation within this paper. Key stressors and intervention needs were identi ed by ERAs and a model comprising of these priorities was developed collaboratively [44].

Phase 2 -Quantitative Survey
The second phase of data collection was the administration of a quantitative survey by ERAs to experiential workers at the four cities where pilot sites are located in September 2019. The survey was informed by the focus group ndings and served as an additional needs assessment to gain a more comprehensive understanding of the stressors faced by experiential workers and the supports they need. The survey was adapted from multiple tools and consisted of demographic questions, measures of experiential workers' perceptions of health and quality of life, substance use patterns and working conditions.
In this paper we provide insight into stressors faced by experiential workers utilizing participant responses to the question "Thinking about stress in your dayto-day life, what would you say are the top three most important things contributing to feelings of stress you may have?". Frequency distributions of the four factors selected as "top three stressors" are presented. Pearson chi-square tests for independence were conducted for gender, age and location comparisons for the different factors selected as stressors. Yates correction was used to adjust for the smaller sample size and low cell count values. Data were analyzed using R statistical software, version 4.0.2 [45].

Results
Eight focus groups were conducted; two in the Fraser region (one in Coquitlam, one in Maple Ridge), two in Vancouver Coastal and four in Island Health (Victoria) (see Figure 1).
Each focus group had three to six participants; the groups were intentionally small to allow participants enough time to voice their thoughts within one hour. A total of 31 experiential workers participated in the focus groups. The demographic pro le of these participants is presented in Table 1. Just over half of the focus group participants were male (55%). Of those that completed the demographic questionnaire, 56% were over the age of 40 and all reported having received at least some high school education.
The survey was completed by 50 experiential workers; 17 from the Fraser region (nine from Coquitlam, eight from Maple Ridge), 16 from Vancouver Coastal, and 17 from Island Health (Victoria) (see Figure 1). The demographic pro le of survey participants is presented in Table 2. Similar to the demographic pro le of focus group participants, the majority of the survey participants were male (54%), over 40 years old (58%), and had obtained at least some high school education (94%). Also, most survey participants self-identi ed as non-indigenous (68%)

Stressors and Challenges Faced by Experiential Workers
Several subthemes of stressors and challenges in experiential work were identi ed by focus group participants. These themes and subthemes are summarized in Table 3 and presented sequentially in more detail below.
In cases where the survey data for a particular theme from the focus groups was available, they are presented (see Tables 4 and 5 in the appendix).

"Scrape up money": Financial Insecurity
Poor nancial situation of workers was consistently mentioned as one of the key stressors among focus group participants. As one participant stated: "Honestly, my biggest hurdle is trying to do my job and then try and scrape up money outside of work trying to just get by." This sentiment re ects the severe nancial hardships and often 'hand-to-mouth' situation many experiential workers are faced with.
Similar to focus group participants, survey participants also indicated nancial insecurity as a key stressor. When asked to choose from a list of 16 potential stressors (see appendix), overall 72% of participants listed nancial situation as one of their top three stressors (Table 4). Although prevalent, nancial situation as one of the top three stressors varied between the four cities (ranging between 62.5% and 88.9%), but was not signi cant p=0.71.

Inequitable Pay
Several focus group participants attributed their nancial insecurity to the inequitable pay they received. Participants spoke about getting paid much less than other support staff employed by their organizations, despite doing the same work. This is apparent in one participant's words: "[Support workers] are making one amount. [Experiential workers] are making another, doing the exact same job." Some participants suggested that the pay inequity may stem from the higher value that organizations place on formal education and certi cation over expertise acquired though lived experience. As one participant mentioned: "We've got people that […] took an eight-month course […] with two months of addictions training and somehow that certi cation is valued above lived experience." Inequitable pay may also be a result of stigma against PWUD which leads to negative attitudes towards experiential workers.
The idea of pay inequity was also echoed by survey participants. When asked if individuals feel they get paid a fair amount, 45% of the participants that responded disagreed and 14% were neutral ( Table 5). The proportion of participants that disagreed ranged between 14% to 69% in the four cities.
These focus group and survey results indicate that experiential workers perceive pay for their work as inequitable and this may contribute to their nancial insecurity.

Job Instability
The nancial insecurity experiential workers face is accompanied by job insecurity. Many experiential workers mentioned that their jobs rely on government funding to non-pro t and other organizations and that they do not have formal long-term employment contracts. As one focus group participant described, "how much sooner is our 'well' going to run dry? When [will] I [be] unemployed? That scares the hell out of me. Am I going to be here next year?". The use of the metaphor of a "well" indicates that that experiential workers work in a precarious environment, often characterized by job instability and this can be a cause of stress for them.
2. "Sets us apart": Lack of Respect and Recognition at work One of the top stressors that emerged from the focus group data is the lack of recognition and respect for experiential workers. Several experiential workers felt that they were not taken seriously or given due respect by their work colleagues and by other professionals they encounter in their work.
The lack of respect seems to stem from stigma against PWUD. Many experiential workers expressed that the use of the term "peer" is not an adequate job title as it sets to de ne the work of experiential workers solely by their history of substance use, rather than by the important work they do and the lived experience and context they provide. As such, it is stigmatizing and derogatory. As one experiential worker mentioned, "This term "peer," I'm really quite uncomfortable with [it].
[…] It sets us apart from normal society." This quote indicates that de ning experiential workers' role in relation to their substance use can be othering and leads to differential treatment of experiential workers by support workers.
The lack of recognition and respect for experiential workers is apparent in the lack of basic resources provided to most working professionals, such as photo IDs or business cards. As one experiential worker mentioned, "We don't have the exact same things as the other support staff".
Focus group participants also pointed out the absence of formal job descriptions and contracts for experiential workers, leading to lack of role clarity among supervisors as well as their support worker colleagues. Several focus group participants mentioned that they are often assigned to menial tasks and are looked down upon despite their extensive expertise and skillset. As one participant described: "Sometimes when I get [to work] and I'm barely even in the door [support workers are] like, 'you gotta go upstairs and go clean the kitchen. You gotta go in here and clean the staff room'".
This quote indicates the constant struggles that experiential workers face at work and how they are given minimal respect due to their history of substance use.
Experiential workers also expressed that they do not feel respected by other professionals they encounter in their work. One experiential worker described a situation that they faced with the police: "Today, for example, a guy was O.D.'ing just across the street here.
[We] went over, we had our Narcan kits and we had everything under control. We were doing our job. Next thing you know we got eight cop cars there and they're telling us we're going to be arrested if we don't leave." This quote shows how police o cers and other service providers may not understand the life-saving work experiential workers constantly perform. A similar sentiment was expressed by another experiential worker who recounted their experience with paramedics: "I think there's a little bit of stigma from the ambulance people [and] from the rst responders.
[…] I nd that they can come in, take over and kind of push the peer aside. I think that there is a lot of stigma against peers." This quote indicates that the lack of respect for experiential workers is rooted in deeper societal stigma that uniformly characterizes experiential workers by their substance use.
Similar to focus group participants, survey participants feel that they don't always get the recognition that they deserve for their work. For the question, "when I do a good job, I get the recognition for it that I should receive", half of the participants (50%) disagreed or were neutral ( Table 5). The proportion of participants that disagreed ranged from 12% to 78% in the different cities. Furthermore, more than a third of the survey participants (40%) listed "work situation (including working conditions)" as one of their top three stressors (Table 4). This ranged from 12.5% to 77.8% in the four cities (p=0.03).
These results highlight how much importance experiential workers place on being recognized and respected at work; lack of respect can be a stressor for them.

"A hoarder's nest": Poor Living Conditions
Another stressor identi ed by experiential workers was poor living conditions which in turn impacts the ability to sustain work. Several participants expressed that they would like to have "somewhere [they] can call a home". Having a safe place one can call 'home' is crucial for experiential workers' productivity and ability to help others. As one participant explained: When you're able to look after yourself nancially and physically and mentally and emotionally, then you're able to do so much more for other people. Several focus group participants mentioned that their housing situations jeopardized both their security and their health. For example, participants mentioned being assaulted in their buildings, having accommodation infested with bed bugs, and having small quarters that felt like a "jail cell". For experiential workers, the conditions of their homes seem to add stress rather than offer a respite to alleviate it.
Some participants mentioned that they felt helpless and were unable to move because they often encounter problems in acquiring housing. BC is known for its exorbitant housing rental prices [46][47][48], which makes safe housing unaffordable for experiential workers with meager wages. One participant mentioned that their home felt like "a hoarder's nest…but I can't move anywhere else. I can't afford to move." This quote indicates that many experiential workers are forced to endure poor living conditions due to a housing market that favours the wealthy and privileged.
Some experiential workers described that they nd it di cult to nd a home within their communities, surrounded by people that they feel safe with. Like focus group participants, survey participants also listed living conditions as a common stressor. More than a third (38%) of the survey participants listed housing-related issues as one of their top three stressors ( Table 4). Perception of housing situation as one of the top three stressors ranged from 12.5% to 66.7% (p=0.31) in the four communities.
When asked if individuals faced housing challenges due to their substance use in the last 30 days, almost a half (48%) of the participants indicated that they 'always', 'often', or 'sometimes' faced such challenges PWUD (Table 5). Although not the majority, 48% is a large percentage of respondents that faced housing challenges in such a short amount of time (30 days). In some cities, almost all participants reported having faced housing challenges in the last 30 days (Table 5). Clearly, acquiring acceptable housing is a challenge for experiential workers and this can add considerable stress to their lives. 4. "Not enough social support": Inability to access or refer individuals to resources Experiential workers often serve as a bridge connecting PWUD to social services and other supports. Several focus group participants stated that PWUD may be unable to access the resources that they need in order to support those they are working with. However, other focus group participants mentioned that in some cases, although resources do exist, experiential workers are not equipped with the skills or credibility to make referrals, despite a genuine desire to help. This creates a sense of powerlessness, and often adds to experiential workers' stress and dissatisfaction. This sentiment is expressed by one participant who mentioned, "I'm not as worried about myself as the clients, but there's not enough social support… in all aspects." The following quote highlights the desire of an experiential worker to be able to do more: Several examples of resources which PWUD nd hard to access were provided by focus group participants, including 'detox', legal services, welfare and income assistance, and civic services such as government identi cation.
Some experiential workers expressed that even when services do exist, PWUD are hesitant to use them as they do not feel welcomed to access those resources, and fear being judged. Healthcare is one such resource; many experiential workers feel that the stigma against substance use often clouds healthcare providers' ability to provide compassionate care. As one participant mentioned, "I feel like a real asshole, like, trying to convince anybody to go to the hospital because I know why they don't want to go". Albeit subtly, this quote communicates a powerful message; it indicates that experiential workers, along with PWUD, feel helpless as they are denied of their fundamental right to compassionate healthcare and left to navigate their own physical and mental health challenges.

"Living through our losses": Constant exposure to death and trauma
Several experiential workers mentioned that the constant loss of lives and trauma that they are exposed to is emotionally taxing and stressful. Unlike most other rst responders, experiential workers have a unique understanding of the lives of PWUD, and can relate to their traumatic stories, which can amplify the stress they feel. In this same vein, the individuals that experiential workers support are not mere clients; they are often friends and family members who are close to them. Losing a client, therefore, is so much more di cult. As one participant mentioned, "I lost a couple of my best friends in the last couple of years and it's just been really friggin' hard." For experiential workers, personal and professional lives are heavily intertwined. Their work is a 24-hour job; unlike other professionals, experiential workers do not get to unwind after a stressful day at work because they are constantly trying to keep their loved ones alive, even outside the work environment. This constant worrying can take a toll on experiential workers' mental health. As one participant stated: Consistent with the focus group results, two-thirds (68%) of the survey participants that responded were at least sometimes "affected by the traumatic stress of those they help", i.e. the sum of those that stated 'always', 'often' and 'sometimes' (Table 5). Furthermore, almost half (47%) of the respondents reported that they "feel worn out because of their work" (Table 5). A similar proportion of respondents (47%) reported that they " nd it di cult to separate their personal lives from their lives as experiential workers" (Table 5).
Despite the traumatic stress and burn-out experiential workers report, only slightly over a quarter (28%) of the survey participants indicated "caring for others" as one of their top three stressors (ranging from 0% to 44.4% across the four communities) ( Table 4). The vast majority (98%) of survey respondents reported they "have happy thoughts about those they help and how they could help" and 94% of respondents "feel a sense of pride in doing their work". Furthermore, 94% and 95% of respondents respectively report that their "work makes them feel satis ed" and that they "make a difference through their work". This clearly indicates that even through their work can be emotionally draining and stressful, experiential workers genuinely care for their community and like to help others.

Discussion
The results of our study demonstrate that experiential workers face multiple sources of stress in their lives. The most prominent stressors include nancial insecurity, lack of respect and recognition at work, poor living conditions, lack of support services for PWUD, and constant exposure to trauma at work and death of loved ones. It is apparent that for experiential workers, personal and professional lives are intimately intertwined; it is di cult to separate one from the other. Thus, while presented separately, the stressors highlighted do not exist independently of each other; rather, they are connected and create a complex, multi-layered structure that can, together, affect experiential worker's mental health.
Our study found that experiential workers' lived experience and association with substance use clouds others' perception of their identity in that they are almost solely de ned by it. This stigma and judgement shapes experiential workers' day-to-day experiences, both within the workplace and beyond. This nding is consistent with intersectionality theory which explores how facets of one's social and political identities, including race, gender, disability, substance use, etc. create unique experiences of oppression for each individual [49]. Previous studies have found that oppression of individuals or groups is often based on their social positioning, which affects their "structural vulnerability" [30]. Substance use is one such factor that generates marginalization of individuals to both drug and health related harms [28]. This stigma is deeply embedded in the long history of drug prohibition in Canada which continues to criminalize substance use [50,51] Our ndings indicate that nancial insecurity is one of the most prominent stressors in experiential workers' lives. Several experiential workers attributed their nancial insecurity to their minimal pay. Poor funding for experiential worker-led programs and strained budgets are often used to justify inconsistent and low wages for experiential workers [52][53][54]. Furthermore, there is often lack of employment opportunities where the experiential knowledge of PWUD is valued [55][56][57][58]. As such, even when PWUD do nd employment, they receive meager pay for their work, notably less than that received by other front-line workers and support staff, despite the similarity of their duties. This nding is consistent with previous studies which report that experiential workers often get low inequitable wages; this coupled with long hours and lack of access to emotional supports, often contributes to burnout [11,34]. Like previous studies, our ndings indicate the need for nancial supports for experiential workers, including assistance with opening bank accounts, discussing nancial barriers, and depositing cheques [11]. There is also a need to advocate for equitable pay for experiential workers, based on the province's living wage rate [59].
Poor living conditions is also one of the major stressors for experiential workers. According to the Canada Mortgage and Housing Corporation, "acceptable" housing is affordable and should not be more than 30% of one's income, has enough space to accommodate the family, is in adequate condition that does not require any major repairs [60]. Given experiential workers' descriptions of their living conditions, it is clear that their housing situation is not acceptable. Almost half of the survey participants indicated that they had faced housing challenges in the last 30 days due to their substance use. This shows that substance use hinders an individual's ability to acquire acceptable housing. Such challenges may be a result of stigma against substance use, leading to the unwillingness of landlords to rent to PWUD. This nding was consistent with other ndings that suggest marginalized population groups, including PWUD, often face housing challenges [60,61]. Studies have shown that housing-related issues can signi cantly contribute to individuals' stress, affecting their self esteem and mental health [62]. Our ndings support housing as a key determinant of health and an important resource to support employment for experiential workers since it affects their productivity and capacity to help others; lack of acceptable housing can be stressful. These results highlight the importance of organizations building relationships with housing providers so that they are better able to refer experiential workers and other PWUD to appropriate facilities.
Another important stressor discussed by experiential workers is lack of respect and recognition from their work colleagues and other professionals they encounter. Several studies have shown that feeling valued and respected at work are key determinants of an individual's job satisfaction and perception of good working conditions [63,64]. This explains why 40% of the survey participants listed "work situation, including working conditions" as one of their top three stressors. Our ndings are consistent with several studies which have shown that experiential workers are not always accepted and respected in the workplace due to their history of substance use [32,33,65,66]. Some studies have also reported that support workers without lived experience of substance use have negative attitudes towards experiential workers, rooted in stereotypes and stigma towards PWUD [31][32][33]65]. These negative attitudes are apparent in the terminology used by support workers to de ne experiential workers, including "unstable," "manipulative," "untrustworthy," and "lacking capacity to participate" [31][32][33]65]. The negative attitudes lead to othering of experiential workers who are relegated to menial labour, excluded from bene t programs, and shirked of professional development opportunities [34]. Our study shows that experiential workers also feel that they are not respected by other professionals, such as the police and paramedics. Such reduction of experiential worker credibility is a form of structural violence in the sense that it enforces marginalization of PWUD and inhibits them from achieving the same professional recognition as their counterparts without lived or living experience of substance use. Our ndings urgently call for implementation of organizational supports for experiential workers that offers them an edge and puts them at an equal footing with their counterparts. These may include photo IDs to increase recognition, o cial job descriptions and contracts to formalize their roles and create role clarity, skill development opportunities, and meet and greet events with other professionals. Increasing recognition of the important work done by experiential workers is also necessary to tackle the negative attitudes and stigma towards them.
Experiential workers discussed how lack of access to resources for themselves and other PWUD leads to stress and dissatisfaction. In another paper (under review), we discuss how experiential workers often see themselves as the bridge connecting PWUD to social services, and this allows them to feel "useful" and gives their lives a meaning. Not being able to refer PWUD to the resources they need due to lack of skills or credibility to make referrals or due to lack of resources creates a sense of powerlessness. This powerlessness felt by individuals due to their inability to act in a particular manner despite knowing the right course of action is termed "moral distress" [67][68][69][70]. Studies have indicated that moral distress ca to severe health consequences including anxiety, depression, demoralization, and workplace alienation [71]. Interventions to reduce moral distress may include skill development opportunities for experiential workers in program navigation and operational processes associated with accessing services. Examples include education on helping people access detox, familiarizing experiential workers with the process of applying for government-issued identi cation cards or income assistance. Having a designated staff member for building relationships with service providers and give referrals to PWUD may also be useful for experiential workers.
Our study found that experiential workers are constantly dealing with the loss of loved ones due to the overdose crisis, which imposes an emotional toll on them. This nding is in line with other studies demonstrating that the overdose crisis has led to considerable grief for PWUD [11,[20][21][22]. Exposure to such trauma leads to distress and is termed "compassion fatigue" [72]. A recent study indicated that even a single exposure to a fatal or non-fatal overdose can cause stress, burnout and overdose-related compassion fatigue [23]. For experiential workers, the grief and the associated stress is ampli ed multifold, as they are repeatedly exposed to others' trauma, coupled with the trauma they face themselves. Studies show that compassion fatigue and burnout can have severe impact on the mental health and productivity of workers [73][74][75]. Yet, while compassion fatigue has been studied widely among other front-line workers, including nurses [73][74][75][76][77], there is lack of literature on this phenomenon among experiential wokers. With the onset of COVID-19, reported deaths related to illicit drug overdoses have reached an all-time high [7], causing additional grief and trauma for experiential workers as they continue to deal with loss of loved ones. This calls for an urgent need to understand compassion fatigue among experiential workers in overdose response settings and design appropriate interventions to tackle this issue.
Our survey results indicate that there are differences across cities in the perception of certain factors as one of the top three stressors, albeit statistically insigni cant for some factors. These differences may be due to high levels of stigma against PWUD in some areas, such as Coquitlam. There are also variances in pay across sites due to the lack of a standardized pay scale for similar jobs between and within regions. Also, different types of sites were represented within the cities; housing agencies in three cities and an experiential worker-led harm reduction organization in one city. 'Work situationincluding working conditions' was found to signi cantly differ across sites. The site where more than three quarters of the participants reported this to be one of the top three stressors had recently received news of a funding cut around the time the survey was conducted. This may have severely impacted the overall morale of experiential workers and the associated stress. On the other hand, the site where only 12.5% of the participants reported 'work situation' as one of the top three stressors has a close-knit team of experiential workers and managers. Given these site differences, our results suggest that some sites may need to pay extra attention to provide supports for experiential workers.
This paper highlights the stressors that experiential workers face, both within their workplace and in their personal lives. While the work itself and the constant exposure to trauma is stressful, the stigma and inequity that experiential workers face in their workplace is doubly stressful. This stigma is not restricted to their workplace; it permeates all aspects of life. Recognition of these stressors and the effects they have on experiential workers' physical and mental health is crucial to inform strategies to better support experiential workers. These supports are needed urgently since the onset of COVID-19 has led to a considerable increase in the workload for experiential workers due to closures and reduced hours of organizations servicing PWUD [15,16]. Over time, this increased workload may lead to burnout. As such, there is a critical need to implement supports and strategies that may help to prevent further marginalization of PWUD who are already in a vulnerable position, disproportionally burdened by poverty, stigmatization and health challenges. Some interventions have been implemented at the four sites included in this paper through the Peer-2-Peer project and will be detailed further in a future paper.
It must be noted that the stressors faced by experiential workers are situated within broader systemic structures, including the criminalization of drug use and associated stigma against PWUD. Thus, while different solutions can be offered to support experiential workers working in overdose response settings, these programs may be impeded by the continuing criminalization of drug use. Unless upstream measures are taken, including decriminalization and even legalization of drug use, experiential workers may never fully feel supported.
Our study has many strengths. Focus group participants had diversity of age, gender, roles, geography, and education level. Survey participants included the majority of experiential workers at the four sites included in this study (50 out of the 58 experiential workers employed during that time, i.e. 86%). The study uses mixed methods which allowed us to compare, contrast and synthesize data from two different sources, leading to robust and comprehensive information. One of the greatest strengths of this study is the use of participatory coding with involvement of ERAs. This prevented implicit bias from academic researchers in the interpretation of results since they may not fully understand the reality of individuals with lived and living experience of substance use.
Despite all its strengths, this study is not devoid of limitations. One limitation is the lack of generalisability as the study provides data from four metropolitan or large urban centers in BC and the experiences of experiential workers in rural settings may be different. However, the sites represent diversity in type i.e. housing agency versus non-housing and diversity in health regions; as three out of BC's ve health regions were covered. Although the survey sample includes most experiential workers from each site, the small sample does not allow conclusive inferences about the differences between variables. However, the primary goal of the paper is to identify stressors faced by experiential workers to inform interventions that can be implemented at an organization level. Focus group participants may have been hesitant to express their opinions due to fear of judgement from other participants or of jeopardizing their jobs. This concern was mitigated to some extent by keeping the focus groups small, and by ensuring that no managers were present. The focus groups and the surveys were both conducted by experiential researchers to promote a power balance and to ensure that participants feel comfortable to provide their honest opinions.

Conclusion
Our study shows that experiential workers face multiple sources of stress including nancial insecurity, lack of respect and recognition at work, inability to access or refer individuals to resources, constant exposure to death and trauma, and poor living conditions. With the increase in the workload for experiential workers due to COVID-19, these stressors may have been augmented. As such, it is critical, now more than ever before, to identify the stressors faced by experiential workers and implement interventions that ameliorate the negative impacts of these stressors at an organizational level. However, these stressors may never be fully eradicated until higher-level systemic changes are made to decriminalize substances use. Until this broader shift towards systemic harm reduction is made, organization-level initiatives to mitigate the stressful impacts of experiential work can, at most, function as temporary band-aid solutions.

Declarations
Acknowledgements: The authors would like to thank the past and present members of the Peer-2-Peer Research Team and the pilot organizations for their tireless efforts in implementing the project (a full list of team members can be found here). We would also like to acknowledge the Harm Reduction Services team at the British Columbia Centre for Disease Control for their support with this project. Our special thanks to Amiti Mehta for her consultations on the quantitative analysis and Alissa Greer for her expertise in peer engagement literature. We are indebted to the experiential workers across the province who are dedicated to being in the frontline to save lives from drug overdoses during the ongoing dual public health emergencies in BC.      Figure 1 Map of sites in BC where the focus groups and surveys were conducted [3]. [3]Urbanicity was determined based on BC Ministry of Health classi cations [78] Supplementary Files This is a list of supplementary les associated with this preprint. Click to download.