Mobile treatment for opioid use disorder: Implementation of community-based, same-day medication access interventions.

Chatterjee A ，Baker T ，Rudorf M ，Walt G ，Stotz C ，Martin A ，Kinnard EN ，McAlearney AS ，Bosak J ，Medley B ，Pinkhover A ，Taylor JL ，Samet JH ，Lunze K ... -  《-》

Mobile addiction treatment and harm reduction services as tools to address health inequities: a community case study of the Brockton Neighborhood Health Center mobile unit.

Opioid overdose deaths continue to increase in the US. Recent data show disproportionately high and increasing overdose death rates among Black, Latine, and Indigenous individuals, and people experiencing homelessness. Medications for opioid use disorder (MOUD) can be lifesaving; however, only a fraction of eligible individuals receive them. Our goal was to describe our experience promoting equitable MOUD access using a mobile delivery model. We implemented a mobile MOUD unit aiming to improve equitable access in Brockton, a racially diverse, medium-sized city in Massachusetts. Brockton has a relatively high opioid overdose death rate with increasingly disproportionate death rates among Black residents. Brockton Neighborhood Health Center (BNHC), a community health center, provides brick-and-mortar MOUD access. Through the Communities That HEAL intervention as part of the HEALing Communities Study (HCS), Brockton convened a community coalition with the aim of selecting evidence-based practices to decrease overdose deaths. BNHC leadership and coalition members recognized that traditional brick-and-mortar treatment locations were inaccessible to marginalized populations, and that a mobile program could increase MOUD access. In September 2021, with support from the HCS coalition, BNHC launched its mobile initiative - Community Care-in-Reach® - to bring low-threshold buprenorphine, harm reduction, and preventive care to high-risk populations. During implementation, the team encountered several challenges including: securing local buy-in; navigating a complex licensure process; maintaining operations throughout the COVID-19 pandemic; and finally, planning for sustainability. In two years of operation, the mobile team cared for 297 unique patients during 1,286 total visits. More than one-third (36%) of patients received buprenorphine prescriptions. In contrast to BNHC's brick-and-mortar clinics, patients with OUD seen on the mobile unit were more representative of historically marginalized racial and ethnic groups, and people experiencing homelessness, evidencing improved, equitable addiction care access for these historically disadvantaged populations. Offering varied services on the mobile unit, such as wound care, syringe and safer smoking supplies, naloxone, and other basic medical care, was a key engagement strategy. This on-demand mobile model helped redress systemic disadvantages in access to addiction treatment and harm reduction services, reaching diverse individuals to offer lifesaving MOUD at a time of inequitable increases in overdose deaths.

Pinkhover A ，Celata K ，Baker T ，Chatterjee A ，Lunze K ... -  《Frontiers in Public Health》

An economic analysis of the cost of mobile units for harm reduction, naloxone distribution, and medications for opioid use disorder.

Mobile substance use treatment units are effective approaches to increase treatment access and reduce barriers to opioid use disorder (OUD) care. However, little is known about the economic costs of maintaining and operating these units. This study aimed to estimate the economic costs of starting and maintaining mobile units providing harm reduction, overdose education and naloxone distribution (OEND), and medication for opioid use disorder (MOUD). As part of the HEALing Communities Study, four communities in Massachusetts (Bourne/Sandwich, Brockton, Gloucester, Salem) implemented mobile units offering OEND and MOUD (buprenorphine and naltrexone only); each selected different services tailored to their community. All provided MOUD linkage via telehealth, but only one offered in-person MOUD prescribing on the unit. We retrospectively collected detailed resource utilization data from invoices to estimate the direct economic costs from August 2020 through June 2022. Cost components were categorized into start-up and operating costs. We calculated total economic cost over the study period and the average monthly operating cost. Implementing a mobile unit offering OEND and MOUD required a one-time median start-up cost of $59,762 (range: $52,062-$113,671), with 80 % of those costs attributed to the vehicle purchase. The median monthly operating cost was $14,464. The largest cost category for all mobile units was personnel costs. The monthly ongoing costs varied by community settings and services: approximately $5000 for two urban communities offering OEND and MOUD linkage via telehealth (Gloucester, Salem), $28,000 for a rural community (Bourne/Sandwich), and $23,000 for an urban community also providing in-person MOUD prescribing on the unit (Brockton). The economic costs of mobile substance use treatment and harm reduction units are substantial but vary by community settings and services offered. Our results provide valuable community-level economic data to stakeholders and policymakers considering establishing and/or expanding mobile units with OEND and MOUD services. Further exploration of cost-effectiveness and efficiency should be considered across different settings.

Castry M ，Tin Y ，Feder NM ，Lewis N ，Chatterjee A ，Rudorf M ，Samet JH ，Beers D ，Medley B ，Gilbert L ，Linas BP ，Barocas JA ... -  《-》

Barriers and facilitators to scaling up medications for opioid use disorder in Kentucky: qualitative perspectives of treatment organization staff.

Underutilization of medications for opioid use disorder (MOUD) remains a persistent obstacle to addressing the opioid epidemic. This study explores MOUD agency experiences with patient census growth as well as multi-level barriers and facilitators to expanding MOUD from the perspectives of agency staff. Semi-structured qualitative interviews were conducted with 66 employees representing 30 MOUD agencies in eight Kentucky counties in the United States from December 2022 to June 2023 as part of the HEALing (Helping to End Addiction Long-term®) Communities Study in Kentucky (HCS-KY). Interviews were conducted prior to the development of partnerships to implement strategies focused on expanding MOUD census and increasing MOUD retention. Facility administrators/directors, prescribers, and clinicians were prioritized for recruitment, but agencies could identify other staff to participate. Interviews were recorded and transcribed. A consensus-based approach to coding and thematic analysis was used. Although some agencies had a fairly static number of patients, most described recent experiences with modest growth in MOUD census and the ability to provide same day/next day MOUD. Multi-level factors, including organizational, patient, and community factors, were perceived to impact MOUD census. Organizational characteristics impacting growth included the physical space of the clinic and staffing. Organizational policies in some agencies constrained treatment retention, while other agencies implemented innovations to better meet patients' needs. Patients often encountered numerous obstacles to treatment initiation and retention, including limited access to transportation, technology, stable housing, and childcare. These patient-level barriers often reflected community characteristics, while community stigma also impeded MOUD growth. Although some degree of growth in MOUD has occurred, multiple barriers are impeding further increases in treatment initiation and retention. Overcoming some barriers would likely require policy changes related to financing and regulation, while other barriers would require community-level efforts to decrease stigma and greater community investment in infrastructure, such as transportation and housing. ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .

Knudsen HK ，Andrews-Higgins S ，Back-Haddix S ，Lofwall MR ，Fanucchi L ，Walsh SL ... -  《-》

Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers.

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail. We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes. Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation. Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.

Stopka TJ ，Rottapel RE ，Ferguson WJ ，Pivovarova E ，Toro-Mejias LD ，Friedmann PD ，Evans EA ... -  《-》