Journal
JOURNAL OF SUBSTANCE ABUSE TREATMENT
Volume 138, Issue -, Pages -Publisher
PERGAMON-ELSEVIER SCIENCE LTD
DOI: 10.1016/j.jsat.2022.108752
Keywords
Homelessness; Medications for opioid use disorder; Opioid overdose; Treatment access; Qualitative research
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Individual factors such as belief in the effectiveness of MOUD, peer influence, and family influence all impact initiation of MOUD among homeless individuals. Social factors play a role in encouraging or deterring MOUD initiation. Structural factors, such as barriers within health and treatment systems, hinder access to MOUD.
Introduction: People experiencing homelessness (PEH) make up a disproportionate share of opioid overdose fatalities. We set out to identify the facilitators and barriers that shape whether PEH initiate medications for opioid use disorder (MOUDs), both generally and after an overdose.Methods: We conducted semi-structured interviews with 29 PEH in Boston who had self-reported history of opioid overdose. Seventeen participants had taken prescribed MOUD, and 12 had not. Using NVivo software we then coded transcripts applying the Borkan Immersion Crystallization method to identify individual, social, and structural factors influencing MOUD initiation.Results: Individual factors: Within the timing theme, non-fatal overdoses often led participants to feel sick with naloxone-induced withdrawal, decreasing treatment-seeking. By contrast, chronic opioid use consequences, like daily stress with finding drugs and shelter, increased interest in MOUD. Within the medication benefits and medication concerns themes, interest in MOUD initiation hinged on whether participants believed in or doubted MOUDs' effectiveness for reducing drug use. In a related theme, participants perceived that individuals must be ready in order for MOUDs to be effective. Social factors: Within the peer influence theme, peers who use opioids were prominent sources of encouragement or deterrence for starting MOUD. Family influence emerged as a theme for participants with MOUD history.Structural factors: Within the health systems theme, participants described that experiencing stigma from care providers toward people who use drugs was a barrier to MOUD. Within the treatment systems theme, regulations made methadone particularly difficult to access, even though nearly all participants had Medicaid coverage to pay for treatment. Within the criminal justice systems theme, participants reported frequent criminal justice involvement, with jails facilitating or preventing MOUD access.Conclusions: Future interventions should (a) increase MOUD interest by messaging-ideally via peers-that MOUDs are effective for PEH and (b) increase MOUD access by making MOUDs available across health, treatment, and carceral systems. Mobile outreach and MOUD treatment would help reach PEH when they are facing daily opioid use disorder stressors and are more open to MOUD initiation. Future research should explore how racial, ethnic, and linguistic identities affect MOUD engagement among PEH.
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