Linkage facilitation services for opioid use disorder: Taxonomy of facilitation practitioners, goals, and activities

Abstract

Introduction:

This article proposes a taxonomy of linkage facilitation services used to help persons with opioid use disorder access treatment and recovery resources. Linkage facilitation may be especially valuable for persons receiving medication for opioid use disorder (MOUD) given the considerable barriers to treatment access and initiation that have been identified. The science of linkage facilitation currently lacks both consistent communication about linkage facilitation practices and a conceptual framework for guiding research.

Methods:

To address this gap, this article presents a taxonomy derived from expert consensus that organizes the array of practitioners, goals, and activities associated with linkage services for OUD and related needs. Expert panelists first independently reviewed research reports and policy guidelines summarizing the science and practice of linkage facilitation for substance use disorders generally and OUD specifically, then met several times to vet the conceptual scheme and content of the taxonomy until they reached a final consensus.

Results:

The derived taxonomy contains eight domains: facilitator identity, facilitator lived experience, linkage client, facilitator-client relationship, linkage activity, linkage method, linkage connectivity, and linkage goal. For each domain, the article defines basic domain categories, highlights research and practice themes in substance use and OUD care, and introduces innovations in linkage facilitation being tested in one of two NIDA-funded research networks: Justice Community Opioid Innovation Network (JCOIN) or Consortium on Addiction Recovery Science (CoARS).

Conclusions:

To accelerate consistent application of this taxonomy to diverse research and practice settings, the article concludes by naming several considerations for linkage facilitation workforce training and implementation.

This article proposes a taxonomy of linkage facilitation services currently deployed to support treatment and recovery goals of persons with opioid use disorder (OUD). Opioid misuse remains a prevalent and often deadly national healthcare problem, with rates of OUD and lethal opioid overdoses at alarming levels across demographic groups (BIHCP, 2020; Townsend et al., 2022). Linkage facilitation (LF)—often called linkage to care—refers to a range of services intended to help persons with OUD access appropriate treatment and harm reduction interventions, maintain adherence to medications and other components of treatment planning, engage in SUD/OUD recovery support services, and obtain behavioral and social capital resources that abet immediate and long-term recovery goals (Centers for Disease Control and Prevention [CDCP], 2022). LF is especially valuable for persons receiving medication for opioid use disorder (MOUD) given the considerable barriers to treatment access and initiation that have been identified (see CDCP, 2022; Crotty et al., 2020). Of note, LF in various forms is used in a multitude of settings to link persons with a wide range of health problems to supportive care (for reviews see Carter et al., 2018; Corrigan et al., 2022; K. J. Kelly et al., 2019). Also, whereas SUD peer support services often overlap meaningfully with LF—that is, many but not most peer support specialists engage in LF, and many but not most linkage facilitators are also peers of their clients—peer support services is a separate discipline with its own array of actors and activities (e.g., Center for Substance Abuse Treatment [CSAT], 2009; Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). As such, facilitation of linkage to clinical treatment services, and MOUD treatment in particular, may or may not be a main focus of peer support services (Corrigan et al., 2022).

LF is becoming increasingly commonplace in settings that serve persons with OUD; in tandem, the workforce that delivers LF, including peer support specialists, is becoming more numerous and diverse. None of the existing research reviews (e.g., Bassuk et al., 2016; Eddie et al., 2019; Grella et al., 2022; Paquette et al., 2019; Stack et al., 2022) and policy guidelines (e.g., CDCP, 2022; National Association of Peer Supporters [NAPS], 2019) that summarize the science and practice of LF for SUD delineates a comprehensive conceptual framework to define and organize the various facets of LF services. To ensure timely and consistent communication about standards and advances in LF research and practice, it is important to develop a pragmatic lexicon for the array of practitioners, goals, and activities associated with LF services for OUD. To this end, the current article first describes the MOUD services continuum and introduces LF as a commonly deployed practice for OUD. It then proposes an organizing conceptual framework—a taxonomy—of LF for OUD focused on eight domains. For each domain, the article defines the domain’s basic categories, highlights key research and practice themes in substance use and OUD care, and introduces recent innovations specific to MOUD. Most of the programs described herein are funded by the National Institutes of Health as part of either the Justice Community Opioid Innovation Network (JCOIN: https://heal.nih.gov/research/research-to-practice/jcoin) or Consortium on Addiction Recovery Science (CoARS: https://www.recoveryanswers.org/coars-landing-page/). We decided to draw LF program examples from these research networks because they feature innovative LF models being rigorously tested by authors of this article in MOUD effectiveness studies set in diverse real-world settings. The article concludes by naming several key considerations in LF workforce training and implementation, with the goal of accelerating consistent application of this taxonomy across diverse research and practice settings; and offers next steps for growing the science of LF for OUD.

1. Research Foundations of OUD and Linkage Facilitation

1.1. MOUD Services Continuum

MOUD, consisting of opioid agonist or antagonist medication combined with medication-supportive behavioral counseling, is an evidence-based treatment for OUD (Volkow et al., 2018). MOUD is well-established for all age groups (Blavatnik Institute for Health Care Policy [BIHCP], 2020), including adolescents (American Academy of Pediatrics, 2016). Initiation onto one of three FDA-approved medications (buprenorphine, naltrexone, methadone) typically occurs during acute crisis-driven episodes of care (e.g., treatment of withdrawal or “detoxification”), after which long-term adherence to a MOUD regimen (“maintenance”) is a standard recommendation to prevent recurrence of opioid use problems. MOUD is often combined with ancillary behavioral counseling and other recovery resources intended to support opioid abstinence and reductions in opioid use and address other substance use and co-occurring mental health problems (BIHCP, 2020).

As depicted in Figure 1, MOUD services can be conceptualized as a continuum, sometimes called a services cascade, consisting of the typical sequence of intervention activities experienced by any given person as they progress through the MOUD service system. The MOUD services continuum is anchored by four overlapping stages (Hogue et al., 2021a). Stage 1: MOUD Preparation includes identification, referral, and enrollment of clients in MOUD services, including re-enrollment following recurrence of opioid use. Stage 2: MOUD Initiation includes initial evaluation and medication induction. Stage 3: MOUD Stabilization includes dose titration and early response, which can be unstable and may include withdrawal management. Stage 4: OUD Recovery includes stability monitoring, recurrence prevention, and interventions to improve overall health and quality of life. Behavioral interventions for substance use and co-occurring disorders are often integrated throughout Stages 2-4 of the MOUD cascade. Note that clients who enter MOUD services typically experience episodic increases and decreases in opioid use—that is, a chronic course-of-disorder marked by regular use, remission, and recurrence (Ashford et al., 2019).

Figure 1.

MOUD Services Continuum

1.2. Linkage Facilitation within the MOUD Services Continuum

1.2.1. LF during OUD Acute Care.

The first three stages of the MOUD services continuum constitute an “acute care” phase during which persons with OUD learn about, access, and engage in services for OUD that feature options for medication (Stage 1: MOUD Preparation); make informed, provider-supported decisions about starting a MOUD regimen (Stage 2: MOUD Initiation); and incrementally adjust the MOUD regimen under provider supervision to maximize medication benefits and minimize side effects and maintenance barriers (Stage 3: MOUD Stabilization). During these acute care stages, LF can play an essential role in helping persons with OUD overcome barriers and support MOUD and ancillary services (Chan et al., 2021). LF has been used to drive MOUD service engagement in numerous settings including primary care, emergency departments, inpatient and outpatient behavioral care, perinatal care, criminal legal settings, and harm reduction settings such as syringe services (CDCP, 2022). Research in various settings shows LF has promising effects in boosting service access, fostering MOUD uptake and adherence, and promoting engagement in supportive behavioral and social services (CDCP, 2022; Chan et al., 2021; Grella et al., 2022).

1.2.2. LF during OUD Recovery.

The term “recovery” is a multidimensional construct indicating the variety of strategies and paths individuals follow to resolve substance use disorders and related problems (J. F. Kelly et al., 2018) and make sustained efforts to improve wellness (Ashford et al., 2019). As extensions of, complements to, or replacements for acute care services, recovery-oriented services comprise a range of clinical and lay support structures such as recovery support services, medical and social supports, and transportation and childcare assistance (Laudet & Humphreys, 2013). Recovery support services (RSS) can be organized into three broad categories (Hogue et al., 2021b): (1) Professional: services offered by licensed clinicians in the context of a provider-client relationship, typically as adjuncts to or extensions of acute care as a monitoring and maintenance device. (2) Peer/Community: support offered by persons with similar lived experiences or credentialed peer support specialists in the context of a recovery-focused relationship; examples include peer recovery coaching, recovery community centers, recovery services housed in community mental health centers, and mutual help groups. Note that many peer support specialists have formal training, and some have regulated licensure, to deliver RSS in specified settings (Gaiser et al., 2021). (3) Direct-To-Consumer (DTC): supports offered by digital channels, social media, or other information brokers that are accessed directly by affected persons; these include standardized (e.g., self-help books, website bulletins) and tailored (e.g., phone or digital helplines) educational and motivational materials. As described below, LF can be implemented by professionals, peers/communities, and/or DTC mechanisms to help persons with MOUD access and maintain recovery-oriented services of numerous kinds and in multiple care settings.

2. Taxonomy of Linkage Facilitation for OUD Services

As depicted in Figure 2, this article proposes a taxonomy of LF services for persons with OUD. Taxonomies are organizational frameworks that categorize a great variety of content in a manner that allows for standardized communication across scholars, programs, and disciplines (e.g., C. Abraham & Michie, 2008). As an added value, taxonomies often give rise to data recording tools that foster consistent and generalizable research and program evaluation (Evenboer et al., 2012). The LF taxonomy described here is the product of deliberations by an expert panel composed of LF researchers and practitioners, each with considerable experience in LF for SUD and OUD; most study authors served as panelists. Panelists first independently reviewed working materials in the form of research reviews (e.g., Bassuk et al., 2016; Eddie et al., 2019; Grella et al., 2022; Stack et al., 2022) and policy guidelines (e.g., CDCP, 2022; NAPS; 2019) summarizing the science and practice of LF for SUD and OUD. Panelists then met several times over three months to discuss panel goals, integrate content from working materials and from LF models currently being implemented in their respective studies, brainstorm candidate domains and domain categories, and iteratively vet the conceptual scheme and content of the taxonomy until they reached a final consensus.

Figure 2.

Taxonomy of Linkage Facilitation for OUD Services

The current taxonomy focuses on eight domains of LF services for persons with OUD: facilitator identity, facilitator lived experience, linkage client, facilitator-client relationship, linkage activity, linkage method, linkage connectivity, and linkage goal. The descriptions below present the basic categories of each LF domain, highlight research and practice themes in substance use (SU) and OUD, and introduce recent innovations specific to MOUD.

2.1. Facilitator Identity

2.1.1. Basic categories.

This domain describes linkage facilitator identity as a form of social identity that can be both formal and informal and is likely to be fluid over the course of one’s training and career experiences. Licensed Clinician: This category includes professionals from various healthcare sectors (e.g., nursing, social work, professional counselors). Early LF functions centered on containing health care costs for clients with chronic and acute illnesses; this strategy gave rise to licensed and credentialed sub-specializations. Licensed (or otherwise certified) clinicians are likely to perform numerous functions in addition to LF and to identify with their disciplines (e.g., social work) rather than the linkage tasks they perform. Certified Peer: This category includes credentialed peers (peer recovery support specialists [PRSS]) or credentialed others with lived experience of SUD (see Facilitator Lived Experience section) who work in a paid navigation role. Other Peer: This category includes other persons with lived experience who provide LF in. unpaid roles (e.g., mutual aid peer providing LF to social or practical supports).

2.1.2. Research and practice in SUD/OUD.

Linkage practice for the differing types of LF identities are often tied to reimbursement rules, which are bound to the service setting. People with SUD/OUD often require public assistance for their care, which extends into the community as recovery support services. Medicaid reimbursement for clients with complex needs, including those with SUD/OUD, may be insufficient from a licensed provider’s perspective, limiting the amount of time that can be spent on LF activities. Medicaid coverage for peers requires them to receive supervision, conduct work as part of an individualized care plan, and possess training and certification based on state requirements.

2.1.3. Innovations in MOUD research.

One CoARS network, Studies to Advance Recovery Supports (STARS; R24DA051973), is developing a research registry for ongoing enrollment and study of a cohort of Appalachian-based PRSS professionals. This registry will be informed by members of the Central Appalachian Peer Partnership, an advisory council of twelve employed PRSS working in the six states of Central Appalachia. The registry’s primary function is to clarify the range and scope of PRSS service delivery along with factors predictive of their professional engagement with MOUD clinics.

2.2. Facilitator Lived Experience

2.2.1. Basic categories.

This domain describes the degree to which a linkage facilitator has lived experience of a life event (e.g., SU, incarceration) that is central to the identity and/or experience of a given LF client. Direct: The facilitator has personally experienced the life event first-hand. Indirect: The facilitator has experienced the life event through a close family member or other close contact who has direct lived experience. Some recovery communities (e.g., 12-step, mutual aid) have historically fostered MOUD stigma, which undermines the status and/or activities of facilitators with Direct MOUD experience (Andraka-Christou et al., 2022; Woods & Joseph, 2018); in such instances, facilitators with Indirect MOUD experience can gain better traction. Remote: The facilitator has no close contacts with first-hand experience of the life event. Facilitators may belong to different categories of lived experience for different life events.

2.2.2. Research and practice in SUD/OUD.

The value of lived experience is being recognized as a potentially important consideration for successful LF (SAMHSA, 2017). When facilitators have relevant lived experience, clients may feel personal empowerment and hope about the future due to (a) connecting with someone who is able to role-model recovery and (b) building a trusting relationship based on shared experience (Gillard et al., 2015; Matthews, 2021). Still, requirements for lived experience vary greatly across associations, states, and projects that provide and certify LF services (SAMHSA, 2020b). Research is needed on the level of importance and details of what category of lived experience are necessary to enhance LF outcomes (Eddie et al., 2019). Currently, JCOIN is systematically advancing research on facilitator lived experience, with various projects requiring multiple Direct lived experiences (experience with SU recovery and the criminal legal system: Martin et al., 2021; M. Staton et al., 2021), one type of Direct lived experience (experience with SUD: Howell et al., 2021; Pho et al., 2021), or Remote lived experience (Knight et al., 2021; Scott et al., 2021; Springer et al., 2022).

2.2.3. Innovations in MOUD research.

A CoARS project (R24DA051950), the Justice and Emerging Adult Populations (JEAP) Initiative has teamed with three national community boards to develop research priorities in the MOUD field using community-based participatory research (CBPR) methods (JEAP Initiative Community Boards, 2021). The community boards consist of adults with Direct lived experience in the criminal legal system and SU recovery, emerging adults (aged 16-25) with Direct lived experience in SU recovery, and adults who provide or pay for recovery support services in their professional roles. Using an iterative process these community boards, in collaboration with the JEAP research team, refined priority areas of research, including a focus on LF for persons with MOUD. The combined expertise led to priorities that are relevant and more likely to benefit the people who are most affected; a toolkit for generating research priorities using CBPR methods is available (JEAP Initiative, 2022).

2.3. Linkage Client

2.3.1. Basic categories.

Facilitators can work with a variety of clients in an attempt to get individuals connected to services. Person in Need: The individual seeking services or determined to need services. Concerned Significant Other (CSO): Individuals who are interpersonally close with, and interested in supporting the goals of, the person in need; examples include family members, partners, close friends. Extended Network: Individuals interested in supporting the goals of persons in need but who are not within their close social support network.

2.3.2. Research and practice in SUD/OUD.

The vast majority of LF studies and programs for SU build their models with the Person in Need as the linkage client (e.g., Eddie et al., 2019). However, as SU treatment models have expanded to include CSO as the direct target of services either in conjunction with the Person in Need (e.g., Behavioral Couples Therapy; O’Farrell & Fals-Stewart, 2006) or even without the Person in Need (e.g., Community Reinforcement and Family Training; Smith & Meyers, 2009), so too are LF models beginning to expand. This expansion may be especially advantageous for clients experiencing low or waning motivation to remain in treatment, for whom incorporating other support persons in LF goals can be vital in creating and maintaining linkage. To date LF research in this area is limited but has strong growth potential (Hogue et al., 2021b).

2.3.3. Innovations in MOUD research.

One CoARS project (R24DA051946) is pilot testing the Relationship-Oriented Recovery System for Youth, a clinical protocol to increase uptake of MOUD and related services among adolescents and young adults (Hogue et al., 2023). One module focuses on training clinicians to link CSO to digital recovery supports that are specifically designed for CSO of youth with SUD/OUD (www.drugfree.org). Clinicians engage in linkage activities with CSO either in person during office visits or during synchronous video or phone-based telehealth sessions. Clinicians focus on two LF principles: (1) Use motivational interventions (Miller & Rollnick, 2012) to enhance CSO readiness to engage in support options. Clinicians also emphasize potential benefits of improved CSO self-care for boosting capacity to support youth engagement in OUD services and augmenting the youth’s overall recovery capital (see Archer et al., 2020). (2) Enact client-centered principles of “warm” service referral that emphasize LF collaboration (Joint Commission, 2017a); see Linkage Connectivity. To this end, clinicians use a recorded virtual tour of the digital support suite and sign-up procedures that clinicians and CSO can jointly view, discuss, and activate in session.

2.4. Facilitator-Client Relationship

2.4.1. Basic categories.

Prior research has identified several models of health-related decision making (e.g., Krist et al., 2017; Stiggelbout et al., 2015) that can be applied to the facilitator-client relationship, which can be condensed into three heuristic categories. Rigid Directive: Clients are expected to follow through with referrals made by the facilitator with no or little input of their own. Collaborative: These relationships balance the facilitator’s knowledge and expertise with client needs, goals, and desires. Permissive Flexible: These relationships emphasize client goals and desires above other considerations, thereby supporting full client autonomy to make healthcare decisions, even if the resulting treatment may not optimize outcomes given extant evidence and local availability.

2.4.2. Research and practice in SUD/OUD.

Overall, research has provided little description regarding what facilitator-client relationships might look like or which relationship elements might result in optimal linkage outcomes. Some evidence suggests that facilitators’ ability to form meaningful connections with clients fills a crucial service gap given clients’ experiences of stigmatized care that make it difficult to trust providers enough to follow through with referrals (e.g., Matsumoto et al., 2022). Specifically, the Rigid/Directive approach is aligned with authoritarian models of health decision-making (Kilbride & Joffe, 2018) that can be found when OUD providers or systems emphasize abstinence-focused approaches over other options with more evidence (Hodgins et al., 2022). This approach also occurs within the criminal legal system in instances of heightened concerns regarding a medication’s diversion potential (Grella et al., 2020), as when injectable naltrexone is presented as the primary or only MOUD option available (M. D. Staton et al., 2021). The Collaborative approach is aligned with the concept of shared decision-making (see Stiggelbout et al., 2015), wherein facilitators and clients collaborate to identify treatments that best suit client needs and preferences (Krist et al., 2017). Within the Permissive/Flexible approach, the responsibility of acquiring knowledge on treatment providers and options lies solely with the client. Few MOUD-based linkage models fully embrace this approach, though individual facilitators can act more permissively to the degree they lack the knowledge or skill to guide a collaborative LF process.

2.4.3. Innovations in MOUD research.

An example of the Collaborative category is the STAMINA (Syringe Service Telemedicine Access for Medication-assisted Intervention through NAvigation) trial investigating the effectiveness of telemedicine-based MOUD linkage (D. P. Watson et al., 2021) in a syringe service program setting. On-site staff use a tool to walk clients through the requirements, benefits, and drawbacks of all three available MOUD options to ensure they can make an informed decision regarding the best option for them before being linked to a physician over video conference. Using a different approach, the Recovery Management Checkup (RMC) intervention investigated in one JCOIN project (UG1DA050065) (see Scott et al., 2021) uses motivational interviewing techniques to develop a collaborative treatment linkage plan that considers a client’s individual MOUD needs, preferences, and barriers.

2.5. Linkage Activity

2.5.1. Basic categories.

This domain describes the functions and responsibilities carried out by a linkage facilitator in service of the client. Case Management: This category refers to a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for services to meet an individual’s comprehensive health needs (Case Management Society of America, 2016). Facilitators providing case management maintain longitudinal engagement with clients for health surveillance and provide continuous reassessment and reapplication of individualized support for emerging needs beyond the attainment of the targeted linkage(s). Targeted Navigation: This category refers to the deployment of LF activities for the purpose of attaining a specific, pre-defined service outcome. Targeted navigation may be triggered by the identification of a specific health event (e.g., overdose), screening result (e.g., lack of housing), or diagnosis (e.g., Hepatitis C) and more likely may be offered by entities with episodic or short-term contact with the client. Ad Hoc Support: This category refers to LF support delivered on-demand or as needed. Support requests may be specific or quickly fulfilled (e.g., a request for information about local recovery supportive housing options).

2.5.2. Research and practice in SUD/OUD.

According to SAMHSA (2020a), as of 2019 case management was available in 83% of SUD treatment facilities, including outpatient, hospital, and residential settings. Case management for clients with SUD has been associated with improved linkage and adherence to SUD treatment (see Vanderplasschen et al., 2019), increased engagement in nonacute care and reduced use of acute care (Kirk et al., 2013), reductions in SU (Joo & Huber, 2015), and improved social outcomes (McLellan et al., 1999). Targeted navigation for linkage to SUD care similarly is available across varied care settings and has demonstrated effectiveness in facilitating linkages to SUD care (e.g., Anderson et al., 2022). Many facilitators who provide case management or targeted navigation also make themselves available to provide ad hoc support to non-longitudinal clients. However, some clinical sites have dedicated resource roles (e.g., community resource specialist) responsible for maintaining current lists of resources available upon client request (Hsu et al., 2018). One major limitation to evaluating LF activities in SUD practice is the considerable overlap in LF functions by role type (K. J. Kelly et al., 2019) and lack of standardization of LF roles, which limits the ability to describe distinct LF roles.

2.5.3. Innovations in MOUD research.

A JCOIN project (UG1DA050066), Reducing Opioid Mortality in Illinois, is a multi-site randomized trial to evaluate the effectiveness of a dyadic delivery of case management and peer recovery coaching to facilitate timely linkage to MOUD during the first 12 months after community reentry from jails and prisons (Pho et al., 2021). This study also innovatively adapts the hub-and-spoke model to provide ongoing training, supervision, and administrative support to case managers and peer recovery coaches. CA Bridge represents an innovative Targeted Navigation intervention (Snyder et al., 2021) that combines MOUD induction in the emergency department (ED) with ED-based LFs who use a strengths-based harm reduction approach to identify and connect with clients with OUD during their ED visit. Facilitators conduct a needs assessment, link patients to outpatient SUD and mental health services, and assist with acquiring resources to address social determinants (e.g., insurance, transportation) that directly support the linkage. Finally, the aforementioned STAMINA trial leverages ad hoc support provided by facilitators to evaluate the effectiveness of same-day linkage to MOUD treatment via telemedicine combined with transportation and medication cost support (D. P. Watson et al., 2021).

2.6. Linkage Method

2.6.1. Basic categories.

This domain pertains to the method by which linkage activities are delivered, that is, the fundamental medium through which linkage activities are conveyed (versus the nature of the linkage connection itself; see Linkage Connectivity below). In Person: This category refers to activities that occur primarily via face-to-face meetings, whether in office, home, or community locations. In-person LF models frequently use supplemental, not-in-person methods (e.g., phone calls, text messages) to solidify or extend prime linkage activities. Digital Synchronous (Human): This category refers to activities that occur during remote meetings in which facilitator and client communicate in real time (i.e., interactively). Also called teleintervention or telehealth, this method uses video or phone calls, immediate text message exchanges, and live chatting in web-based environments. Digital Asynchronous (Automated): This category refers to LF activities that occur without participants being simultaneously present, such as automated text messaging, self-paced internet-based courses, and digital web support. This option is important for clients who are not ready, or prefer not, to interact with facilitators directly. It can be used as a component of larger support services for reminders and recovery support salience.

2.6.2. Research and practice in SUD/OUD.

While researchers have expanded the literature on using synchronous and asynchronous digital communication to support SUD/OUD (Ashford et al., 2020; Bergman & Kelly, 2021), few studies exist that are specific to LF as a stand-alone intervention outside of telehealth care. A recent review of telehealth-based MOUD initiatives highlights that the well-known mechanisms of telehealth and digital supports such as improved outreach, access, engagement, and reduced wait times enhance MOUD/OUD outcomes and engagement in treatment (Mahmoud et al., 2022). Other network models of care for OUD, such as hub-and-spoke models based on LF principles, shifted during COVID-19 to provide digitally supported services (SAMHSA, 2021). Whereas the empirical literature is heavily weighted to human-mediated digital OUD care as opposed to purely automated asynchronous support, some studies have examined the effects of automated reminders on appointment attendance and LF. For example, short message service (SMS) reminders (e.g., text services) reliably improve medical compliance and appointment attendance (e.g., Schwebel & Larimer, 2018).

2.6.3. Innovations in MOUD research.

As we move forward with digitally mediated support services across various digital media, numerous real-world implementation examples will continue to emerge: fully remote commercial MOUD clinics, hybrid hub-and-spoke models, traditional OUD clinics that use a range of digital services in a non-networked system, and so forth. Stepping back to understand the unique benefits and downsides of each digital option (e.g., resource availability, perceived connection, relationship building, salience) will allow us to build more efficient and effective models of digitally supported LF.

2.7. Linkage Connectivity

2.7.1. Basic categories.

This domain describes the nature of the linkage connections or communication between the facilitator and the target service. Integrated: This category refers to linkages conducted within integrated service contexts or between organizations with interconnected data systems. For the target service, this practice allows a more comprehensive understanding of the clients’ experiences and needs. Integration also allows the facilitator to easily confirm that the client reached the target service. Warm Handoff (Assertive Linkage): This category refers to a transfer and acceptance of responsibility for client care that programmatically ensures care continuity and safety (Joint Commission, 2017a). Handoffs occur synchronously in real-time, usually in-person, face-to-face via telemedicine, or verbally, with accompanying written documentation. Warm handoffs feature clear communication about the reason for referral, account of relevant clinical and psychosocial history, summary of relevant services received to date, description of referral objectives, and opportunity to address questions (Joint Commission, 2017b). Referral (Passive Linkage): This category refers to written orders requesting specific services and is often required for insurance coverage. Referrals are delivered by electronic medical record, fax, or postal mail, with no built-in feedback mechanism to confirm receipt, review, or decision status. Referrals within healthcare contexts must be placed by a clinical provider, whereas some social and community referrals can be placed independently by facilitators.

2.7.2. Research and practice in SUD/OUD.

Research among the general population has shown that only about half of referrals result in a successful linkage to the target service (Barnett et al., 2012). Yet, referrals remain the standard practice for SUD/OUD services. Whereas linkage to SUD treatment often fails due to time delays between the client’s decision to seek treatment and treatment delivery (Carr et al., 2008), same or next-day access to outpatient SU treatment greatly improves linkage success (Roy et al., 2020). By nature of direct communication, integrated and assertive linkages can facilitate rapid communication and effectively connect patients to SUD services (e.g., Rawson et al., 2019; Richter et al., 2016).

2.7.3. Innovations in MOUD research.

One JCOIN-funded multi-level hybrid implementation study (UG1DA050074) utilizes both integrated and assertive linkages to improve multi-system coordination (Knight et al., 2021). The clinical intervention examines the effect of the Opioid Treatment Linkage Model on linkage to community-based MOUD and behavioral health treatment upon release from incarceration. Correctional officers are trained to provide assertive linkages to the target community service. The implementation intervention aims to improve health and social outcomes by using cross-system data sharing to facilitate interagency collaboration. Researchers are also exploring strategies to increase synchronous connections between traditionally asynchronous services to facilitate assertive linkages, such as deploying a 24/7 crisis team to abet linkage to OUD services after a nonfatal overdose (Dahlem et al., 2021) and co-locating ED departments and outpatient SU clinics that co-employ ED providers and facilitators (Anderson et al., 2022).

2.8. Linkage Target

2.8.1. Basic categories.

This domain pertains to the endgame target of LF activities, that is, the primary services or supports to which the client is being linked. MOUD Services: As described in above sections, many LF practices have a particular focus on linkage to MOUD services from a variety of settings including criminal legal, general health care, and specialty SUD treatment settings. Co-Occurring Treatment: In addition to co-occurring SUDs such as stimulant use disorder (Chan et al., 2020), persons with OUD typically present with one or more mental health problems (Jones & McCance-Katz, 2019) and other chronic medical conditions (some of which require ongoing pain treatment that is a primary vulnerability for OUD; Baker et al., 2021), including Hepatitis C and HIV and soft tissue infections for injection users (Rich et al., 2018). Ancillary Services: This category refers to social services and SUD/OUD harm reduction interventions considered adjunctive to ongoing OUD treatment. The category includes services to help secure basic needs such as housing, food, and medical benefits; enrichment needs such as education and employment; logistical assistance such as childcare and transportation that support attendance at services, and harm reduction interventions such as syringe services. Recovery Supports: This category refers to the continuum of recovery-oriented programming, described above (Laudet & Humphreys, 2013), that are designed to support SUD/OUD recovery goals.

2.8.2. Research and practice in SUD/OUD.

Identification and engagement with linkage targets for persons with SUD/OUD are highly dependent on community resources, client characteristics (Paino et al., 2016), and payor sources (Kravitz-Wirtz et al., 2020). The CDCP offers a technical package of policies, programs, and practices for linking people with OUD to medication treatment, demonstrating how LF targets can also be bi-directional (CDCP, 2022). As detailed above, a number of recent studies have explored how to optimize LF and retention in identified target services. Because longitudinal rates of MOUD adherence and retention are low (O’Connor et al., 2020), emerging research has focused on using LF to re-connect individuals to MOUD after treatment dropout, particularly among individuals at greater dropout risk (e.g., younger age, criminal legal involvement, negative attitudes toward MOUD; see Fishman et al., 2021; Wenzel & Fishman, 2021). Importantly, client engagement and retention in target services can be strengthened by culturally responsive assessment and treatment practices (Guerrero, 2013).

2.8.3. Innovations in MOUD research.

One CoARS pilot project (R34DA057627) is testing the impact of a peer-delivered intervention to promote MOUD retention and re-engagement for individuals living in recovery residences. Those initiating MOUD receive recovery coaching, care navigation, and recovery management checkups to promote overall recovery, with a special emphasis on MOUD adherence. In the case of MOUD dropout, peers shift from general case management activities to a targeted navigation approach, prioritizing (re)linkage to MOUD and other targets as appropriate. Peers rely on in-person and digital synchronous linkage methods and operate within an integrated system of care to improve LF.

3. Putting the LF Taxonomy to Work: Training and Implementation Challenges

3.1. Supporting the LF Workforce

3.1.1. Supervision.

Supervision remains ill-defined for facilitators (Deussom et al., 2022). The primary education of some facilitators comes from lived experience, regaining wellness, and achieving a self-defined recovery (Forbes et al., 2022). Thus, LF supervision may not readily conform to an explicit professional practice domain such as Social Work or Psychology. Facilitators may not receive enough (Tate et al., 2022) or adequate supervision (Hill et al., 2014), and supervisors may have insufficient knowledge and skills to support LF work (Gillard et al., 2015). Similarly, facilitators with supervisory responsibilities may not have background, training, or support in how to provide supervision (Tate et al., 2022). Competent and regular supervision contributes to facilitator job satisfaction (K. M. Abraham et al., 2022) and success (Eisen et al., 2015), and it may be an important factor in promoting facilitator resiliency (K. M Abraham et al., 2022; Stack et al., 2022). Guidelines exist (NAPS, 2019) on how to align core values (e.g., mutuality/reciprocity) with LF practice (e.g., encourage LFs to give and receive) through specific supervisor activities (e.g., welcome feedback during supervision). Other recommendations include regular constructive feedback based on tools to assess practice quality; and sustaining supervision with adequate policy and financial support (Deussom et al., 2022).

3.1.2. Self-Care.

As some facilitators support high-acuity populations while maintaining their own recovery, their work can be challenging (Pasman et al., 2022a). Combined with other stressors such as operating within overwhelmed treatment systems, unsupportive working environments, and navigating client deaths (Vandewalle et al., 2016), facilitators may face increased vulnerability to burnout (K. M. Abraham et al., 2022). Self-care routines have been identified by facilitators as important in mitigating burnout and improving resiliency against chronic work stressors (Brady et al., 2022). Consistent with a variety of helping professions (Hayes & Skeem, 2022), facilitators’ self-care can be promoted through professional development, funding structures, and organizational policies promoting flexible scheduling and emotional support (Stack et al., 2022; Tate et al., 2022).

3.1.3. Consideration of Youth LFs.

Ability to engage youth in services may be enhanced with youth facilitators, who are uniquely equipped to relate to other youth, build trust via shared experience, and serve as role-models (Ojeda et al., 2021). Most LF research has focused on adult clients or on adult facilitators providing support to youth (Ojeda et al., 2021); “mentors” educating youth, without attention to linkage or lived experience (Paquette et al., 2019; Burton et al., 2022); and youth facilitators who are somewhat older than youthful clients (e.g., Paquette et al., 2019), although youthful clients may prefer facilitators to be slightly older (Hiller-Venegas et al., 2022). Though some caution that youth may lack the maturity, skills, and perspective-taking needed to readily assist fellow youth, with adequate adult supervision youth leaders may be effective (Burton et al., 2022).

3.2. Considerations for Implementing and Sustaining LF Services

3.2.1. Leadership.

Commitment of organizational leadership is vital to LF implementation (Ibrahim et al., 2020) and especially germane when clarifying the need, importance and practices of facilitators and initiating policy changes to support them (Mirbahaeddin & Chreim, 2020). Leaders are in a key position to convey support and full endorsement of facilitators, oversee policies for LF services, include facilitators in decision making, and support ongoing training to teams in which facilitators are embedded (Mancini, 2018).

3.2.2. LF Integration and Role Clarification.

Clashes in philosophy between a medical model where an expert knows best, versus experiential knowledge and self-determination, preclude integration of some facilitators within systems (Mirbahaeddin & Chreim, 2020). Integrating facilitators into systems is improved by providing them with a peer network, preparing staff through training (e.g., how to interact with facilitators) and role clarification (Mancini, 2018; Sianz et al., 2016), and attending to staff attitudes towards facilitators (Ibraham et al., 2020). Resistance to facilitators’ integration due to stigma and discrimination can be strongly mitigated via certification that confers formal professional recognition and signals investment in LF roles and activities (Mirbahaeddin & Chreim, 2020).

3.2.3. Strategies to Implement and Sustain LF Services.

Strategies to address facilitators and barriers in a given local ecology when implementing and working towards sustaining LF services can be distilled into: obtain a knowledgeable facilitator (perhaps external to the system); have a process to illustrate the need for, benefits of, and concerns about use of LF services; formalize commitment to install and maintain services (e.g., in written form) in consideration of resources; form a team of key stakeholders to steer the process and continued involvement of leadership in decisions; identify a feedback process to track success so that changes can be made as needed and to garner support for long-term programming; and ensure that written documentation of decisions, policies, and procedures is developed and maintained by leadership (Chinman et al., 2010; Franke et al., 2010; Kokorelias et al., 2021; Mancini, 2018; Valaitis et al., 2017).

4. Conclusion: Promising Avenues for Advancing the Science of LF for OUD

4.1. Valuing Lived Experience

People with lived experience are increasingly being involved in research, and as a result, are informing improved research protocols and the uptake of effective treatments and recovery supports (Stull et al., 2022). For example, the National Institutes of Health specifically sought feedback from persons with lived experience when developing the Helping to End Addiction Long-term (HEAL) initiative (Stull et al., 2022). As a result of this new focus on engaging persons with lived experience, many CoARS studies are actively engaging persons with lived experience using CBPR, community engaged research, and other methods (e.g., Hagaman et al., 2023). The formalization and professionalization of lived experience as a tool for navigating treatment and recovery, and as a means to connect difficult-to-reach populations through credentialed peer workers, is a promising avenue for advancing the science, as these practices become increasingly standardized and as evidence grows for their effectiveness.

MOUDs have traditionally been stigmatized among the recovery community (Andraka-Christou et al., 2022; Woods & Joseph, 2018) and SUD/OUD treatment providers (Pasman et al., 2022b). These attitudes may be changing, however. People who use MOUDs as part of their recovery may be under-represented among providers at present but improving this representation may help improve MOUD adherence and outcomes for clients (Anvari et al., 2022). Similarly, SUD researchers are also increasingly embracing other researchers with lived experience, and in some cases, listing lived experience as a preferred qualification. Researchers with lived experience may be able to build rapport and trust with research participants, especially in qualitative interviews (Cioffi et al., 2023), which may be critical to engaging participants who use MOUD or have other MOUD lived experience.

4.2. Exploring Mechanisms of Action

Due to variation in LF services and the systems in which they operate, along with the scarcity of extant LF mechanisms research, it remains challenging to determine how LF produces change. E. Watson (2019) identified several potential mechanisms including lived experience, which is important in fostering credibility and mutuality; emotional honesty and connection; being a role-model; social and practical support; and being strengths-based. Notably, these constructs all relate to Rogers’ (1959) core conditions needed for healing relationships: emotional honesty is related to congruence (being genuine), lived experience fosters empathy, and being strengths-focused relates to unconditional positive regard. In addition, several guiding theories have been proposed to explain LF mechanisms (see Fortuna et al., 2022). Social support provided by facilitators may enhance problem-solving and signal that stressful events are benign, thereby dampening adverse reactions to stress (Taylor, 2007). Social cognitive theory (Bandura, 2012) posits that clients model facilitators whom they perceive as successful and similar to themselves, thereby learning coping skills and improving self-efficacy. Self-determination theory (Deci & Ryan, 1985) holds that clients are able to strive towards well-being as facilitators assist them in meeting their needs for control, self-sufficiency, competence, and social connection. To advance the science and practice of LF for SUD/OUD, future research should more clearly define LF roles, tasks, proposed mechanisms using theory, and outcomes—all of which will avail stronger evaluation of LF mechanisms. So strengthened, mechanisms research will invariably help to standardize LF research constructs and intervention development, improve the interpretation of LF research findings, foster consistent communication about LF program evaluation, and assist in the translation of LF research and program evaluation data into practice.

4.3. Taxonomy Extensions and Limitations: How the LF Taxonomy can Advance LF Research, and Vice-Versa

As stated, the LF taxonomy has both scientific and clinical value for advancing consistent communication about LF practices and guiding research on diverse LF models delivered in diverse OUD treatment and recovery settings. For example, it can serve as a basic component checklist for researchers, model developers, and practitioners involved in LF activities: How do the practice standards and guidelines of the given LF model reflect the eight domains of the taxonomy? What intentional and implicit decisions about LF program design are operationalized in the given model’s facets, and how are training, supervision, and fidelity standards calibrated accordingly? Conversely, future applications of the taxonomy to diverse LF models and practice contexts will inevitably spur development of the taxonomy itself. As noted, the current taxonomy is based primarily on recommendations from one group of expert panelists and with examples of innovations from two research networks. Further research and development are needed to supplement the taxonomy and the research supporting it. For example, although we made every effort to define each of the eight domains in a differentiated matter, some may view domains to be overlapping on conceptual or pragmatic grounds. As the limited evidence base on LF for OUD expands, it may (soon) be possible to derive an empirically grounded LF taxonomy that would amend, or perhaps wholly rewrite, the consensus-driven version presented here—itself a welcome advance for the field.

Manuscript Highlights.

• Linkage facilitation (LF) is becoming increasingly commonplace in settings that serve persons with opioid use disorder

• A formal taxonomy is needed to promote consistent communication about LF standards and practices

• LF activities fall in eight consistent domains and are exemplified by current research innovations from two federally funded research networks