Mobile Treatment for Opioid Use Disorder: Implementation of Community-Based, Same-Day Medication Access Interventions

Abstract

Background:

Medications for Opioid Use Disorder (MOUD) are lifesaving, but <20% of individuals in the US who could benefit receive them. As part of the NIH-supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as units that provide same-day access to MOUD at remote sites. We aimed to (1) document the design and organizational structure of mobile programs providing same-day or next-day MOUD, and (2) explore the barriers and facilitators to implementation as well as the successes and challenges of ongoing operation.

Methods:

Program staff from five programs in two states (n=11) participated in semi-structured interviews. Two authors conducted thematic analysis of the transcripts based on the domains of the social-ecological model and the semi-structured interview guide.

Results:

Mobile MOUD units sought to improve immediate access to MOUD (“Our answer is pretty much always, ‘Yes, we’ll get you started right here, right now,’”), advance equity (“making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,”), and decrease opioid overdose deaths.

Salient program characteristics included diverse staff, including staff with lived experience of substance use (“She just had that personal knowledge of where we should be going”). Mobile units offered harm reduction services, broad medical services (in particular, wound care), and connection to transportation programs and incorporated consistency in service provision and telemedicine access.

Implementation facilitators included trusting relationships with partner organizations (particularly pharmacies and correctional facilities), nuanced understanding of local politics, advertising, protocol flexibility, and on-unit prescriber hours.

Barriers included unclear licensing requirements, staffing shortages and competing priorities for staff, funding challenges due to inconsistency in grant funding and low reimbursement (“It’s not really possible that billing in and of itself is going to be able to sustain it”), and community stigma toward addiction services generally.

Conclusions:

Despite organizational, community, and policy barriers, participants described mobile MOUD units as an innovative way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.

Introduction

Fatal overdose deaths continue to increase in the United States (US), largely due to the influx of synthetic opioids in the drug supply, with a 14% increase in overdose deaths from 2020 to 2021 alone (Mattson et al., 2021; O’Donnell, Gladden, & Seth, 2017; Spencer, Miniño, & Warner, 2022). Medications for opioid use disorder (MOUD)—e.g., buprenorphine and methadone—are evidence-based, life-saving medications associated with a decrease in fatal overdoses and a decrease in all-cause mortality (Larochelle et al., 2018; Mancher & Leshner, 2019; Santo et al., 2021; Sordo et al., 2017; Wakeman et al., 2020). However, the individual and public health benefits of MOUD are limited by barriers to implementation and access (Blanco & Volkow, 2019). As a result, only about 20% of US individuals with an opioid use disorder (OUD) receive MOUD (Krawczyk et al., 2022).

Access to MOUD is particularly low among racially minoritized populations due to the impacts of structural racism (Mauro, Gutkind, Annunziato, & Samples, 2022; Stahler, Mennis, & Baron, 2021). In New York City, the predominantly white, highest income zip codes have seen the greatest increase in buprenorphine access over time (Hansen, Siegel, Wanderling, & DiRocco, 2016). Nationally, white patients who use self-pay or private insurance have higher odds of receiving buprenorphine prescriptions (Lagisetty, Ross, Bohnert, Clay, & Maust, 2019). Methadone clinics are disproportionately located in predominantly Black and Hispanic communities and buprenorphine is more accessible in predominantly white communities (Goedel et al., 2020), which confers MOUD access challenges (Mattick, Breen, Kimber, & Davoli, 2009). Thus, structural racism appears to influence the geographic barriers to MOUD.

People who use drugs (PWUD) also face myriad interpersonal and systemic barriers to healthcare including discrimination, stigma, geographic availability, and regulatory barriers (Drake et al., 2020; Knudsen, Abraham, & Oser, 2011; Mancher & Leshner, 2019; Motavalli et al., 2021). Experiences of discrimination and anticipated stigma dissuade people who inject drugs from seeking treatment even if they would otherwise be interested (Biancarelli et al., 2019; Mancher & Leshner, 2019; Meyerson et al., 2021; Muncan, Walters, Ezell, & Ompad, 2020; Paquette, Syvertsen, & Pollini, 2018; Wakeman & Rich, 2018).

To address inequitable access and barriers to receiving MOUD, communities in the US have implemented mobile units. While program designs vary, surveys and interviews of mobile clinic participants indicate lower levels of stigma compared to fixed locations, reduced geographic and scheduling barriers, and strengthened provider-patient relationships (Bartholomew et al., 2022; Berk, 2020; Fine et al., 2021; Grieb et al., 2022; Hall et al., 2014; Regis et al., 2020). The flexibility and accessibility of mobile clinics may be well-suited to engaging populations underserved in traditional settings, including people experiencing homelessness, people recently released from incarceration and people in minoritized populations (Berk, 2020; Chan et al., 2021; Yu, Hill, Ricks, Bennet, & Oriol, 2017). While there is an existing literature base on the benefits of mobile clinics for addressing OUD, limited evidence exists around mobile clinics that specifically seek to provide same-day access to MOUD, with existing studies presenting program evaluations of single programs (Fine et al., 2021; Regis et al., 2020) or assessing acceptability of a proposed mobile unit (Bartholomew et al., 2022).

The HEALing (Helping to End Addiction Long-Term) Communities Study (HCS) is a multi-site study in 67 communities in four states (Kentucky, Massachusetts, New York and Ohio) which uses the Communities that HEAL (CTH) intervention to reduce opioid overdose deaths (Knudsen et al., 2020; Lefebvre et al., 2020; Sprague Martinez, 2020; “The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices,” 2020; Winhusen et al., 2020). Participating communities, in collaboration with the study team, chose and implemented evidence-based practice strategies to reduce overdose and related deaths (Winhusen et al., 2020). As part of the first wave of HCS, five programs across two states, Massachusetts (MA) and Ohio (OH), implemented mobile MOUD programs. We define mobile MOUD programs as non-stationary units that sought to provide same-day access to a MOUD prescriber at an outreach site, either in-person or via telehealth. Importantly, while we sought to include programs that offered same-day access to any MOUD, none of the HCS mobile units offered same-day access to methadone.

This qualitative study assessed implementation of mobile MOUD programs via semi-structured, in-depth qualitative interviews with community providers of five mobile MOUD programs in two states. We aimed to (1) document the important features of mobile programs providing same-day MOUD, and (2) explore the barriers and facilitators to mobile unit implementation as well as the successes and challenges of ongoing operation. By assessing multiple programs in diverse geographies, our goal was to inform future implementation of mobile clinics as a low-barrier model for MOUD access.

Methods

To study mobile MOUD unit implementation, we conducted deductive and inductive analysis of facilitators and barriers to effective implementation and explored related programmatic challenges, with particular attention to perspectives on the diversity of patients served. We collected no specific utilization data. The sampling frame for this qualitative study included program staff at mobile MOUD clinics from all programs within the first wave of HCS intervention communities. Inclusion criteria required that mobile MOUD clinics had to provide same-day access to either in-person or telehealth linkage to a prescriber of MOUD, at various outreach sites. We did not include mobile programs that only offered referrals to MOUD prescribers.

Participants were 18 years of age or older, English-speaking, affiliated with the mobile MOUD programs, and provided written informed consent. We conducted a thematic analysis guided by a public health iteration of the social ecological model, which provides a framework for understanding how individual, interpersonal, community, and societal factors shape public health phenomena (Dahlberg & Krug, 2006).

Study Setting

We conducted 11 individual semi-structured in-depth interviews with key informants at five HCS mobile MOUD units located in MA and OH between August 2022 and January 2023. Three of the mobile MOUD units served urban MA communities (Brockton, Gloucester, and Salem), and one served a rural cluster in MA (Bourne and Sandwich). One mobile MOUD unit served rural OH (Ashtabula County). We recruited at least two interviewees per mobile MOUD unit. Key informants worked directly on the unit or in affiliation with the mobile program through the MOUD referral process and reported diverse professions (see Table 1).

Table 1.

Interviewed participants involved with the mobile MOUD units

State	Organization	Role
Massachusetts	Community Health Center	Recovery Support Navigator
	Community Health Center	Director of Substance Use Services
	Community Health Center	Family Nurse Practitioner
	Community Health Center	Mobile Services Project Manager
	Community Health Center	MOUD Navigator
	Community Health Center	Registered Nurse/Program Manager
	Harm Reduction Program	Program Director
	Harm Reduction Program	Program Director
	Harm Reduction Program	Harm Reduction Specialist
Ohio	Community Health Center	Medical Director
	Community Health Center	Nurse Practitioner/Associate Medical Director

Data Collection

HCS staff shared contact information for possible participants with our research team. Some participants also referred us to other implementing community partners, i.e., via snowball sampling. We invited participants via email to participate in a semi-structured, videoconference-based interview. Potential participants learned about the research goals and were aware of HCS through their work on study strategies, but they were not told more about the researchers. Of 24 individuals approached for recruitment, 11 completed interviews. The vast majority who did not participate simply did not respond to emails. The average interview length was approximately 60 minutes (range: 32–95 minutes). We offered participants compensation of a $50 gift card; some were not able to accept payment due to employer regulations.

We conducted one-on-one key informant interviews using a semi-structured interview guide that the co-authors devised, including those who have worked on mobile MOUD units (see supplement). Interviewers asked about the implementation process and different barriers and facilitators the units were experiencing/might have encountered. We video and audio recorded interviews both via the videoconferencing platform and a backup recording device, and a transcription service manually transcribed them verbatim.

Data Analysis

We conducted thematic analysis to deductively categorize findings and identify themes as the analysis progressed (Armat, Assarroudi, Rad, Sharifi, & Heydari, 2018; Vaismoradi, Turunen, & Bondas, 2013). The study team created a preliminary codebook based on the domains of the social ecological model and the semi-structured interview guide. First, two members of the research team (AC and CS) coded two interview transcripts shoulder-to-shoulder, collaboratively reaching consensus on codes and definitions. These two members of the research team then coded the remaining nine transcripts separately, meeting regularly to clarify application of codes, though throughout the process the two coders found themselves in agreement on application of codes. The coders inductively identified emergent themes within the larger codes of the preliminary codebook using the constant comparative method (Fram, 2013). The coders added these emergent themes as subcodes to an expanded codebook (see Supplement for codebook) and applied them to all transcripts. The coders sought thematic saturation, which we defined as no new themes emerging (Saunders et al., 2018) in the last two coded transcripts. Coders conducted data analysis manually in Microsoft Word, without software.

Positionality Statement

The interviewers, TB, MR, EK, and AM, were research team members from MA trained in qualitative data collection, and had no prior relationship to participants. They conducted the interviews, all in English. AC, an Indian American addiction medicine physician trained in qualitative research, and CS, a White American research team member with a bachelor’s degree in psychology and substantial experience in qualitative methods and implementation science, coded the transcripts. AP established the mobile MOUD program in one of the HCS communities, and as a potential participant and co-author, provided feedback on the findings. JT supported mobile MOUD programs in two HCS communities. All other authors are addiction medicine researchers with varied educational backgrounds and levels of experience.

Results

Overview of Themes

Table 2 provides an overview of program characteristics, and Table 3 provides an overview of facilitators, barriers, and future directions. With all five programs continuing to enroll patients over six months since the end of the HCS Wave 1 study period, we considered all mobile programs to have been effectively implemented. Participants described their perspective on why the mobile program was developed, the physical characteristics of the mobile unit, the medications and other services they offered, as well as unique service delivery approaches and staffing strategies. Participants shared perceptions of important facilitators to mobile MOUD units including care driven by personal and organizational values, strong relationships with partner organizations and the community, and funding and technical support from HCS. Barriers to establishment of mobile MOUD units included intra-agency issues, funding, community and inter-agency tensions, clinical concerns and mobile care regulations, and the demands, strict timeline, and perceptions of HCS. We indicated whether facilitators and barriers operate at the individual, interpersonal, community, or societal level as suggested by the social ecological model (Dahlberg & Krug, 2006). Finally, participants described future directions for mobile MOUD units, including pursuing formal assessment, expanding services, and seeking new funding sources.

Table 2:

Physical space considerations and services offered as reported by 11 staff at 5 mobile Medication for Opioid Use Disorder Programs

	Items Mentioned by Participants	Supporting Quotes
Physical Space Considerations	• Storage space • Space to see patients • Locking cabinets • Wireless internet • Chargers for electronic devices • Restroom (urine tests) • Phlebotomy chair (if offering  more comprehensive clinical services	“So I went and looked at the van and drew up some plans to re-outfit it. So the back should be more comfortable. It should have more storage room, like locking file cabinets. Things like that.” “Then it was a lot of learning curves around just purchasing the van, what we wanted the van to look like...I already had an idea of how we wanted to have a phlebotomy chair in there, how we wanted to have the shelves set up, how we could do testing, how we could have lights.”
Services Offered	• Harm reduction supplies (naloxone, fentanyl test strips, smoking supplies) • Nursing services • Insurance enrollment • Snacks, clothes, sleeping bags • Transportation support • HIV, Hepatitis C, and Sexually  Transmitted Infection testing and treatment • Post-Overdose Outreach • Recovery Coaching	“I mean, sometimes it’s not just MOUD...I remember this one time I got five financial counseling appointments. They wanted insurance...and also PrEP [pre-exposure prophylaxis to prevent HIV infection], Hep C treatment.” “That they’re there reliably with snacks, supplies, whatever else, is something that people have really enjoyed.” “Fentanyl test strips were a really big hit too.”

Table 3.

Facilitators, Barriers, and Future Directions from 11 interviews with staff members from mobile medication for opioid use disorder (MOUD) programs, with barriers and facilitators designated, and practical recommendations offered for each subtheme.

Major Theme	Subtheme	Practical Recommendations
Facilitators	• Values-Based Motivations for Starting a Mobile MOUD Program • Thoughtful Decision on Medications Offered • Creative Service Delivery Strategies • Staffing Considerations • Personal and Organizational Values • Community Relationships • Federally-Funded Study Participation As Facilitator	• Offer buprenorphine and naltrexone, including injectable forms • Partner with local agencies to determine where a mobile unit would be the most effective • Combine foot outreach with mobile unit-based services; combine telemedicine and in-person services • Staff with lived experience of substance use and/or homelessness are particularly effective on the mobile unit • Select staff whose values are consistent with the need for judgment-free, flexible care on mobile units • Loop in relevant partner agencies and stakeholders early in planning process and continue to meet as mobile programs are implemented • Take advantage of resources offered by federal study participation
Barriers	• Intra-Agency Operational Challenges • Financial Sustainability • Community Relationships • Clinical and Regulatory Barriers • Federally-Funded Study  Participation as a Barrier	• Dedicate adequate staff and resources to the project • Maximize billing practices, pursue varied grant opportunities • Invest in relationships early and make anticipatory plans regarding how stigma may shape reception for new programs serving people who use drugs • Leave time to address unanticipated regulatory hurdles • Weigh pros and cons of federal study participation; anticipate data collection requirements and stringent timelines
Future Directions	• Services • Funding • Program Evaluation	• Consider logistics of offering methadone, hepatitis C screening and treatment, injectable buprenorphine and pre-exposure prophylaxis • Learn about local process for opioid settlement funds • Consider resources and partnerships to pursue quantitative and qualitative evaluation

Facilitators

Value-Based Motivations for Starting a Mobile MOUD Program

At the individual-level, participants reported that saving lives was a major motivation for engaging in this work: “I think everybody doesn’t want to see people dying of overdoses. And so if we’re putting out an intervention there to kind of help decrease that...it’s pretty well received.” Participants were also motivated by limitations to existing brick-and-mortar MOUD treatment, including transportation and geographic access, especially in rural areas: “Whether it’s north, south, east, west, doesn’t really matter, it’s about 40 to 45 minutes from that location. So we really tried to target those areas that just don’t have access.” Reaching people who used drugs alone and away from areas targeted for overdose prevention resources was also important: “And we found that a lot of people were using at home, there’s no [overdose] hotspot [in that community].” Participants felt that mobile units, consistent with participant motivations, served to make medication treatment available to more people: “I feel like it’s just easier for them. It’s just hard for them to make those first steps that sometimes when it just comes to you, I guess you’re just more open to it if it’s right there. So they’re like, you know what, let me just do it. Right?” Thus, expanding access to life-saving treatment at sites not traditionally served was an important driver in the creation of mobile MOUD units.

Thoughtful Decisions on What Medications to Offer

Buprenorphine, short-acting naltrexone, and long-acting injectable naltrexone were offered on mobile MOUD units; methadone was not offered on any of the units whose staff we interviewed due to regulatory barriers: “So, we will do Suboxone, usually. And then, we have the capacity to do Vivitrol if we wanted to. They will prescribe some oral naltrexone...we’ll make referrals for methadone.” In addition to traditional induction and MOUD continuation, some programs offered low-dose buprenorphine induction strategies to better engage people on fentanyl who were concerned about buprenorphine precipitated opioid withdrawal: “Some prescribers are doing microdosing to get on Suboxone from fentanyl use.” Some units had prescribers on-board for every session, while others utilized telemedicine (“we would call [the doctor], he would be able to look up [in the electronic medical record], he would talk to the person directly”), and others utilized a combination of in-person and telemedicine services. Some observed induction (“typically they will get inducted with the nurse and then they return the next day to do an observed dosing again, just to make sure they tolerate it”) on the van but others prescribed medications for home induction (“at this point, we do home inductions for pretty much everyone.”)

Creative Service Delivery Strategies

Organizations leveraged community-level relationships and interpersonal skills to offer services in a creative manner. Programs used overdose data provided by community partners, with sharing often facilitated by HCS staff and locations of existing services to determine routes: “We pitched the locations based on what we deem to be hotspot areas or areas where there’s a need for MOUD treatment services...including areas with high risk for overdose.” Participants described foot outreach as an additional way to reach patients: “So, for each of the sites, they will do some outreach on foot, depending on each of the locations.” Program staff reported being very thoughtful about physical space considerations, and were thoughtful about offering a variety of services, highlighting insurance enrollment and wound care (“a lot of wound care, which is something that we didn’t foresee, but it actually is a big reason for visit is, the wounds that we’ve been able to treat out on the street level”) (Table 2). Participants emphasized the importance of consistent days of the week and times spent at each location: “I really believe in consistency, especially for outreach. If we show up at those times for people, then they’re going to start to get used to us being there and expect us to be there.” Another important characteristic of service delivery was open access for walk-ins, so patients did not need to pre-schedule appointments: “The whole schedule for the day is just open.” Discretion was also an important aspect of mobile services presentation: “We made sure not to put a clear sign about what it is versus just our logo...and we pushed the logo on social media because we wanted to maintain some privacy and yet be recognizable.” Finally, a thoughtful plan to advertise services was important: “We were thinking of ideas and advertised what we were doing. So we did a billboard, we did some flyers, we did these posters with barcodes on them for people to scan and then it would take them to our Facebook...We would put flyers on the windshields of cars and stuff.” In addition to formal advertising, word of mouth was vitally important: “We keep meeting all these new people that were like, ‘Oh, I was referred by my friend.’” Thus, choosing locations with high need, maintaining open-access scheduling, being consistent but discreet, and advertising in a variety of ways were important service delivery considerations.

Thoughtful Selection of Staff

Participants provided important insights on staffing. Limited buprenorphine prescriber availability was an important concern. Some programs had a prescriber on the mobile unit, while some had a prescriber accessible via telehealth: “So, we had to make sure we had the staff on the van, they had the telemed capacity with the laptops and et cetera, and we just needed to make sure we had free providers.” As noted above, adequate nursing staffing—in particular for wound care—was important: “There were just times where, for example...[we had] someone with an open abscess and so we would have to tell them to go to the main office to get that taken care of. But it’s a missed opportunity.” Having staff with lived experience, including harm reduction specialists and recovery coaches, was seen as very important: “She just had that personal knowledge of where we should be going. She went to that homeless encampment and she was like, ‘Dude, you need a phone, you need this, you need that.’” Making sure to have enough staff who can drive was noted to be important as well, and sometimes overlooked. Staff safety was also a concern, which often required having a minimum number of people on the mobile unit: “I was always just more concerned around safety if something happened on the van, and we only had one staff person and a volunteer.” Thus, having MOUD prescribers, nurses, staff with lived experience, and people who can drive were important staffing considerations.

Alignment of Personal With Organizational Values

At the individual and interpersonal level, specific values held by staff and organizations underpinned the successful implementation of mobile units, including commitment to broadening access to MOUD: “We really saw the need for people to get connected.” Equity was also a guiding value during implementation, with participants noting a need to tailor programs to reach Black, Native American, and other communities not served by traditional services: “So [our city] is, I think it’s the only predominantly Black city in [the state and] we’ve noticed that typically the clinical appointments in general, that’s reflective of the demographic, but the MOUD appointments that it’s not as reflective. It’s still mostly white males of 30 or 40 years of age...So I think that we want to try to expand the groups that we’re offering that service to.” Cultural and linguistic diversity among staff was deemed important to support equity efforts, with program staff noting intentional hiring to promote this diversity: “We actually have two community health workers. One, she speaks Haitian Creole. She’s originally from Haiti. And one is from Cape Verde, can also speak Portuguese and Cape Verdean and Creole.” Other populations that programs sought to increase access for included people experiencing homelessness (“[we] went to homeless encampments”), recently incarcerated individuals (“If they had gotten out of jail, and something was wrong with their insurance, they had their Suboxone prescription waiting at the drugstore. A lot of times we would see people right after they got released”), individuals who are pregnant (“I think that mobile services have just allowed us to reach a more high-risk population of women who are pregnant, that we’ve struggled to reach previously, just because we’re out in the community”), and workers in certain industries (“So we are trying to target fishermen. ... the members from the coalition decided to do ‘Provider on the Pier.’”). No participant described equity-tailored programs being more challenging to implement, rather, reaching special populations was a motivating and an intrinsic part of the work: “Yeah. I mean, I think we’ve always tried to prioritize some of the higher risk populations as DPH defines them.”

Creativity and flexibility at the individual and team level were important for successful implementation: “So, we never get too stuck on, ‘This is our spot. And we’re always going to go to this spot,’ because if our patients leave and go somewhere else and that’s where we’re needed, then we’re going to try to move over to where they’re located.” Finally, creating a stigma-free, judgment-free treatment environment was vital to success: “it’s much less stigmatizing. I think the community can feel that and I think it speaks to why we just have so many patients in treatment right now.” Thus, equity, outreach to populations without prior access to services, flexibility, and stigma-free care were important guiding values facilitating mobile programs.

Community Relationships

Community engagement and partnerships—operating at the community level of the social ecological model (Dahlberg & Krug, 2006)—were important for success of mobile units: “Everyone was just working together...I don’t know, everyone was just on board and it’s great. We’ve even had people from the shelter hop on the meetings, which were helpful because I wasn’t aware of certain things.” Community relationships allowed agencies to better serve specific clients (“also, we would update each other, I’d say every two weeks. And then our meetings were monthly. We were part of the coalition, and we would share difficult cases and we would learn from each other”) as well as to help with outreach (“we did collaborate with...the post-overdose program [on outreach]”). In addition to the importance of relationships across broad sectors (e.g., police, local political leaders, libraries, homeless shelters, social service agencies), participants noted the importance of developing specific relationships. Positive relationships with police, for example, helped facilitate operations (“I think the first people to really embrace our program in that city were the police, they are the ones that invited us in and asked us to expand our services there”) especially when relationships with police was a challenge for other communities (see below). Relationships with pharmacies was crucial for implementing MOUD services: “We usually know which [pharmacy] is the closest. I think there are some that are easier to work with than others in terms of whether or not someone has an ID [identification]. And so, we tend to know which ones those are.” Relationships with correctional facilities and formerly incarcerated individuals also helped mobile MOUD programs connect with patients after release: “the manager of the mobile unit had done a lot of work within [local jail] for us. And so, the number of people that she knows just out on the street from working in the jail is astonishing. And so, there was just already this trusted relationship there.” Thus, relationships with community partners, and specifically pharmacies and correctional facilities, were important.

Federally-Funded Study Participation As Facilitator

Participants cited being a part of a flexible, federally-funded study (i.e., the HEALing Communities Study) as a societal-level facilitator to establishing mobile MOUD units. HCS provided training and technical assistance (TTA) as well as data resources that were noted to be very helpful: “And you have training and technical assistance, help with technology and data collection. They were like, ‘You’ve got a question, we’ve got people to answer that.’” HCS staff was noted to be accessible and a helpful resource: “Everyone from the study was super accessible. [Our community faculty member] was a huge resource, just in general to be able to say like, ‘Hey, I’m having a hard time explaining this to people. Could you talk in your doctor talk and get everyone to understand what the hell we’re trying to do?’” HCS provided financial resources that were integral to implementing programs and staffing the mobile units: “HCS graciously took over a percentage of my salary so that I could dedicate a lot of my time to doing that.” Finally, HCS helped build community relationships necessary for rolling out mobile units: “Because we didn’t really have a relationship with them prior to the HEALing Communities Study, so I will say that for us was the good thing that came out of it.” TTA, helpful staff, funding, and building community relationships were all important aspects of federally funded study participation.

Barriers

Intra-Agency Operational Challenges

At the interpersonal/organizational level, participants described important barriers to implementing mobile MOUD programs. Intra-agency issues including learning the logistics of ordering and managing a mobile unit (“There were some barriers around just not understanding supply purchasing and the van stuff”) as well as dealing with flat tires and other emergency repairs (“somebody had stolen our generator already. There were snowstorms and really bad weather, and just things that you expect will happen, but are frustrating when they do happen.”). Competing priorities were an additional concern: “that happened quite a bit where I was needed to do other things...my agency had two different additional projects under HEALing Communities.” Staffing shortages (“there’s just such a tremendous workforce shortage right now”) were a problem across sites and were persistent over time. Programs reported difficulties coordinating prescriber hours (“But I think the nighttime hours would’ve been successful. But also doctors aren’t working. The providers who would give aren’t available at night”). Programs that deployed prescribers on the mobile units (as opposed to utilizing telemedicine) did not report the same challenges contacting prescribers. Staff safety, as noted above, was an ongoing concern, as was staff burnout: “She’s kind of the one constant on the trailer. She used to be out there all four days, but then we kind of realized that that was a recipe for burnout. So we reduced it to three days.” Thus, some programs were able to address burnout with creative staff schedules, while others did not report a plan for addressing burnout. Careful thought to mobile unit logistics and staffing were vitally important.

Financial Sustainability

At the organizational/interpersonal level, funding and financial sustainability were major concerns to continuing the work of mobile units supported by HCS: “And then it’s funding. I can’t do 16 visits on a van that doesn’t have a lobby to have anywhere in the winter for people to sit outdoors or wait.” Grant funding was noted to be an important source but often had challenging stipulations and inflexibility: “So, federal funds, they’re not going to let us buy syringes. They’re not going to let us buy safer smoking supplies. And so, then you’re always on the hunt for private money or money that’s going to allow you to do those things.” Navigating financial stability, via reimbursement for services or inflexible grant funding, with its limitations, was an important challenge.

Community Relationships

Community relationships and inter-agency tensions could be challenging, particular in the context of stigma. Organizations faced challenges when collaborating to put forward a mobile MOUD unit: “I just think that working with three agencies probably wasn’t best.” Local politics, particularly regarding syringe services, sometimes limited care: “We weren’t allowed to give out syringes anymore...because of some news article that came out only talked about syringe services and didn’t talk about any of the other stuff that the van did.” Social media was often a means for opposition voices to amplify their message: “It was a small group of people on social media who were like, ‘This is terrible. There are children near that van.’” City leadership in particular could provide such opposition: “The city generally was supportive of mobile medical services, but they still kind of set limitations or tried to set limitations on things that we are able to do or offer. I don’t get the impression they’re big fans that we offer syringes and safe use supplies.” Police in some communities were opposed to mobile services: “I’ve heard stories of staff getting stopped by the cops, or once our participants pick up supplies, the authorities would stop them and search them.” The need for cultural change around the idea of harm reduction was cited as important: “it was about a change and a cultural change happening where there were new voices there that were saying, ‘We need to change the way people who use drugs are being treated and accessing services, and here are some other ways to do it.’” Thus improving city leadership and police attitudes toward harm reduction might help improve community reception of mobile MOUD services.

Clinical and Regulatory Barriers

Certain clinical and regulatory issues served as societal/policy-level barriers. Getting mobile units licensed was a challenge: “the way that the licensing regulations are right now for mobile programs, they weren’t designed for the type of programs that are mobile...And some of the regulations just don’t transfer very well in that setting... like, ‘Oh, you need a whole utility closet for storing cleaning supplies.’” Specific barriers existed for certain services: “To do the rapid HIV testing, we have been needing to update our CLIA [Clinical Laboratory Improvement Amendments] certificate.” Buprenorphine prior authorizations (PA) were another identified challenge: “Sometimes they need a PA.” While the need for a PA is not unique to mobile units, the more limited resources of a mobile setting made PA requirements harder to address.

Federally-Funded Study Participation as a Barrier

While some participants noted federally-funded study participation to be helpful, as described above, others cited certain barriers presented by the study. Some described feeling condescended to: “I feel like HCS people came in with the best of intentions, but...zero regard or respect for work that’s already been done and being done. Trying to teach us how to do overdose prevention and trying to teach us how to provide buprenorphine, and it was rather insulting.” Relatedly, how feedback was given was perceived as non-collaborative: “It was during the coalition meeting, we felt bamboozled. All of a sudden they split us into these breakout rooms and people were supposed to give feedback for like, what do you think [our mobile unit] should do to get more people? It was so uncomfortable...we were like, “What the heck is happening?’” Others noted that the expectations from the study were too high: “I was mad and I said, ‘Hey, I literally am from [this town]. I grew up here most of my life.... The goals that [study staff] have set for this van are impossible.” Thus, while HCS was cited as facilitating mobile MOUD programs in some ways, researcher attitudes and demands of the study—operating from societal;policy level—could also be burdensome.

Future Directions

Services

Participants cited long-acting medications as important: “And so, we want to be able to offer the long-acting injectable on the trailer because we think, people lose their meds all the time. They get stolen at the shelter.” Programs wanted to be able to offer injectable naltrexone, if they didn’t already, as well as injectable formulations of buprenorphine and HIV pre-exposure prophylaxis. Programs were also exploring ways to offer methadone: “We are looking into getting an MCSR [Massachusetts Controlled Substances Registration] to allow for us to prescribe methadone via the 72-hour rule, which will be happening probably down the line.” Programs also aspired to increase drug checking, comprehensive primary care, and infectious disease services, including Hepatitis C screening and treatment: “So the goal will be that she will also be able to start doing maybe primary care visits or infectious disease screenings, fibroscans, things like that, especially in those more rural areas where access to treatment’s a little more difficult.” Many mobile MOUD units aspired to provide more comprehensive care in order to better engage high-risk populations.

Funding

As far as future funding opportunities, a participant noted that they are “keeping a really close eye on the opioid litigation settlement money” which may provide a unique, but substantial source of funding.

Program Evaluation

Participants also cited program evaluation as something they had begun to do and aspired to do more: “I did just compile the data from year one about clinical appointments. I think it would be a good idea to supplement that with some interviews or surveys from patients to hear about what they would like to see the next phase of the trailer to be. We haven’t developed that yet, but that’s something to think about.” Thus, program evaluation, incorporating patient voices, could also inform future service delivery.

Discussion

Our interviews with program staff and leadership revealed that mobile MOUD programs implemented during HCS provided same-day access to MOUD (even months after the end of the study period), and sought to respond to community needs. Staff perceived that mobile units advanced equity for communities by engaging populations (e.g., those in homeless encampments) that had not previously been engaged by brick and mortar clinics. Important challenges to operation included stigma in response to the mobile unit (sometimes manifested on social media), limited staff and resources with competing priorities, as well as long-term financial sustainability.

Care on mobile units was driven by personal and organizational values. Participants noted that flexible and nonjudgmental care was necessary in order to be effective. Indeed, our results echo previous researchers’ findings: providers on mobile units demonstrated lower levels of stigma; care on mobile units reduced geographic and scheduling barriers; interactions strengthened patient-provider relationships; and this model has the potential to increase access for people who experience homelessness and people in minoritized populations (Berk, 2020; Fine et al., 2021; Hall et al., 2014; Messmer et al., 2023; Regis et al., 2020). Stigma from health care providers is a documented barrier to engagement in OUD treatment (Meyerson et al., 2019; Olsen, Sharfstein, A, MP, & RP, 2014; Paquette et al., 2018). Indeed, health care providers, including physicians, can have negative attitudes toward harm reduction principles (Russolillo et al., 2023), so selection of staff who demonstrate low stigma care and embrace harm reduction is important; mobile MOUD units also likely attract staff that have less stigma towards PWUD. Equity was an important motivating value for HCS mobile units, which prioritized outreach to Black communities and non-English speaking communities, consistent with past documented equity promotion efforts of mobile MOUD units (Bartholomew et al., 2022). Given alarming increases in overdose deaths among Black, Native American and Latinx communities (Opioid-Related Overdose Deaths, All Intents, MA Residents – Demographic Data Highlights, 2022), and documented challenges with engaging people who experience homelessness in outpatient MOUD treatment (McLaughlin, Li, Carrero, Bain, & Chatterjee, 2021), the equity-promoting mobile units could play an important role in addressing this need. Recruiting staff with lived experience—not just for recovery coach and harm reduction positions, but as nurses and providers as well—is also an important strategy to support treatment engagement (Peers Supporting Recovery From Substance Use Disorders, 2017).

At the program level, a commitment to a variety of services beyond MOUD was important. Harm reduction services (including syringe access and disposal and fentanyl test strips), wound care, and snacks and other supplies helped engage patients, particularly in rural areas and to address barriers such as homelessness. Indeed, a “one-stop-shop” mobile model for marginalized populations has been endorsed previously as important for effective service delivery (Bartholomew et al., 2022). Furthermore, an on-unit prescriber was described by study participants as the ideal model for providing same-day access to MOUD. However, a well-thought out plan for telehealth access to providers when an on-site provider was not available was also important. Indeed, the flexibility of telehealth has been demonstrated to support MOUD adherence (Jones et al., 2022), and the ability of mobile units offering both in-person and telehealth services may promote retention as well. Additional unique logistical issues for consideration in future iterations of the mobile MOUD model include an adequate number of drivers, planning for emergency repairs, anticipating wireless internet and electronic device charging needs, storage, and space for labs including a bathroom for urine tests. Existing mobile MOUD unit toolkits are an important resource (Mobile Addiction Services Toolkit, 2019). Designing programs to minimize staff burnout is another important consideration (Fentem et al., 2023).

At the agency and inter-agency level, leveraging established, trusted relationships between implementing organizations and community members was a major facilitator. Strong relationships with pharmacies, correctional facilities, local businesses, law enforcement and local government were foundational to successful implementation. Indeed, working closely with community pharmacies will likely be an important future strategy for improving access to methadone and buprenorphine (Deronne, Wong, Schultz, Jones, & Krebs, 2021; Wu et al., 2022). Many implementers had a nuanced understanding of local politics that enabled them to secure community buy-in prior to the implementation of the mobile unit. These facilitators helped organizations nimbly respond to community backlash, often promulgated via social media, which affected implementation of mobile unit services. Investing in such inter-agency relationships, making a plan for potential social media backlash, and advance planning for community-wide crises are also important, perhaps overlooked, components of a mobile MOUD implementation plan. Several findings at the program level, for example, creative prescribing practices including buprenorphine microdosing to help taper patients off of methadone or illicit opioids, deserve future study in their own right.

At the policy level, streamlined regulatory frameworks and support for financial sustainability of mobile MOUD units is imperative. Importantly, none of the programs were able to provide methadone, aside from referrals. Mobile methadone programs do exist (Chan et al., 2021), and recent regulatory changes impacting mobile methadone programs highlight ways in which federal policy can support mobile MOUD treatment (Knopf, 2020). However, just as in brick and mortar facilities, methadone and buprenorphine are typically not both available under the same roof. Allowing for more flexibility for mobile unit licensing, including the potential for mobile units to offer both buprenorphine and methadone, would tremendously expand access to MOUD. Furthermore, methadone and buprenorphine are known to be offered in a racially segregated manner (Goedel et al., 2020); thus, adjusting regulations such that mobile units could provide both buprenorphine and methadone may be an equity-promoting policy. Next, preserving telemedicine access to buprenorphine, initially expanded during the COVID-19 public health emergency, will be crucial (“DEA Announces Proposed Rules for Permanent Telemedicine Flexibilities,” 2023). Policy change that would increase reimbursement for mobile unit visits would also be helpful. Earmarking opioid settlement funds (Knopf, 2018) at the state and local levels to support mobile MOUD units may help ease the reliance of such programs on grant funding. The HCS study was repeatedly lauded by participants in its ability to provide financial support and promote inter-agency relationships via coalitions, however, notable limitations including the requisite demands and its limited timeframe; the ambitious goal of a 40% reduction in overdose deaths over the course of the year set expectations for new program enrollment (such as mobile MOUD programs) very high (“The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices,” 2020).

This study has several limitations, including generalizability limited to five communities, with four in Massachusetts and one in Ohio. Furthermore, only 11 of 24 individuals approached to participate completed an interview, and thus the influence of non-response bias limits internal validity. Still, the interview transcripts we did analyze reached thematic saturation, though whether staff from less successfully implemented mobile MOUD programs were less likely to participate, and may have introduced different themes, remains unknown. Additionally, we did not have the resources to interview mobile unit patients themselves. Despite these limitations, our study adds to the expanding literature as one of the first qualitative attempts to assess the facilitators and barriers of delivering MOUD through a mobile program.

Despite organizational, community, and policy challenges, interviewed program staff described mobile MOUD units as an innovative and feasible way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma. Opportunities for further research include the expansion of medical services (e.g., injectable, long-acting buprenorphine, methadone, on-site primary care and infectious disease services, expanded harm reduction services like drug checking and long-acting, injectable pre-exposure prophylaxis for HIV). In light of ever-increasing overdose deaths, particularly among historically marginalized communities, expansion of mobile MOUD units may be an important strategy for increasing access to life-saving medications.

Highlights.

• Mobile units can promote equitable access to medications for opioid use disorder

• Judgment-free, culturally responsive care, informed by lived experience, was key

• Service variety (e.g., wound care, harm reduction) was noted to be important for engagement

• Agency, community, and policy (licensing, funding) barriers to mobile MOUD exist

• Future goals include comprehensive medical care, methadone, and program evaluation