Exploring barriers and potential solutions before implementing a scale-up strategy to expand methadone coverage among people who inject drugs in Tajikistan

Abstract

Introduction:

The Eastern European and Central Asian region has the most rapidly growing HIV epidemic worldwide, concentrated among people who inject drugs (PWID). Scaling up opioid agonist therapies (OAT) is a highly effective primary and secondary HIV prevention strategy, yet coverage remains low (2.7 %) among the 18,000 PWID injecting opioids in Tajikistan.

Methods:

As part of a pre-implementation activity before using the blended NIATx implementation strategy, we focused on the first NIATx principle, to understand and involve the customer by exploring the barriers and facilitators to OAT scale-up (i.e. greater methadone program entry and retention resulting in more people on methadone). From October to December 2023, recipients (i.e., PWID) were assessed across all 14 OAT sites in 12 cities in 28 focus groups, stratified by those on (N = 120) and not on (N = 108) methadone. Nominal group technique (NGT) was selected as a rapid, inclusive and mixed methods strategy to identify and prioritize the most important barriers and facilitators. Barriers and solutions were categorized to guide implementation targeting individual (i.e., patients/providers), organizational (i.e., clinic) and policy (e.g., laws/regulations) factors.

Results:

The three highest-ranking barriers nationally to scaling up methadone were similar for both groups: 1) organizational factors like logistical inconvenience and demands on patients (transport, schedule, daily dosing); 2) policy factors like requirements to be listed in the national OAT registry which can restrict access to a driver’s license and employment; and 3) individual and societal factors like widespread disinformation about methadone. The three highest-ranking solutions included: 1) changing policies to allow take-home dosing (both groups); 2) expanding the number of sites where methadone could be dispensed (e.g., primary healthcare clinics and pharmacies); and 3) widely disseminating reliable information about methadone to PWID and other stakeholders like governmental organizations and police. For those not on methadone, site expansion was the second highest solution, while for those not on methadone, disseminating accurate information was second highest.

Conclusion:

This pre-implementation study provides important insights into implementation strategies that might be considered to scale-up methadone that targets recipients (patients, providers, and family), organizations and policies.

1. Introduction

The prevalence of people who inject drugs (PWID) in the Eastern European and Central Asian (EECA) region, especially opioids, is among the highest in the world (Ivasiy, Madden, et al., 2024; LaMonaca et al., 2019; United Nations Office on Drugs and Crime, 2024; Vagenas et al., 2013). Large numbers of PWID and suboptimal HIV prevention for PWID, including low coverage of syringe services programs (SSP) and opioid agonist therapies (OAT) (Nachega et al., 2023), has contributed to high HIV prevalence among PWID and their sexual partners in the region (Altice et al., 2016; Joint United Nations Programme on HIV/AIDS (UNAIDS), 2023; LaMonaca et al., 2019). In Tajikistan where there are an estimated 18,000 PWID who inject opioids, HIV prevalence is high (8.9 %), with considerable opportunities for improved HIV prevention and treatment (Joint United Nations Program on HIV/AIDS (UNAIDS), 2022). Unlike reductions in new HIV infections and mortality globally, the EECA has one the world’s fastest-growing HIV epidemics that remains concentrated in PWID with opioid use disorder (OUD) (Nachega et al., 2023).

Treatment of OUD with maintenance on opioid agonist therapies (OAT) like methadone or buprenorphine is the most effective (Tan et al., 2020) treatment for OUD (Degenhardt et al., 2019). It not only confers social and medical benefits directly related to OUD, including reductions in medical and psychiatric comorbidity and mortality (Stone, Degenhardt, et al., 2021; Stone, Walker, et al., 2021), but is one of the most effective (Tan et al., 2020) and cost-effective (Alistar et al., 2011) HIV prevention strategies. It also reduces HCV transmission and prevents reinfection (Dore et al., 2016; Dore et al., 2017; Grebely et al., 2022; Latham et al., 2019; Stone, Degenhardt, et al., 2021; Zelenev et al., 2021). Tajikistan’s OAT program (in the case of Tajikistan, OAT refers only to methadone) evolved from a pilot program in 2010 funded by international donors like the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) (Ii et al., 2017) and had 591 people on treatment by year-end 2023, translating to only 2.7 % of the estimated 18,000 PWID who might benefit from it (Joint United Nations Program on HIV/AIDS (UNAIDS), 2022). International funders have prioritized methadone scale-up for the country as one of its most important goals, emphasizing that scale-up involves the dynamic process of enrolling new patients, but keeping them retained on treatment. Despite the increased number of sites across the country, OAT scale-up has remained stalled over the past several years, making scale-up a critical opportunity to control the HIV epidemic. As part of an implementation study to disrupt methadone service delivery, this planned pre-implementation scale-up assessment was designed to further understand the barriers and potential solutions to guide scale-up through an active implementation process.

The Practical, Robust Implementation and Sustainability Model (PRISM) is particularly well-suited for pre-implementation assessments for scaling up OAT, specifically methadone maintenance therapy (MMT). PRISM provides a comprehensive framework that addresses the complexities of implementation in real-world settings to help evaluate how well implementation is working. PRISM integrates multiple perspectives—patients, providers, organizations, and the external environment like policies and regulations—to ensure a holistic and sustainable approach to scaling up evidence-based practices (EBP) like MMT in healthcare settings (Feldstein & Glasgow, 2008). PRISM especially calls for an understanding of the recipients (i.e., patients and providers) of the evidence-based practice (i.e. MMT) who directly interact with the EBP.

This pre-implementation assessment is focused specifically on PWID to better understand how the customer views the EBP (Hoffman et al., 2008; McCarty et al., 2007). As scale-up involves both attracting new clients and retain those already engaged, it is crucial to include diverse perspectives, in this case, those currently on OAT and those who have never been on it. While this assessment focuses specifically on the patient perspective, other analyses are exploring the perspectives of clinical staff at OAT clinics as well as the socio-political context, including policies related to opioid use and governmental policies that influence MMT delivery.

While PRISM is a framework for evaluating implementation, this study outlines how this evaluation can translate into execution of OAT scale-up that will be guided by the Network for the Improvement of Addiction Treatment (NIATx). NIATx is a blended implementation strategy that includes a combination of implementation strategies (e.g., process improvement, audit and feedback, collaborative learning, etc.) linked to a bundle of effective tools (e.g., walk-throughs, flowcharting, rapid-cycle change projects, etc.). This study focuses on the first principle of NIATx by involving and understanding the perspectives of the customer (i.e., recipient). NIATx specifically focuses on implementing process changes (e.g. clinic staff workflow) based on systematic identification and alteration of process barriers (e.g. long patient wait times) to achieve a desired outcome (i.e., OAT scale-up) and does so through guided facilitation, an especially key element for promoting process improvement changes (Evans et al., 2008; Fleddermann et al., 2023; Ford et al., 2018; McCarty et al., 2007).

2. Material and methods

2.1. Context

Tajikistan is the poorest country in EECA with 10.1 million people and a GDP per capita of $1189 USD. It is geographically adjacent to some of the largest opium trade routes that emerge from neighboring Afghanistan (The World Bank, 2023). Poverty levels are high with millions of Tajiks migrating to other countries like Russia for work, where many initiate injection of opioids and return with HIV (Bromberg et al., 2021; Vagenas et al., 2013). The estimated numbers of PWID and people with HIV (PWH) are 22,500 (18,000 inject opioids) and 15,000 (Joint United Nations Program on HIV/AIDS (UNAIDS), 2022), respectively. Though national data report a decreasing proportion of PWID contributing to new HIV infections, several triangulation studies from EECA suggest that drug injection risk is substantially under-reported as studies of heterosexual men with HIV who do not report drug injection have high levels of HCV infection (Cakalo et al., 2015; Rutherford et al., 2010)^,. Since 2010, MMT has grown from two sites in the county’s capital (Dushanbe) to 14 sites in 12 cities.

A review of legislative documents confirms that sites which dispense methadone are highly regulated and require costly infrastructure investment. The clinic must have cement walls that are at least 30 cm thick, electronic security systems, an approved safe to store methadone, two security guards on premises at all times, and at least 3 clinical personnel to observe patients taking the medication daily 365 days per year. Personnel operating the clinics are paid by international donors (GFATM) and salaries are substantially lower than those paid to permanent Ministry of Health employees.

Further, initiating methadone requires a panel of three physicians certified in addiction medicine (in EECA, narcologists) to agree on the diagnosis of OUD, which results in the patient being placed on the narcological registry. Being on this registry results in the loss of or inability to obtain a driver’s license and restricts patients from certain types of employment (in practice, nearly all employers require patients to obtain a certificate that they are not on the registry). After registration, patients are required to complete many additional assessments, often at other geographical locations (e.g., laboratory testing for liver and HIV, screening for tuberculosis, physical examination, etc.). Unlike other countries in EECA like Ukraine (Altice et al., 2022; Ivasiy, Galvez De Leon, et al., 2024; Meteliuk et al., 2021) and Kyrgyzstan (Ivasiy, Madden, et al., 2022), patients are not allowed to receive take-home medications, which in other settings, has reduced demands on patients and providers and allowed for substantial scale-up (Altice et al., 2022; Bromberg et al., 2022; Ivasiy, Galvez de Leon, et al., 2022; Ivasiy, Madden, et al., 2024; Meteliuk et al., 2021).

2.2. Nominal group technique (NGT)

NGT was initially developed from social psychology for aggregating group decision-making and has been successfully used in health services research (Delbecq et al., 1975; Humphrey-Murto et al., 2017; Madden et al., 2017; Murphy et al., 1998; Muthulingam et al., 2019), including implementation research (Brooks et al., 2023; DiDomizio et al., 2023a; Eger et al., 2022; Kronfli et al., 2024; Lafferty, Altice, Leone, Stoove, et al., 2024; Lafferty, Altice, Leone, Stoové, et al., 2024; Muthulingam et al., 2019; Rosen et al., 2023). NGT was selected as a mixed methods strategy to quickly and comprehensively identify and prioritize barriers to scaling up OAT combined with subsequent inquiry about potential solutions to overcome such barriers. We have successfully used NGT in diverse settings (Brooks et al., 2023; DiDomizio et al., 2023b; Eger et al., 2022; Kronfli et al., 2024; Lafferty, Altice, Leone, Stoove, et al., 2024; Rosen et al., 2023), including to understand the barriers and facilitators to OAT (Madden et al., 2017; Muthulingam et al., 2019). NGT typically involves 8–12 participants and promotes group participation in the decision-making process so that recipients can be part of the solution (Delbecq et al., 1975). In this way, NGT captures the perspective of the customers who are the recipients that receive the evidence-based practice (i.e., MMT) and actively involves them in identifying and generating solutions to implementation challenges, the first step in NIATx to guide implementation. This method generates both quantitative estimates (rank-ordering) combined with qualitative information to weigh and contextualize priorities among stakeholders (Delbecq et al., 1975; Jones & Hunter, 1995; Sav et al., 2015). Rank-ordering is key to prioritizing which issues are most important. The advantage of NGT relative to traditional focus groups is inclusivity, by facilitating equal participation despite group power imbalances (Delbecq et al., 1975). For each question, a silent generation of responses ensues with round-robin listing of barriers. Independent voting follows to ensure everyone’s participation. Voting and discussion allows aggregation of individual judgments into group conclusions that can be presented back to the group for further discussion.

2.3. Procedures and recruitment

The study recruited PWID on and not on methadone from all 14 methadone clinics across twelve cities from October through December 2023: Dushanbe, Rudaki, Juybodom, Vahdat, Bokhtar, Khujand, Buston, Istaravshan, Panjakent, Kamar, Kulob and Khorugh (see map in Fig. 1). Inclusion criteria included: 1) age 18 years or older; and 2) meeting DSM-IV criteria for opioid dependence using the Rapid Opioid Dependence Scale (Wickersham et al., 2015). For those on methadone, clinical staff approached individuals to determine if they were interested in participating. Individuals were informed that the research team conducting the study aimed to collect customer opinions to determine how to improve the MMT program across Tajikistan. The study recruited PWID not on methadone from harm reduction sites and through social networks with the assistance of local outreach workers. All recruitment was anonymous, and the study obtained informed consent. After explaining the NGT procedures, the discussions centered around two consecutive questions: 1) “What gets in the way of PWID in your city from initiating OAT?” followed by 2) “Based on the top three ranked barriers, what are some potential solutions that could overcome these barriers?” Each question involved a 2–5-min silent generation period where participants created an exhaustive list of ideas. Then, the facilitator allowed each participant to list one idea using a round-robin style, repeating until ideas reached saturation. Then the group discussed items to see if items should be grouped together, remain separate or be re-named. Participants could then provide 3 votes (all on one or divided). Votes were tallied and discussed and placed into themes agreed upon by participants. Each final theme was discussed further for clarity.

Fig. 1.

Sites where participants were recruited in Tajikistan (N = 14).

Map adapted from mapsofindia.com.

All focus groups were conducted primarily in Russian. Though the target was 8–12 participants per group, some groups were smaller due to stigma and mistrust. Participation in the FOCUS GROUPs was anonymous, with patients not required to provide their names. The study recorded minimal data (age, sex, distance from place of residence to OAT site in kilometers in Table 1). We did not specifically seek diversity in participants by any characteristic other than enrollment in a methadone program. The study did not record the number of individuals who were contacted about participation by researchers as most had agreed in discussions with the OAT or harm reduction programs from which they were recruited. Each NGT required 60-min. Two of the facilitators were male Tajiki nationals (AB, MA) and one (GO) was an American fluent in written and spoken Russian with previous experience conducting Russian-language qualitative interviews of people with OUD in Ukraine (O’Hara et al., 2022). In settings where Tajiki, Uzbek or Pamir languages were preferred, facilitators translated participant responses into Russian from Tajiki and Uzbek (AB), or Pamir (MA). After the 60-minute focus group discussion, participants were paid 100 Tajiki Somoni (~10 USD) for their time. The Institutional Review Boards at Yale University and the Tajik Ministry of Health approved the study. Facilitators conducted focus groups in private settings, and no one else was present besides the participants and researchers.

Table 1.

Characteristics of study participants, stratified by experience with methadone (N = 228).

		Participants on methadone
		Yes (N = 120)	No (N = 108)
Male (%)		115 (96 %)	103 (95 %)
Mean age, years (SD)		46.0 (7.7)	47.6 (9.3)
Mean distance to travel to methadone clinic, km (SD)		7.0 (7.0)	5.53 (6.9)
Region, city (%)
Dushanbe	Site 1	10 (8.3)	8 (6.7)
	Site 2	7 (5.8)	9 (7.5)
Rudaki		10 (8.3)	10 (8.3)
Juybodom		8 (6.7)	3 (2.5)
Vahdat		10 (8.3)	7 (5.8)
Khujand		10 (8.3)	5 (4.2)
Buston		8 (6.7)	3 (2.5)
Istaravshan		7 (5.8)	8 (6.7)
Panjakent		8 (6.7)	11 (9.2)
Kamar		8 (6.7)	8 (6.7)
Bokhtar		9 (7.5)	10 (8.3)
Kulob		8 (6.7)	10 (8.3)
Khorugh	Site 1	8 (6.7)	8 (6.7)
	Site 2	9 (7.5)	8 (6.7)
Total		120 (100)	108 (100)

2.4. Focus group analysis

As described with prior NGT analyses where numerous groups were included (Eger et al., 2022; Kronfli et al., 2024; Lafferty, Altice, Leone, Stoové, et al., 2024; Muthulingam et al., 2019), two authors (GO, AB) independently grouped similar items and where there was disagreement, a third author broke the tie (FLA). For example, if the barrier was restricted hours of operation, solutions like open clinic earlier or keep it open later were grouped together as “expand hours of operation”. The study combined votes from participants accordingly: if earlier hours had 2 votes from participants and later hours had 3, then the combined score for “expand hours of operation” was 5.

All focus groups were recorded, transcribed, translated and back-translated to ensure meaning of content (Brislin, 1970) and confirmed through field notes taken by one facilitator. The study coded all content using Atlas.ti (GO, AB) through an iterative process, guided by the thematic clusters described in the previous paragraph (see Tables 2 and 3) to ensure understanding of content, and then analyzed using thematic analysis. Quotes were selected to illustrate key themes.

Table 2.

Barriers to scale-up of methadone in Tajikistan, stratified by experience with methadone (N = 228).

Question 1: “What gets in the way of most people who inject opioids in [city] from joining the methadone program?”	On methadone?
	Yes N = 120 (%)	No N = 108 (%)	Total N = 228 (%)
Perceived barrier	Votes		Votes
Logistical inconvenience and demands on patients (transport, daily dosing, schedule)	118 (32.8)	86 (26.5)	204 (29.8)
• Transport access, duration and cost	77 (21.4)	27 (8.3)	104 (15.2)
• Daily supervised dosing	33 (9.2)	47 (14.5)	80 (11.7)
• Limited hours of operation	8 (2.2)	12 (3.7)	20 (2.9)
Inclusion in narcological registry endangers work and personal liberty opportunities	105 (29.2)	68 (21.0)	173 (25.3)
Widespread disinformation and myths about methadone	70 (19.4)	61 (18.8)	131 (19.2)
Bureaucracy (paperwork and multiple visits restricts entry)	11 (3.1)	40 (12.3)	51 (7.5)
Police harassment occurs in methadone clinic vicinity	22 (6.1)	19 (5.9)	41 (6.0)
People still have enough money to buy heroin and prefer heroin to methadone	16 (4.4)	21 (6.5)	37 (5.4)
Poor treatment by medical personnel	15 (4.2)	13 (4.0)	28 (4.1)
The program lacks wrap-around psychosocial support and legal counseling	0 (0)	14 (4.3)	14 (2.0)
Perceived instability of the program – people are afraid that since the methadone program is completely financed by the Global Fund, the Tajikistan government could shut the program down at any time.	3 (0.8)	2 (0.6)	5 (0.7)
Total	360	324	684

BOLD indicates it is ranked in the top three.

Table 3.

Potential solutions to scale-up of methadone in Tajikistan, stratified by experience with methadone (N = 228).

Question 2: “After reviewing the top three barriers, what would need to change to make it easier to join and remain in the methadone program?”	On Methadone?
	Yes N = 120 (%)	No N = 108 (%)	Total N = 228 (%)
Solution	Votes
Take-home dosing	188 (52.2)	70 (21.6)	258 (37.7)
Expand number of methadone sites (local primary care clinics, pharmacies, mobile dispensation, syringe exchange centers, etc.)	25 (6.9)	110 (34.0)	135 (19.7)
• Local primary healthcare clinic (polyclinic)	11 (3.1)	42 (13.0)	53 (7.7)
• Pharmacy	11 (3.1)	2 (0.6)	13 (1.9)
• Mobile dispensation	3 (0.8)	17 (5.2)	20 (2.9)
• Syringe exchange programs	0 (0)	5 (1.5)	5 (0.7)
• Sites that are not visible to the public	0 (0)	30 (9.3)	30 (4.4)
• Automated machine that allows private dispensing accessed by code – in each district	0 (0)	14 (4.3)	14 (2.0)
Provide reliable information about methadone to society, governmental organizations and police	68 (18.9)	42 (13.0)	110 (16.1)
Train medical personnel to respect patient confidentiality and administer methadone effectively; establish transparency of personnel responsibilities before patients	20 (5.6)	31 (9.6)	51 (7.5)
Reduce complexity of bureaucratic requirements to methadone program entry	15 (4.2)	35 (10.8)
• Upon enrollment, protect anonymity by assigning each patient a code; broaden proof-of-identity documentation options			50 (7.3)
Expand clinic schedule	17 (4.7)	16 (4.9)	33 (4.8)
Improve transport network to methadone site; subsidize transport	14 (3.9)	0 (0)	14 (2.0)
Incentive grocery package every 3 mos. to improve family’s attitude toward methadone	8 (2.2)	0 (0)	8 (1.2)
Expand medical services at methadone clinic to treat HIV, HBV, HCV and TB	0 (0)	6 (1.9)	6 (0.9)
Combine psychosocial counseling and legal assistance with methadone	1 (0.3)	5 (1.5)	6 (0.9)
Lobby the Tajikistan government to finance the program partially - so that people do not fear that the government will close the program	2 (0.6)	4 (1.2)	6 (0.9)
In-patient rehabilitation on methadone, coupled with vocational skill training	0 (0)	5 (1.5)	5 (0.7)
Provide buprenorphine at pharmacy	2 (0.6)	0 (0)	2 (0.3)
Total	360	324	684

BOLD indicates it is ranked in the top three.

This study used COREQ reporting guidelines (Consolidated Criteria for Reporting Qualitative research (Tong et al., 2007)) to ensure comprehensive reporting of qualitative research.

3. Results

There were 28 focus groups conducted at 14 sites, with one group being on methadone (N = 14) and the other not on methadone (N = 14) at each site. Sociodemographic characteristics did not vary significantly between participants on methadone and those not on methadone (Table 1). Nearly all participants were male who were mostly in their mid-40s and who traveled on average 6 km to the nearest methadone clinic.

Tables 2 and 3 show rank-ordered lists of barriers to methadone scale-up, with scale-up meaning more entry into and retention in methadone treatment programs resulting in more people on methadone – and solutions to those barriers, respectively. Each participant had three (3) votes in response to each question. For the 120 participants on OAT and 108 not on OAT, this resulted in 360 and 324 total votes, respectively, for each question. The study summed results for each category to provide an overall ranking of barriers and solutions but also involved prioritization of those most important to those on methadone and those who were not.

Though the rank-ordering differed for those on and not on methadone, the three highest ranked barriers to scaling up methadone were perceived 1) logistical demands to clients (i.e., costs from missing work traveling to clinics, limited hours of operation, daily supervised dosing requirements), 2) requirements to be placed on a narcological registry (i.e., reduced employment opportunities, including associated restrictions on driving), and 3) misinformation about methadone (i.e., misinformation about risks or about its effectiveness as a treatment). When stratifying by those on and not on methadone, there were differences, with those not on methadone ranking requirements to be placed on a narcological registry higher.

3.1. Highest ranking barriers

The highest-ranked barrier to scaling up OAT involved logistical demands on patients. In most cities, except for two, there was only one methadone clinic available. These clinics often had limited operating hours, requiring patients to commute long distances daily, seven days a week, which conflicted with their work schedules. Patients on methadone especially emphasized challenges with required daily commuting, with it interfering with work and being costly (Supplemental Table 1.1). Quotes are cited by location (city) and whether the participant is on methadone or not.

“There is no money for transport and scant access to transport to commute to the clinic. Most heroin users in this area live 15 kilometers from the narcology clinic, and they do not have access to a car to come here - especially in the winter when there is a lot of snow and no one will drive them.”

– Kamar, on methadone.

“The clinic doesn’t open early enough and you have to wait too long for the medical staff to dispense methadone, which causes you to arrive late to work.”

– Vahdat, on methadone.

“People definitely do not have enough money for a trip to the clinic every day – it is better to find work quickly and buy drugs somewhere than to have to go to the clinic every day.”

– Panjakent, not on methadone.

The infringements on personal opportunities that occur through inclusion in the narcological registry (Russian: narkologichesky uchyot) were the second highest-ranked barrier, especially among methadone patients. Patients perceived heightened discrimination through loss of their driver’s license, exclusion from employment and targeting by the police (Supp. Table 1.2). While the registry officially limits only employment in the government’s ministry of interior and justice, most employers insist that any prospective employee provide a certificate from the registry that indicates that they do not have a substance use disorder. Participants also reported instances of police harassing clients and removing their driving licenses when they found their name in the registry, which in turn, infringed on their employment.

“If you are on methadone, your family will turn you out because you will have to enter your name into the registry to start receiving methadone - whereas you can use narcotics quietly.”

– Dushanbe, Site 1, not on methadone.

“It is not desirable to be in the registry – this interferes with finding or keeping a job, as in this country it is not allowed to drive while on methadone, and if your employer finds out that you are on methadone, you will be fired.”

– Buston, on methadone.

Misinformation about methadone or even addiction treatment was the third highest barrier to methadone scale-up (Table 2). While many methadone clients had learned much about methadone, they perceived that their peers, family, community and society were inaccurately informed and, consequently, this heightened stigma toward methadone itself, the clients who took it, and the system that supplied it.

“Society does not understand methadone – and it does not accept it. Husbands do not allow their wives to get onto methadone because they are afraid of being judged negatively by their peers and family. Women themselves are scared of this judgment as well. Their husbands beat them if they disobey.”

– Khujand, not on methadone.

“If you get on methadone, it will kill you faster than heroin will. Methadone eats up your liver and teeth and it should only be used as the last possible way out when nothing else has worked.”

Dushanbe, not on methadone.

Methadone is not integrated into the healthcare system and is treated as a specialty condition in isolated clinics, or if in other healthcare settings, marginalized by separate entrances and security. The clinic and staff are paid independently by international agencies, and not integrated fully into the healthcare system, making it not aligned with what is perceived as routine healthcare (Turaeva & Turaeva, 2021). Consequently, myths and misinformation about methadone proliferated, including false beliefs that it damages the liver, causes symptoms attributed to other diseases, and equates to heroin as a drug of abuse (Supp. Table 1.3).

“The lack of information [about methadone] enables the perception that ‘all is of one picture’ – that to enter the methadone program is to switch from one addiction, heroin, to another, methadone. And, being at the methadone site, you can be seen as using methadone as just another type of drug use– how and with what to mix methadone. Tajik society believes that methadone is even worse than heroin. The medical personnel at the methadone clinic treat patients like outcasts from society and do not know how to dispense doses at the proper concentration. Many people believe that it is impossible to get off methadone and hesitate to start methadone because there are no projects designed to phase people out of treatment in the long-term.”

– Dushanbe, Site 2, not on methadone.

“People do not want to try methadone because many of their friends died of methadone, so they consider methadone a slow death. They believe they have never seen a worse substance, although this opinion can be mistaken. Often, people who die on methadone actually die of untreated HIV, AIDS, and hepatitis.”

– Vahdat, not on methadone.

Less frequently reported barriers included perceptions of poor treatment by clinic staff, lack of psychosocial counseling (Supp. Table 1.4), and burdensome administrative requirements for program entry (Supp. Table 1.5). For instance, patients were often required to submit a signed certificate proving their residence (Russian: propiska) in the local district. Obtaining a propiska could be costly and challenging, especially for those without official addresses due to property taxes based on household occupancy. Individuals with a propiska from another city were ineligible for treatment unless they re-registered their residence, a process fraught with logistical difficulties. There were also reports that OAT clinics required people seeking OAT to prove that one of their elder relatives or their spouse had approved their enrollment, which is not an established regulation (Republic of Tajikistan Ministry of Health, 2015):

“An elder relative or a spouse must give their permission for the patient to begin participation in the methadone program – this is like a bomb – it causes family strife, including fights and conflicts. Then there is the propiska [a formal document confirming a legal living address] – when the raisimahallah [district community leader] finds out you are on methadone, then everyone in your neighborhood will find out.”

– Bokhtar, not on methadone.

Police often harass methadone clients near the clinic, which causes many PWID to avoid going there (Supp. Table 1.6). Individuals not on methadone especially emphasized that people would not start OAT while they could still afford heroin. Finally, a less endorsed barrier was perceived instability of the national OAT program due to its full reliance on external financing by international donors.

3.2. Highest-ranked solutions

The three highest-ranked solutions (Table 3) across both participant groups were to 1) reduce demands on patients by introducing take-home dosing (ranked twice as high among those on methadone), 2) expand the number of methadone sites outside narcology clinics and integrate them into settings like primary healthcare clinics (PHCs) and pharmacies (five times higher among those not on methadone), and 3) disseminate reliable information about methadone to PWID and key stakeholders like governmental organizations and police. Among those suggesting expansion of OAT sites, the proportion of those not on methadone was substantially higher, with the most common suggestion being in PHCs, followed by sites that are not visible to the public (Table 3, Supp. Table 2.1). Disseminating reliable information about methadone included educational outreach to community authority figures like district community leaders (Tajiki: raisimahallah) and local law enforcement (Supp. Table 2.2; Appendix M).

Less endorsed solutions included expanding clinic hours beyond the very restricted 8:00 am-10:00 am to accommodate employment and childcare and to subsidize transportation for those traveling long distances (Supp. Table 2.1; Appendix B, C). They also suggested minimizing bureaucratic requirements for program entry and introducing more robust measures for staff accountability to protect patient confidentiality (Supp. Table 2.3).

4. Discussion

To our knowledge, this study is the first to examine barriers and potential solutions to scaling up methadone in Tajikistan in each city where OAT is available and where there is a high prevalence of OUD among PWID with increasing HIV incidence and mortality. Before introducing NIATx as a blended implementation strategy to promote methadone scale-up, this study used PRISM to understand the perspective of the customer, including both current and potential clients, to comprehensively understand the perceived barriers and solutions to scaling up methadone. Findings from this pre-implementation process of identifying barriers and solutions within PRISM to scale-up methadone using NIATx points to key opportunities that sites may embark upon. Since logistical impediments to entry and retention were the highest ranked barriers, teams at each site might choose one that they perceive as actionable. One rapid-cycle change project in NIATx might include conducting a physical exam (required) by the onsite physician rather than require the client to travel to a primary care center and return with a signed physical exam.

Of interest here is that while there were common barriers and solutions to guide scale-up, the prioritization differed substantially between those on and not on methadone. As OAT scale-up is dependent on new patients entering the program combined with keeping existing patients on treatment, understanding the barriers and solutions for those not on OAT would target encouragement of new patients to enter the program. As patients on methadone might primarily provide insights into retaining patients on treatment, improving the program may also have longer term benefits by improving the perception of the program so that the existing clients might disseminate more favorable perceptions of the program and also improve treatment entry.

4.1. Policy and clinical care delivery changes

Importantly, OAT in Tajikistan is at a similar point as Ukraine was in 2014, with low OAT coverage (2.7 %). Ukraine sites focused on site-level process improvement using rapid-cycle change projects (e.g., a pilot study of take-home buprenorphine dosing, reducing the evaluation time before initiating OAT and creating rapid assessment tools like symptom-based screening for tuberculosis, etc.) – activities that were readily accessible to them. Meanwhile, findings from their pre-implementation activities through focus group discussions with stakeholders (i.e., those on and not on OAT) improved understanding by multiple stakeholders, mostly through collaborative learning central to NIATx, that ultimately changed the system to align with the patient perspective in Ukraine (Bojko et al., 2015; Bojko et al., 2016; Madden et al., 2017; Makarenko et al., 2016; Makarenko et al., 2017; Mazhnaya et al., 2016; Rozanova et al., 2017). Specifically, in November 2016, they changed their legislation to remove two failed “detox” attempts before entering OAT, allowed for the first time for patients to receive take-home dosing (after six months of monthly urine drug testing) and allowed OAT to be prescribed outside specialized addiction treatment settings, including in governmental primary care clinics and in private addiction treatment clinics. By late 2023, one-third of the >30,000 patients on OAT received it in private clinics, (Bromberg et al., 2022; Bromberg, Machavariani, et al., 2023; Mazhnaya et al., 2023) take-home dosing reducing clinical demands on staff and patients (Meteliuk et al., 2021) allowing for the largest rate of increase in OAT scale-up (Ivasiy, Madden, et al., 2024), and OAT has been expanded to primary care clinics (Bromberg, Madden, et al., 2023; Machavariani et al., 2024; Morozova et al., 2017; Morozova et al., 2020; Pashchenko et al., 2022). With regards to the Tajik patient perspective, expanding OAT to new settings would potentially benefit recruiting new patients to OAT, while take-home dosing would certainly improve retention for those on OAT, but having this as a feature of OAT could certainly improve entry to treatment as new patients might see that they can earn downstream flexibility as they succeed in their treatment. In the case of providing OAT at specialty or primary care clinics, the government has mostly limited them to one site per city as the costs for setting them up are high based on the current regulatory policies. Changing policies to reduce costs to equip them, will be needed to appreciably increase adoption to other sites. While it may be the case that sweeping legislative changes may not be palatable, creating pilot projects for take-home dosing or delivery in pharmacies to test these strategies might provide expansion opportunities, as was done successfully in Vietnam (United Nations Office on Drugs and Crime, 2020).

4.2. Addressing misinformation about methadone

Misinformation and negative attitudes about addiction and its most effective treatment, opioid agonist therapies, remain significant challenges globally for patients, providers, and society (Bruneau et al., 2018; Livingston et al., 2012; Madden, 2019; Volkow et al., 2014). In Ukraine, such misconceptions greatly hindered the expansion of OAT programs in the early scale-up period (Bojko et al., 2015; Makarenko et al., 2016; Polonsky et al., 2015; Polonsky et al., 2016). Similar issues are likely present in Tajikistan, as both countries’ healthcare systems evolved from practices in the former Soviet Union, where OAT was banned—a prohibition that continues in Russia today. Notably, Ukraine’s approach to OAT changed markedly after Russia’s initial invasion, setting the country on a distinct political, economic and medical reform trajectory. In contrast, Tajikistan, the poorest nation in EECA, remains susceptible to external influences, particularly financial support from Russia.

Unlike Russia, Tajikistan relies on international donors—excluding Russia—for nearly all of its HIV prevention and treatment funding. In EECA countries where OAT is available, it is predominantly supported by international donors as an HIV prevention strategy rather than as an evidence-based treatment for OUD (Stuikyte et al., 2024). This approach leads to a mismatch between the goals of the addiction treatment professionals, who may not perceive OAT as an effective treatment for OUD, but feel compelled to prevent HIV.

Addressing these challenges requires comprehensive education and policy reforms to align perceptions with evidence-based practices, ensuring that OAT is recognized and utilized both as a preventive measure against HIV and as a legitimate, effective treatment for OUD (Polonsky et al., 2016). The World Health Organization (WHO) recommends that to effectively address the HIV epidemic among PWID, countries should achieve at least 20 % national coverage of OAT to stabilize the epidemic, and 40 % coverage to reverse it (World Health Organization, 2014). International donors, including those supporting Tajikistan, aim to meet these targets to significantly reduce HIV transmission and mortality among PWID. Current OAT coverage in many countries, however, remains substantially below these recommended levels. For instance, in several EECA nations, OAT coverage is under 10 %, with Tajikistan (2.7 %) among those with lower rates (Eurasian Harm Reduction Association, 2019). Achieving WHO’s recommended OAT coverage levels is crucial for controlling and reversing the HIV epidemic among PWID throughout EECA. Presently, international donors continue to support efforts in countries like Tajikistan to expand OAT services and improve public health outcomes.

Early in the HIV pandemic, antiretroviral therapy (ART) was often perceived as marginalized treatment. Longitudinal assessments of ART scale-up in Kenya, however, suggest that HIV stigma and misinformation decreased concomitantly as this EBP was scaled up and its practice become more common (Camlin et al., 2020) – a practice that was observed in Ukraine for OAT after a critical mass of PWID accessed treatment (Altice et al., 2022; Bromberg, Machavariani, et al., 2023; Ivasiy, Madden, et al., 2024). In Tajikistan, PWID have internalized societal myths about methadone, endorsing at being more harmful than heroin, damaging to the liver, or a last resort for those who have exhausted their finances. This misinformation has led to backlash from relatives, friends, and colleagues, reinforcing a well-documented barrier to methadone uptake (Mackey et al., 2020; Woo et al., 2017). Implementing effective public education and social media campaigns to dispel these myths may increase treatment entry and retention rates. As demonstrated in other contexts, such efforts can foster broader societal acceptance of methadone treatment (Rath et al., 2022).

OAT has been successfully scaled up in a number of non-specialty and non-clinical sites, including primary care clinics, privatized clinics, syringe services programs (U.S.) (Bachhuber et al., 2018; Haddad et al., 2013, 2015; Haddad et al., 2024; Jakubowski et al., 2022; Lambdin et al., 2022; Machavariani et al., 2025; Machiavariani et al., 2024; Morozova et al., 2017; Morozova et al., 2020; Schwarz et al., 2012; Sivakumar et al., 2022), pharmacies (U.S., Ukraine, U.K.) (Bachireddy et al., 2015; McCarty et al., 2021) and secured dispensing stations outside medical facilities (U.S.) (Bowman et al., 2023; Dunn et al., 2021). Such innovations, which were endorsed more by PWID not on methadone, have great potential to increase access to new patients by reducing demands on travel and conflicts with work or family schedules, which are crucial for PWID to achieve recovery within their community.

Mandatory enrollment into the narcological registry, a remnant from the Semashko healthcare system in many EECA countries (Latypov, 2011; Mravcik et al., 2014), requires either structural changes in the law or changes in implementation. Though Ukraine never removed this requirement, over time through process changes in NIATx, they implemented it differently by only completing certificates if the patient was perceived as “impaired” rather than stating that the patient was “addicted”, or issuing certificates that the patient was stable for the type of employment. Findings here support that patients in Tajikistan perceive narcological registration as a barrier to methadone uptake and while the addiction treatment specialists who certify that a patient is on the narcological registry are not the same ones that prescribe methadone, aligning experts across the addiction treatment field will be crucial. Patient confidentiality concerns and rigid bureaucratic assessment for entry into OAT are not unique to Tajikistan or the EECA region (Cooke et al., 2017; Kehler Curth et al., 2009; Klingemann, 2017; Richert & Johnson, 2015; Yee et al., 2022). Strategies to overcome this barrier focused on creating anonymized codes (Supp. Table 2.3) and potentially altering the order of when certificates and other documentation must be provided (Table 3). In one program in Connecticut, NIATx was used to change the flow of activities such that only those that were required to safely induct a patient were needed (e.g., diagnosis of opioid dependence, physical exam, assessment of mental status before providing the first dose, and allowing other less urgent assessments or documents (e.g., proof of insurance or housing, screening for HIV, HCV and tuberculosis) to be done within 14 days of treatment initiation. This rearrangement of activities resulted in an “open access” model where waiting lists were abolished, waiting time for treatment decreasing from 21 days to 3 h and scale-up increased 4-fold without any increases in overdose (Madden et al., 2018). An analysis of the legal landscape of OAT in Tajikistan, much like those conducted in neighboring Kyrgyzstan (Liberman, Kurmanalieva, et al., 2024) and Kazakhstan (Liberman, Ivasiy, et al., 2024) would provide additional insights into how to interpret and respond to structural impediments.

Participants prioritized: 1) designing advertisements to convey the benefits of methadone specifically to the spouses, children, and relatives of PWID; and 2) lay-language information seminars to educate PWID more about the benefits and risks of methadone. These findings build on PWID-endorsed need for education at the patient and community levels and the association of social and family support with willingness to initiate OAT regionally (Bojko et al., 2016; Makarenko et al., 2016). An alternative strategy might also include creation of an informed decision-aid that could be used for PWID to align their treatment preferences based on objective information. (Elwyn et al., 2006; Muthulingam et al., 2023; Scalia et al., 2019) Education initiated via advertising may benefit from follow-up with a decision aid that helps PWID and close family members to evaluate OAT as one of multiple treatment options for OUD from their personal view of how important the possible benefits and associated side effects are (Haber et al., 2017; Liberman et al., 2021; Stacey et al., 2017).

Design of this educational intervention can leverage cultural context (Baldwin et al., 2021; Butler et al., 2016; Hai et al., 2021). Conservative social values based on long-standing local interpretations of religion are common in Tajikistan. Social capital derives heavily from family relationships, similar to other socially conservative settings. As an illustration, modern settlements (rural and urban) in Tajikistan each remained based almost exclusively around extended families until the 1920s (Kalinovsky, 2018). Information campaigns and decision aids should engage family structures in Tajikistan around the proven psychological and social benefits of methadone to the family unit: reduced depression in patients, fewer relationship disruptions, and further education and employment for patients’ children (Mohammadi et al., 2020; Skinner et al., 2011).

4.3. Other barriers and solutions

From an implementation perspective, NIATx would prioritize rapid-cycle change activities that are most meaningful, yet PWID did express other concerns worth mentioning. Specifically, they were concerned about the sustainability of OAT, which is entirely supported by international donors, as a negative influence on enrollment. Though OAT has been continuous since its inception in Tajikistan, twice Kazakhstan failed to procure methadone for their clients for over a month, resulting in large numbers of patients experiencing withdrawal symptoms and relapse to drug use (Liberman, Ivasiy, et al., 2024). Both those on OAT and those not on OAT distrusted clinic staff dosing of methadone and feared staff would turn over patients’ information illegally to police (Table 2). Perceptions of incorrect dosing reinforced inaccurate information about methadone not being effective (Supp. Table 1.4). While mistreatment by OAT staff is a documented barrier to OAT generally throughout EECA (Rozanova et al., 2017), findings here suggest it is also a barrier to uptake (Bojko et al., 2016). Similarly, police harassment of OAT patients reinforced negative societal views of methadone based on this disinformation (Supp. Table 1.6).

Organizational-level solutions to increase OAT uptake were to strengthen OAT staff accountability to patient confidentiality and to optimize methadone dosing, measures adopted in EECA and elsewhere to increase OAT uptake (Kehler Curth et al., 2009; Wickersham et al., 2013). The former promises to address long-standing inconsistent legal enforcement of OAT confidentiality in Tajikistan and the EECA region (Aizberg, 2008; Ii et al., 2017; Kehler Curth et al., 2009). Additionally, increasing government OAT funding, a well-documented problem of OAT implementation in Central Asia, promises to improve confidence in the longevity of the OAT program and thus increase uptake (Hawkins et al., 2023; Ii et al., 2017; Rechel et al., 2023).

While our study yielded significant and novel insights, certain limitations should be acknowledged. First, the barriers reported by participants are based on their personal perceptions, which, although genuine and significant to them, may not fully represent actual systemic obstacles. These perceptions, however, are consistent across multiple sites and highlight areas that may require attention. For example, participants cited various sources to explain their understanding of Tajik law enforcement policies regarding methadone—such as rights to confidentiality and the legality of driving while on methadone—including perceived government sources, hearsay from other patients, and personal interactions with police. Some expressed uncertainty in their understanding of the law, suggesting that legal interpretations or implementations may vary throughout the country. Importantly, perceived barriers, even when they diverge from official policies, are real obstacles for these individuals and provide valuable insights into why some do not enter or remain in treatment. In qualitative research, however, acknowledging the subjective nature of participants’ perceptions is crucial, as it reflects their lived experiences (Mcleod, 2023), which are essential for understanding personal barriers to treatment.

Second, while 8–12 participants were targeted for each focus group, six of 28 (21.4 %) had fewer than 8 participants, potentially under-representing views in some locations. Additional limitations include limited information on who did not participate and lack of involvement by other stakeholders as they are assessed elsewhere.

5. Conclusions

Aligned with NIATx, understanding the customer identified important barriers to OAT scale-up, many of which can be addressed through quality process improvement techniques, expert facilitation and policy changes. This assessment not only sought to understand barriers, but also proffered potential solutions that are actionable and attainable as has been observed elsewhere. As NIATx begins to scale-up methadone in Tajikistan, being cognizant of these barriers and solutions will provide insights into potential rapid-cycle change projects that accelerate scale-up. Moreover, findings here will be presented to other stakeholders like governmental and non-governmental agencies to ensure that all constituencies are aligned on a common goal – OAT scale-up and advancements in HIV prevention.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.josat.2025.209682.