“It was good because they have a relationship with us:” A qualitative study on low-threshold buprenorphine treatment at syringe services programs

Abstract

Introduction:

Syringe service programs (SSPs) reach people who inject drugs with opioid use disorder (OUD) and are novel “low-threshold” venues to initiate buprenorphine treatment. The study investigated patients’ experiences with SSP-initiated buprenorphine treatment, which could aid in improving buprenorphine treatment delivery at SSPs.

Methods:

The study included 12 participants who completed qualitative exit interviews after a randomized controlled trial of buprenorphine treatment at SSPs. In the parent study, participants received buprenorphine treatment through an onsite model at an SSP or enhanced referral to a community health center based on the randomization sequence. Most participants started taking buprenorphine at home. Exit interviews included participants from both study arms, and the semi-structured interview guide focused on their experiences with clinicians, experiences initiating buprenorphine, prior experiences with OUD treatment, and perceptions about continuing buprenorphine treatment. Four researchers iteratively read, coded, and discussed each transcript, then they derived recurring themes using thematic analysis.

Results:

Participants were mostly male, middle-aged, and 50% identified as Latino. Four main themes related to buprenorphine treatment initiation: 1) Onsite treatment facilitated buprenorphine prescription, but some participants also expressed a need for additional support; 2) Precipitated withdrawal complicated participants’ buprenorphine initiation in both arms; 3) Participants largely experienced the SSPs as affirming and welcoming; and 4) Developing strong relationships with healthcare providers was critical to successful buprenorphine treatment initiation.

Conclusions:

The SSP-based model provided rapid access to buprenorphine prescriptions, but precipitated withdrawal was a common complication. Some participants desired additional support and guidance when they started taking buprenorphine at home. The findings point to a “low-threshold, high-touch” approach where participants receive expedited access to buprenorphine providers at SSPs but also additional support throughout the initiation process to avoid and/or manage precipitated withdrawal. Despite some challenges, SSP-based buprenorphine treatment was highly valued by study participants.

Introduction:

Opioid use disorder (OUD) and overdose deaths have increased dramatically in the United States over the past 3 decades, yet annually, up to 80% of persons with OUD receive no treatment (Ciccarone, 2019; Jones et al., 2023; Krawczyk et al., 2022). Buprenorphine, a safe and effective medication for opioid use disorder (MOUD), helps people decrease non-prescribed opioid use, opioid overdoses, and risk of injection-related infections (Mattick et al., 2014; Bhatraju et al., 2017). Regulations allow for buprenorphine prescribing in a variety of settings (Fox et al., 2015; Mattick et al., 2014); nonetheless, people with OUD underutilize buprenorphine treatment (Duncan et al., 2015).

Syringe service programs (SSP) can reach people who inject drugs (PWID) who otherwise would face barriers to medical care (Frost et al., 2021; Hood et al., 2020). In 2026, there were 598 known SSPs in 47 US states, Washington DC, and Puerto Rico (North American Syringe Exchange Network, 2026). SSPs and their staff members reduce substance use-related harms by providing sterile injection supplies, counseling on safer use practices, substance testing strips, and in some cases medical care, case management, and mental health services (Behrends et al., 2022). Three decades of research on SSPs demonstrates that sites can be venues to link PWID to addiction treatment or even offer onsite buprenorphine treatment (Jakubowski et al., 2023). Like other people with OUD, SSP participants frequently face structural barriers to buprenorphine treatment, such as long waitlists or transportation needs, and many report negative experience with stigmatized care while receiving OUD treatment (Hall et al., 2014; Hayes et al., 2021; Stancliff et al., 2012). Integrating buprenorphine treatment within SSPs could address some of these barriers by making treatment available onsite and reducing stigma through the harm reduction ethos of SSPs (Jakubowski & Fox, 2019).

Co-locating buprenorphine treatment at SSPs is feasible. Programs at SSPs in New York City (NYC), Philadelphia, Seattle and Miami have shown that SSP clients are willing to start buprenorphine treatment, and the programs have treatment retention rates that are similar to standard office-based addiction treatment (OBAT) programs (Bachhuber et al., 2018; Hood et al., 2020; Suarez et al., 2023). Nationally, approximately 20% of SSPs report offering buprenorphine treatment among program services (Behrends et al., 2022). The ”low-threshold” approach to buprenorphine treatment at SSPs, which emphasizes a harm reduction orientation and flexible policies and procedures, likely contributes to program success by reducing stigma and other barriers to care (Fox et al., 2015; Frost et al., 2021; Hood et al., 2020). However, studies on low-threshold buprenorphine treatment at SSPs have not reported on patient experiences with the model.

This study used qualitative methods to investigate patients’ experiences with receiving buprenorphine treatment at SSPs during a randomized controlled trial (RCT) of onsite buprenorphine treatment initiation. Prior research with SSP administrators documented challenges with implementing buprenorphine treatment at SSPs, but to our knowledge, this is the first qualitative study exploring patients’ attitudes toward SSP-based buprenorphine treatment (Jakubowski et al., 2022). Study objectives were to identify opportunities to improve buprenorphine treatment delivery at SSPs, especially in the current era where treatment initiation can be complicated by fentanyl in the unregulated opioid supply (Weimer et al., 2023). The study could have implications for a broad range of innovative care delivery models of low-threshold buprenorphine treatment.

Methods:

Study design and participant selection

From July 2023 to December 2023, research staff recruited 12 participants from the parent RCT (NCT03150173) to participate in semi-structured exit interviews for this qualitative study (Perez-Correa et al., 2022). In the parent study, 97 SSP participants received either onsite buprenorphine treatment initiation at an SSP or enhanced referral to a community health center (CHC) for buprenorphine treatment based on the randomization sequence. Parent study eligibility criteria were: 1) English or Spanish speaking; 2) age ≥ 18 years; 3) OUD by DSM-5 criteria; 4) interest in buprenorphine treatment; and 5) willingness to accept a CHC referral. All RCT participants qualified for qualitative exit interviews after they completed the trial. Investigators used convenience sampling but attempted to recruit participants from both parent study arms. Participants completed a detailed locator form during enrollment, and a research assistant called them or their identified contacts to invite them to participate. For participants completing their final RCT study visit during the qualitative recruitment period, the research assistants also offered participation at that visit. Participants provided verbal consent and received a $40 gift card as compensation. The Institutional Review Board of Albert Einstein College of Medicine provided ethics approval.

Setting

Three NYC SSPs participated in the parent study. All served neighborhoods with majority Latino and non-Latino Black populations, high poverty rates, and high rates of opioid-related mortality. A CHC in the Bronx, which was accessible by public transportation from all SSPs, received referrals for the enhanced referral arm. The CHC had a well-established office-based buprenorphine treatment program that had experience working with SSP clients (Cunningham et al., 2008). Two of the SSPs served as the setting for most interviews; however, the research staff conducted one interview at the CHC and another through a video conferencing platform due to participant preference.

Research team

Author EM conducted 10 interviews, author JCP conducted one interview, and author SM conducted one interview. EM is a female medical student, JGP is a male research assistant with public health training, and SM is a female research assistant with a background in case management. All three interviewers completed a two-day training in qualitative interviewing techniques that included practice with the study’s interview guide. Investigators also included two physicians with experience prescribing buprenorphine and a licensed clinical psychologist, all with qualitative research experience. The interviewers did not have any relationship with participants prior to the parent study initiation, but JGP and SM had served as research assistants for the RCT.

Data Collection

Investigators developed a semi-structured interview guide that focused on the following areas: experience meeting with the provider (either at the SSP or CHC), experience initiating buprenorphine, prior experiences with OUD treatment, and factors affecting the continuation of buprenorphine treatment. Staff audio recorded the semi-structured interviews and either transcribed them manually or used a professional transcription service.

Data analysis

Following the approach to qualitative analysis described by Auerbach and Silverstein, investigators reviewed the transcripts in an iterative process to identify repeating ideas and organize them into themes, theoretical constructs, and an overarching theoretical narrative (Auerbach & Silverstein, 2003). The team conducted analysis contemporaneously with data collection. Author EM developed a preliminary codebook based on repeating ideas present in the first 4 interviews. Two team members independently then coded each of the 12 transcripts (EM, JGP, SM, NW, or TLC). Members of the analytic team (EM, AF, BH, and TLC) evaluated the coded transcripts as they were completed to discuss discordance between codes and refine the preliminary codebook. Building from the preliminary codebook, the team suggested additional codes as necessary while discussing transcripts. The team identified common themes based on the frequency of each code and relevance to explaining buprenorphine treatment utilization, but they did not maintain a quantitative coding count or use analytic software. In iterative discussions, the team refined themes based on the data and established theoretical constructs that described the relationships between multiple themes. The team stopped data collection when no new codes or themes emerged from the data, which indicated thematic saturation. As they discussed new transcripts, the analytic team established themes, theoretical constructs, and selected representative quotes to highlight an overarching theoretical narrative.

Theoretical Framework

The research team used an inductive coding process, but during post-hoc analysis, they decided to use the Behavioral Model for Vulnerable Populations (BMVP) to categorize emergent codes as a way of orienting the data around buprenorphine treatment utilization (Gelberg et al., 2000). Specifically, the team employed this model, and its domains of predisposing, enabling, and need factors to organize and visualize codes and their potential relationships to buprenorphine treatment (see Figure 1). BMVP identifies population characteristics, such as victimization history or competing needs, which are important to consider when evaluating health behaviors and healthcare utilization in vulnerable populations (Gelberg et al., 2000). Ultimately, the analysis yielded theoretical constructs and an overarching narrative that extended beyond this conceptual framework.

Figure 1.

Factors contributing to buprenorphine initiation among syringe services program (SSP) clients based on the Behavioral Model for Vulnerable Populations

Modified from Gelberg et al. (2000)

Buprenorphine Treatment Initiation Timeline

To facilitate interpretation, the analytic team also visually mapped participants’ narratives onto timelines demarcating five sequential milestones associated with bupenorphine initiation (see Figure 2). The team did not establish these milestones a priori, but the detailed interviews allowed determination of whether participants: saw the assigned prescriber, received a buprenorphine prescription, initiated buprenorphine treatment, experienced complications during treatment initiation, and continued buprenorphine following completion of the trial. The five-step timeline complements themes and depicts participants’ progress in buprenorphine initiation and treatment.

Figure 2.

Buprenorphine initiation steps for syringe services program clients

Results:

97 participants received onsite treatment (N = 48) or enhanced referral (N = 49), and of these, 12 participants participated in qualitative exit interviews. No participants declined to be interviewed. Most participants were middle-aged, male, and half were Latino (see Table 1). Figure 1 presents additional factors, categorized based on the BMVP, which help contextualize the participants’ experiences initiating buprenorphine. For example, several participants experienced homelessness while enrolled in the study, and as described below, their housing status influenced multiple themes relating to buprenorphine treatment initiation.

Table 1:

Baseline characteristics for syringe services program participants with opioid use disorder participating in exit interviews after a buprenorphine clinical trial (N = 12)

Participant Characteristic	N (%)
Age, median years (range)	50.5 (26-60)
Gender
Male	9 (75)
Female	3 (25)
Race
Black	3 (25)
White	8 (67)
Other	1 (8)
Ethnicity
Latino	6 (50)
Clinical
Study arm
Onsite buprenorphine initiation	5 (42)
Enhanced referral	7 (58)
Buprenorphine initiation milestones
Received a prescription but never picked up medication	2 (17)
Picked up medication but never started taking it	2 (17)
Started medication and experienced precipitated withdrawal	3 (25)
Started medication and discontinued	1 (8)
Started medication and continued it for the study duration	4 (33)

There were four main themes that related to buprenorphine treatment initiation: 1) onsite treatment facilitated buprenorphine prescription, but some participants also expressed a need for additional support; 2) precipitated withdrawal complicated buprenorphine initiation for both SSP and CHC participants; 3) participants largely experienced the SSP as affirming and welcoming; and 4) developing strong relationships with healthcare providers was critical to successful buprenorphine treatment initiation. Below, each theme is described in greater detail with representative quotations from participants to elucidate the findings.

Theme 1: Onsite treatment facilitated buprenorphine prescription, but some participants also expressed a need for additional support

All interviewees from the onsite treatment arm reported meeting with a provider and getting a buprenorphine prescription the same day they enrolled in the parent study. One participant stated, “They made it very easy to get a prescription.” Participants found onsite treatment to have several advantages in comparison to other clinical venues where they had previously received care. These advantages included co-location at the SSP where they are already accessed services, being more familiar with the SSP environment and staff, and its proximity to where they lived. One participant, Sarah, noted the convenience of the SSP over the CHC:

Honestly, it’s just a pain having to go to [the clinic] because it’s in the Bronx and I’m in Manhattan… I missed three appointments because I was late getting to the Bronx because I didn’t realize how long it would take to get there.

Participants who received onsite treatment at the SSP also appreciated the quality of clinical services. Many reported that the provider had time to thoroughly answer any questions about buprenorphine and provided non-judgmental care to SSP participants. Manuel stated:

They give me a good service, like you know, they ask me questions before the prescription, you know, if I was using drugs or methadone, stuff like that. And they gave me a good access to start with the prescription.

While some participants appreciated the efficiency and improved access, other participants expressed a desire for more support during the buprenorphine initiation process. Jessica was interested in starting buprenorphine at home, but requested more guidance in how to take the medication:

…I would just like to do it in my house and my own time when I feel like…but because I would have to have guidance like, ‘okay, so when you feel this and this and this or just this and this and it's been 12 hours, you can take a little tiny piece’.

Several participants indicated that having a peer or clinician checking in on them during initiation would have been helpful. Michael, who started buprenorphine at home, reported:

Your home should be your most comfortable environment. The only thing was, I was by myself.

Participants requesting additional support had experienced or feared precipitated withdrawal; therefore, they recommended additional guidance on initiating buprenorphine or outreach and support while they started taking buprenorphine at home. Jessica, who never started taking buprenorphine, because she did not understand when it was safe to take it, noted:

Maybe I didn’t explain clearly enough that I needed more guidance. Maybe because I felt like I don’t want to make them feel like I think that they’re not explaining right, or I don’t know.

Thus, while the onsite treatment model made it easier for participants to receive their first buprenorphine prescription, some participants would have liked greater support during initiation.

Theme 2: Precipitated withdrawal complicated buprenorphine initiation for both clinic and SSP participants.

Many participants reported precipitated withdrawal as a major source of fear and uncertainty. This led some participants to forgo starting buprenorphine after they received a prescription, while several others experienced severe precipitated withdrawal that prevented them from continuing treatment. Others started buprenorphine successfully, but experienced precipitated withdrawal at a later point when they switched back and forth between using buprenorphine and other opioids. Michael described his experience with precipitated withdrawal:

You wait until you’re sick, you know. Then I waited a while after that too. But I didn’t know that the fentanyl lasted that long in your system … Yeah, cause it’s when I was taking [buprenorphine], I was getting sicker. Throwing up, like projectile, like The Exorcist. I tried it for a week, and I couldn’t deal with that, and I ended up going back to methadone.

Precipitated withdrawal was a significant factor in deterring participants from continuing buprenorphine treatment. Figure 2 outlines each milestone along the buprenorphine initiation process where participants faced barriers to continuing treatment, and Table 1 summarizes these results. Participants varied widely in how much support they had while going through precipitated withdrawal. None of the participants who went through severe precipitated withdrawal during buprenorphine initiation remained on buprenorphine at the time of their interview, although some had stopped using opioids entirely. Most participants would have preferred to manage withdrawal in the comfort of their own homes, but some mentioned a more supervised setting would have been ideal.

Precipitated withdrawal and buprenorphine initiation, in general, were especially difficult for participants experiencing homelessness, although some appreciated having shelter staff available if something went wrong. One participant experiencing homelessness chose to start buprenorphine while being supervised by a provider at the SSP. Mateo described the challenges of starting buprenorphine while experiencing homelessness:

So basically, my issue with starting [buprenorphine] was, at the time I was homeless, and being opiate-dependent when you’re going to detox, or get off of opiates, or switch to a different opiate, it’s extremely uncomfortable. The pain is unimaginable, and it’s very difficult to get through that initial phase just to get on to Suboxone. So, my barriers were, I didn’t have a place where I could be uncomfortable long enough to start the medication.

Theme 3: Participants largely experienced the SSP as affirming and welcoming.

All trial participants used the SSPs regularly, and they universally reported that they felt comfortable in the venue and less stigmatized than in other health care settings. Many remarked on the level of care demonstrated by SSP staff, and the rapport they had developed with SSP staff over time, which also conveyed trust in the clinical services. Participants shared that the SSP environment felt welcoming and they had accessed a variety of services including food pantry, showers, laundry, and social work. In describing the compassionate care, Mary said:

[They] have a relationship with us. Yes, they just care about us. That’s why it’s good to come here…More compassion. More help with a lot of other things. Even to some doctors, you go, and you tell them that you use heroin, right away they treat you different. The staff treat you different.

Several participants also believed that the SSP worker’s lived experience with substance use positively impacted the care they provided. Overall, they felt respected and understood by SSP staff who espoused a harm reduction, person-centered approach in their client interactions. Michael describes this:

People are friendlier here [at the SSP]. Yeah, it seems like they understand what you’re going through a little. I don’t know if some of them used to be addicts or whatever themselves, maybe, so they know what you’re going through.

In addition to the caring staff, the dynamics of the SSP space influenced participants’ views of the SSP environment. Though participants trusted the clinical and non-clinical SSP staff, they held more mixed views on the SSP as a venue to deliver buprenorphine treatment. While most experiences were positive, a few noted the friction of initiating buprenorphine treatment in a social, drop-in environment with active drug use nearby. One enhanced referral participant was concerned that these factors at the SSP would have prevented him from initiating treatment had he been randomized to onsite treatment. Another participant, Mary, describes the experience of starting buprenorphine onsite around those who were using substances:

It’s a little difficult sometimes. Because some people don’t stop talking about that. They constantly talking about the drugs that they use. What they use and stuff. No matter what you’re not talking to them, but you’re listening, so you hear it.

Because the SSP functions as a relatively open, informal space, people came and went freely, social interactions unfolded spontaneously, and staff typically focused on clients with urgent or complex needs. While this openness contributed to the participants’ experience of heightened accessability and appeal, several participants noted that it could present challenges for those initiating buprenorphine treatment. A few participants described that the environment could be chaotic, distracting, or difficult to manage alongside their recovery goals. Luis mentioned:

The atmosphere is charged with negativity. The stress. But the staff, I have to commend them. They do, under those circumstances, they do a hell of a job.

It is worth noting that while several participants raised theoretical concerns about the close proximity to substance use at the SSP, it did not prevent any of the SSP participants from starting buprenorphine treatment in the onsite treatment arm.

Theme 4: Developing strong relationships with healthcare providers was critical to successful treatment initiation.

Participants consistently expressed that they prioritized a strong therapeutic relationship with their prescriber. Of note, participants in both trial arms described achieving such an alliance. Participants characterized that this type of relationship was predicated on respect and communicated by the provider through an investment of time and attention during clinical interactions. Many participants had experienced stigma or discrimination due to their substance use during prior healthcare encounters. Luis, assigned to the enhanced referral arm, compared his prior experiences to the treatment he received during the study:

Those other clinics, they just wanna rush you through. Sometimes they don’t even see you. They don’t even like, probably never make eye contact with you. Everything is just by rote. It was just like, you’re just another name on a piece of paper. No, these people, they made you feel like they saw you, they got you, and they just made you feel comfortable.

Most participants had positive experiences with their buprenorphine prescriber. Because of prior negative experiences, they wanted trust and some autonomy in treatment decisions. John started treatment onsite at the SSP and transitioned to a clinic after several weeks on buprenorphine (as per the study protocol). He described his experience with his clinic provider saying:

The doctor was really good. He’s very helpful, very friendly, very attentive. His memory was excellent. It was awesome. Everything I spoke to him about he remembered… He did not ever make me feel like I was making his day longer. It didn’t matter what was happening in his workday, his time with me was focused with me no matter what. I felt very comfortable with him.

However, others recounted initiation experiences—at the SSP or at the clinic—that fell short of this and underscored the importance of a foundational relationship with providers. Participants reported that initial buprenorphine prescription appointments could be brief and the provider was sometimes rushed, which reinforced negative impressions about medical care. Michael noted it was, “Just like going and seeing any other doctor. You get your five minutes to spit out whatever you can think of.” This participant felt unprepared to start buprenorphine, experienced severe precipitated withdrawal and switched to methadone treatment. Thus, although access to buprenorphine prescriptions may have increased, the strength of participants’ therapeutic relationship with their buprenorphine provider, and occurrence of precipitated withdrawal, affected buprenorphine initiation success.

Discussion:

Overall, most participants had positive experiences with buprenorphine treatment likely due to the non-judgmental approach of SSP staff and clinicians. The SSP and referral clinic both offered a caring environment, but the familiarity, proximity, and diverse services at the SSPs made them more consistently appealing than the clinic. Despite positive interactions with SSP staff and clinicians, some participants had challenging interactions with other SSP clients or struggled with buprenorphine initiation due to precipitated withdrawal. These findings suggest that SSPs are good venues to engage people with OUD and small practice changes, such as providing additional support during buprenorphine initiation, could improve the current model of low-threshold buprenorphine treatment at SSPs.

Overall, our findings reinforce the extant literature that describes SSPs as an acceptable and accessible setting for buprenorphine treatment initiation (Fox et al., 2015; Stancliff et al., 2012; Patterson et al., 2025). All participants in the SSP arm met the provider and easily received a buprenorphine prescription. Additionally, many participants described having prior negative experiences with OUD treatment but feeling comfortable in the SSP environment and with prescribers who respected their autonomy in treatment decisions. In prior qualitative research, people who use drugs have strongly endorsed the concept of a “one-stop shop” that provides both medical care and harm reduction services (Bartholomew et al., 2022). Another study from Washington state demonstrated that SSP-based buprenorphine clinics are scalable within the larger health system (Banta-Green et al., 2024).

The main findings expand prior work by using participant experience to guide ways to improve buprenorphine initiation at SSPs. The current model expedited receipt of buprenorphine prescriptions, but some participants wanted greater support while starting the medication. Some participants had unanswered questions about when to start buprenorphine, how to avoid precipitated withdrawal, or how to manage the symptoms of precipitated withdrawal if they occurred. Multiple participants identified fentanyl in the unregulated opioid supply as a new obstacle to starting buprenorphine. Taken together, our findings provide empirical grounding for a “low-threshold, high-touch” model for buprenorphine treatment initiation, which would provide ready access to buprenorphine while also offering additional support during the initiation process.

A low-threshold, high-touch model would build upon proposed principles for low-threshold buprenorphine treatment (same day prescriptions, flexibility around visit frequency and missed visits, and a harm reduction approach to non-prescribed opioid use) (Jakubowski & Fox, 2019), while delivering ongoing support and guidance as patients start taking buprenorphine at home. A “high-touch” approach could mean multiple contacts with participants during initiation where the clinician provides the initial assessment, and a peer mentor or care navigator reaches out to patients to help navigate uncertainty and manage precipitated withdrawal. For example, patients could request guidance around medications to treat symptoms such as nausea, vomiting, diarrhea, and anxiety, or adjusting the dose or schedule for buprenorphine initiation. One buprenorphine telehealth provider has already established a similar model, where a peer mentor and clinician provide real-time support via an application for mobile devices during the buprenorphine initiation process (Bosse et al., 2022).

The involvement of peers in the low-threshold, high-touch approach, rather than solely clinical staff, is supported by participants’ favorable perceptions of SSP staff. Some literature suggests that peer recovery coaches may harbor negative attitudes or stigma toward MOUD (Pasman et al., 2023; Pasman et al., 2024); however, peers also help address barriers related to power, stigma, and miscommunication that affect PWID (Marshall et al., 2015). The results presented here demonstrate how power differentials can operate in clinical scenarios. For example, a participant (Jessica) shared her hesitation to ask for clarification about initiation instructions because, “I don’t want to make them feel like I think that they’re not explaining right,” suggestive of how the inherent hierarchy of clinical relationships may inhibit patients from voicing uncertainty or distress. By contrast, peers with lived experience of substance use and recovery can function as trusted intermediaries to reduce stigma and translate clinical information into accessible language while simultaneously creating a space in which patients may feel safer to ask questions and express vulnerability (Collins et al., 2019). Harm reduction research consistently shows that peers serve as effective bridges between people who use drugs and health care systems, especially in contexts of mistrust, discrimination, and criminalization of drug use (Marshall et al., 2015). Thus, while the terminology of “low-threshold” buprenorphine treatment emphasizes access, the “high-touch” component reflects the personalized, responsive support that could maximize buprenorphine usability.

The concept of a low-threshold, high-touch model applies to SSP locations or traditional medical clinics, as participants struggled with precipitated withdrawal in both settings. Some OBAT models have nurse care managers or other clinical leads that provide additional guidance and support to patients receiving buprenorphine prescriptions (Beharie et al., 2022). Peers may add additional benefits to these efforts. In this study, although many participants had negative prior experiences with traditional healthcare, they still reported positive interactions with clinic staff in the enhanced referral arm. Patient-centered buprenorphine treatment can be successfully delivered in primary care and specialty settings (Fox et al., 2016). While the SSP remained more appealing for some participants because of proximity, familiarity, and the other available services, other participants expressed experiencing a comparable level of care and compassion at the CHC and SSPs.

The study has the following limitations. Firstly, the study includes only 12 participants from the 97-person parent study; however, the team conducted interviews until reaching thematic saturation. Secondly, convenience sampling from an RCT may make participants somewhat different than other people with severe OUD. Nonetheless, participants struggled with issues like unstable housing and prior experiences of stigmatized care, and those experiences are reflected in reported data. Thirdly, recall bias and social desirability may influence findings, but the team designed the semi-structured interview script to welcome both positive and negative reflections on buprenorphine initiation and treatment. Moreover, the interviewers were not part of the clinical team, which may have allowed participants to comfortably provide critical feedback.

Conclusion:

While starting buprenorphine treatment, participants had positive experiences with both SSP and CHC staff and felt cared for by providers in both locations. Most participants found the SSPs to be familiar and convenient, and while some were bothered by the unstructured environment, most were still able to pursue buprenorphine treatment and recovery goals despite the direct exposure to others’ substance use. Precipitated withdrawal complicated some participants’ experiences, and providing additional support and guidance while they started taking buprenorphine at home would have improved care. In the future, incorporating a “low-threshold, high-touch” model could both increase access to buprenorphine treatment and alleviate some of the difficulties participants experienced with navigating precipitated withdrawal on their own.