Engaging marginalized people in MOUD: harm reduction, relationships, and outreach

Abstract

Introduction: Marginalized populations have high overdose risk yet face barriers in accessing evidence-based OUD treatment, particularly medication for opioid use disorder (MOUD). This indicates a need for low-threshold, community-based models for engaging and retaining marginalized people in treatment. In 2018, RIZE Massachusetts Foundation awarded grants to Lynn Community Health Center, Brockton Neighborhood Health Center, and Boston Health Care for the Homeless Program to improve access to evidence-based treatment for populations at highest risk of opioid overdose and death, with emphasis on improving access to MOUD. Grantees implemented innovative, collaborative treatment models that incorporated clinical-community partnerships, focusing on people experiencing homelessness and those reentering the community after incarceration. Here, we describe the funded programs and results from a mixed-methods external evaluation conducted by the Institute for Community Health (ICH).

Evaluation Methods: The mixed-methods evaluation incorporated data from the grantees’ electronic health records and qualitative key informant interviews. Evaluators developed measures to track progression through a cascade of care for OUD treatment. These measures included definitions for initiation and retention of patients on MOUD and engagement in behavioral health care and were captured at baseline and four times during the grant period, allowing evaluators to track trends on both individual grantee and cohort levels. Evaluators also conducted semi-structured qualitative interviews with grantee and partner agency staff to document program successes, challenges, and impacts.

Results: On the cohort level, the OUD patient panel increased by 20% from baseline to the end of the grant (from 3,142 to 3,777 patients). In addition, there was an increase in the number and percentage of patients who were initiated on MOUD over this timeframe, from 1,136 (36%) to 1,828 (48%). This demonstrates that even as the centers focused their efforts on highly marginalized populations, they were able to engage them in treatment. In terms of retention, between baseline and the end of the grant, the cohort demonstrated an increase in the number of patients retained on MOUD for each retention time interval; however, the percentage of patients retained for each time interval decreased (from 529 (62%) to 837 (55%) for 6-month retention). This may be due in part to the fact that over time, grantees were initiating patients with increasingly complex retention challenges. Important themes that emerged from the qualitative analysis included the importance of devoting time for relationship- and trust-building between staff and individuals, allowing individuals to direct their own path to treatment, and removing barriers to care. Grantees also described multi-level, interconnected impacts of their programs including increased capacity for low-threshold programming, strengthened partnerships, reduced stigma, and increased acceptance of harm reduction approaches. Conclusions: Evaluation results showed that the grantees were successful in implementing programs that engaged marginalized populations in OUD treatment. The findings highlighted the crucial role of harm reduction and low-threshold approaches, multifaceted outreach strategies, and relationship-building between service providers and patients. Findings can be used to inform program development in other settings, as well as the operationalization of a care cascade framework for tracking trends in MOUD treatment.

References: 1. Madras, Bertha K, Ahmad, N. Jia, Wen, Jenny, & Sharfstein, Joshua. (2020). Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers Within the Treatment System. NAM Perspectives, NAM Perspectives, 2020-04-27. 2. Baggett, Travis P, Hwang, Stephen W, O’Connell, James J, Porneala, Bianca C, Stringfellow, Erin J, Orav, E. John, . . . Rigotti, Nancy A. (2013). Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-Year Period. JAMA Internal Medicine, 173(3), 189-195. 3. Joudrey, Paul J, Khan, Maria R, Wang, Emily A, Scheidell, Joy D, Edelman, E Jennifer, McInnes, D Keith, & Fox, Aaron D. (2019). A conceptual model for understanding post-release opioid-related overdose risk. Addiction Science & Clinical Practice, 14(1), 17-14.

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