Providers of mobile programs for opioid use disorder medication note many strengths, and also many challenges
Mobile programs that use a van or bus to go where help is needed in the community can provide life-saving opioid use disorder medications and help overcome access barriers. Yet, this novel and logical approach also faces many barriers. Researchers in this study assessed mobile program providers’ views on important program characteristics, barriers and facilitators to implementation, and goals for future directions.
Medications used to treat opioid use disorder, such as buprenorphine, naltrexone (often prescribed in a monthly injection), and methadone, are proven treatments that can help prevent fatal overdoses and other causes of mortality. Despite this, there are significant barriers that limit access to these medications among people who may benefit. In combination with the reality that some with opioid use disorder choose not to take a medication despite being offeredit, these barriers result in 20% or less of people with an opioid use disorder receiving medication treatment, with engagement and access particularly low among racially minoritized populations.
Mobile programs that provide medications for opioid use disorder using a van or bus may offer one strategy for overcoming barriers to access and implementation, such as geographic location, limited transportation, stigma (preventing people from seeking help in public), and language. This may be due to the flexibility and accessibility of such programs, which can help “meet people where they’re at” and reach populations that have been traditionally underserved (e.g., people experiencing homelessness, people who are uninsured).
The HEALing Communities Study aims to reduce opioid overdose deaths by helping communities implement evidence-based strategies of their choice. During the first wave of the study, 5 programs in Massachusetts and Ohio implemented mobile medication programs, which were defined as ambulatory units that provided same-day access to a prescriber. Researchers in this study assessed these program providers’ experiences with implementing the program. This research can help inform future implementation of mobile medication programs, which can help save lives and improve public health.
HOW WAS THIS STUDY CONDUCTED?
In this qualitative study, the research team conducted semi-structured, in-depth interviews with community providers of 5 mobile medication programs in Massachusetts and Ohio. Interviews were conducted between August 2022 and January 2023 and asked about program characteristics that influenced the implementation process and different barriers and facilitators of implementation, as well as ideas for future directions.
The interviews were video and audio recorded. A transcription service transcribed the recordings word-for-word. The transcripts were then coded by two members of the research team using thematic analysis, which involves categorizing findings into themes. The research team members worked together to reach consensus on the codes.
Participants were recruited by referrals from the HEALing Communities Study or via snowball sampling by other implementing community partners. Of the 24 community providers that were asked to participate, 11 completed an interview. These 11 participants were from 4 programs in Massachusetts and 1 in Ohio, who worked in community health centers and harm reduction programs. Their roles consisted of: Recovery Support Navigator (1); Director of Substance Use Services (1); Family Nurse Practitioner (1); Project Manager (1); Medication Navigator (1); Program Manager or Director (3); Harm Reduction Specialist (1); Medical Director/Associate Medical Director (2).
WHAT DID THIS STUDY FIND?
Program characteristics
Participants reported important physical space considerations that included the need for more space for storage and to see patients, as well as how to set up the space (e.g., where to put a phlebotomy chair, how to set up shelves). Other considerations for the physical space mentioned by participants included locking cabinets, wireless internet, chargers for devices, and restrooms for urine testing.
Participants also reported that offering a variety of services improved engagement. Services offered included harm reduction supplies (e.g., naloxone), nursing (e.g., wound care), insurance enrollment, basic necessities (e.g., snacks, clothes), transportation support, testing and treatment of HIV, Hepatitis C, and sexually transmitted infections, outreach after overdoses, and recovery coaching.
Values and motivation for being engaged in the work
Participants reported their personal values involving the desire to save lives and expand access to medications for opioid use disorder as motivation for program implementation. For example, participants mentioned the program’s ability to overcome barriers to traditional medication treatment (e.g., geographic limitations, transportation) and wanting to reach people who use drugs alone and live outside of areas targeted for overdose prevention resources, as well as people experiencing homelessness, who have been recently incarcerated, who are pregnant, and who work in certain industries (e.g., fisherman).
Participants also cited equity and the need to reach underserved communities as guiding values for program implementation. This involved intentionally hiring diverse staff who can speak other languages, for instance. Other values that were mentioned as important included creativity and flexibility to go where needed, as well as creating an environment free of stigma and judgment.
Community relationships
Engaging and building relationships with the community were mentioned as being important for the success of the program and that it helped the programs better serve patients by learning from each other. Communities also helped programs with outreach. In addition, relationships with organizations both across broad sectors and within specific sectors, such as police, correctional facilities, pharmacies, and local political leaders, were helpful for implementation. Positive relationships with police were especially important when communities’ relationship with police was challenging.
On the other hand, participants also described facing pushback from the communities and other agencies, which they attributed to stigma. For example, one participant described how local politics prohibited them from providing syringes anymore because of a news article that focused only on that and none of the other services offered.
Having adequate staffing and concerns mentioned by staff
Participants described their concerns regarding having a buprenorphine prescriber available. Some programs were able to have a prescriber on-site, while others used telehealth. Having adequate nursing staffing was also important for wound care and related medical problems, in addition to having enough staff who can drive the van to avoid safety issues. Perhaps most important was having staff with lived experience (i.e., harm reduction specialists and recovery coaches) because they have that “personal knowledge of where [they] should be going.”
Within each program, participants described challenges involving the logistics of ordering supplies, managing a mobile unit, and dealing with unexpected emergencies such as flat tires and bad weather. Other difficulties participants mentioned included competing priorities, staffing shortages, coordinating prescriber hours, and staff safety and burnout.
Service delivery and medication decisions
Creatively determining service routes by using overdose data to determine hotspots was seen as helpful for implementation. Doing outreach by foot, consistently being in the same place at the same time each week, and allowing walk-ins were all also described as helpful for reaching patients. Finally, participants described advertising in a discretionary and thoughtful way as important (i.e., having a logo that was not clear about what the programs were; putting out flyers with a barcode that directs people to the programs’ Facebook page), as was advertising via word of mouth.
Participants noted thoughtful decisions about what medications to offer. For instance, programs offered buprenorphine, short-acting naltrexone, and long-acting injectable naltrexone, but not methadone because of regulatory barriers.
Mixed views on participating in the study
Participants had mixed views on being part of the federally-funded Healing Communities Study. Some viewed it as an important facilitator, since study staff could provide training and technical support, be available to answer questions, and help build community relationships. Funding from the study helped with program implementation and staffing.
However, others viewed the study staff as being condescending, disrespectful, and non-collaborative, with burdensome and unreasonable expectations from the study. For example, one participant described how they felt insulted that the study staff was trying to teach them how to provide buprenorphine. Another participant described how they felt that the “goals that [study staff] have set for this van are impossible.”
Sustaining funding and regulatory issues
Funding and financial sustainability were cited as a major concern for continuing the mobile programs. While funding from grants was described as an important financial resource, participants also found that the grants prohibited particular services and purchases (e.g., purchasing syringes and safer smoking supplies).
Participants also mentioned how clinical and regulatory issues served as barriers to implementation. These included how licensing regulations were not designed for mobile programs, how some regulations do not transfer well to a mobile setting, needing a specific certificate to be able to do rapid HIV testing, and obtaining prior authorizations for buprenorphine.
Goals for future implementation
Goals for expanding services included wanting to offer long-acting injectable formulations, such as extended-release naltrexone and buprenorphine (if they did not already) because “people lose their meds all the time. They get stolen at the shelter.” Participants also mentioned the desire to offer HIV pre-exposure prophylaxis (i.e., commonly referred to as PReP; used to prevent the transmission of HIV) and methadone. Beyond medications, other services participants expressed wanting to offer included drug checking (e.g., to detect fentanyl), comprehensive primary care, and infectious disease services.
Participants also expressed a desire to do more program evaluation, such as supplementing data with interviews or surveys from patients. This would allow them to understand the patient’s experience.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
The research team conducted interviews with community providers of mobile programs that provided medications for opioid use disorder to assess important program characteristics, their views on barriers and facilitators to implementation, and their goals for the future. Participants described their considerations for the physical space (e.g., how to set things up) and how offering a variety of services improved patient engagement. While participants reported several barriers to implementing the mobile program involving challenges running the program, pushback from the community and other agencies, tension with the study staff, funding, and regulations, all mobile programs were able to be successfully implemented. Successful implementation was attributed to important facilitators, such as being motivated by personal values of saving lives and expanding access, building relationships with the community, and hiring diverse staff with lived experience.
Participants viewed the mobile programs as an important way of advancing equity because they help reach people where they are – both in terms of physical location and lower/fluctuating motivation for change – and can increase access by providing services to hard-to-reach and under-served populations (e.g., those experiencing homelessness; people in rural locations; people in minoritized populations). Indeed, previous research has shown that mobile programs can increase patients’ probability of using outpatient services and methadone maintenance services due to the advantages they offer over traditional programs. Mobile programs add to the growing number of strategies for removing barriers to medication and capitalizing on patients’ current motivation, such as providing buprenorphine in ambulances to overdose survivors and initiating medication treatment in emergency departments, as well as broader harm reduction approaches, such as the installation of dispensing machines that provide harm reduction supplies. Finally, participants viewed staffing decisions as critical for advancing equity and reducing stigma. This included the decision to hire diverse staff who speak different languages and staff with lived experience.
It is important to note that only 11 of the 24 providers who were asked to participate in the interview completed it. These participants may have had strong views about mobile program implementation that motivated them to participate. It is possible, for example, that staff with especially positive views or especially negative views may have wanted to share their perspective with the research team. Accordingly, the experiences shared by participants in this study may not be representative of all mobile program providers.
Overall, while participants described several barriers to program implementation, participants also viewed the programs as an innovative, equitable strategy to help improve access to medication treatment. Understanding community providers’ experiences with implementing mobile programs is important for informing future implementation. In the midst of the ongoing public health crises related to opioid and other substance use disorders, such innovative programs are critically needed to help save more lives.
The study was conducted in 4 US communities in Massachusetts and 1 in Ohio. Results may not generalize to other communities, states, or countries.
Only 11 of the 24 providers who were asked to participate in the interview completed it. These participants may have had especially strong views that opinions about mobile program implementation that motivated them to participate. Accordingly, the experiences shared by them may not be representative of all mobile program providers.
Mobile programs that provide medication for opioid use disorder can help overcome the barriers to traditional medication treatment. This research found that, despite several challenges noted with program implementation, the study participants who were responsible for providing these services also viewed their programs as an innovative, equitable strategy to help improve access to medication treatment.
For individuals and families seeking recovery: Mobile programs that provide medication for opioid use disorder “meet people where they are” and help reach underserved populations. Individuals who take advantage of mobile medication programs, if available in their area, are likely to benefit from the improved accessibility and may have a greater likelihood of initiating and sustaining recovery.
For treatment professionals and treatment systems: This study demonstrated that community providers of mobile medication programs for opioid use disorder experienced several barriers to program implementation, but were able to successfully implement the program. Professionals who wish to implement similar mobile programs can learn from these experiences and improve future program implementation. Such strategies may include, for example, ensuring an adequate number of drivers, planning for unexpected emergencies such as flat tires and bad weather, and considering needs for wireless internet and enough storage space.
For scientists:Because this study was conducted with a small and somewhat select sample and in only 2 US states, future research that investigates barriers and facilitators of implementing mobile medication programs with more provider/participants in different geographic locations will shed light on whether the experiences shared by the participants in this study generalize or are unique to the study locations. Since only 11 of the 24 providers that were asked to participate completed an interview, additional research with a larger number of providers will provide a broader and more comprehensive understanding of providers’ experiences with mobile program implementation. Finally, research that interviews people in the community who are using this service will allow for an understanding of their experience as well.
For policy makers: This study demonstrated that community providers of mobile medication programs for opioid use disorder experienced several policy-level barriers to program implementation, such as how to sustain funding and issues with regulations translating to a mobile setting. Accordingly, policy makers who support policies to promote funding of mobile medication programs and adjust existing regulations to be better suited within a mobile setting can help improve mobile program implementation. From the prospective of program staff in this study, these programs offer an equitable strategy to help improve access to medication treatment, which can help save lives and improve public health.
Medications used to treat opioid use disorder, such as buprenorphine, naltrexone (often prescribed in a monthly injection), and methadone, are proven treatments that can help prevent fatal overdoses and other causes of mortality. Despite this, there are significant barriers that limit access to these medications among people who may benefit. In combination with the reality that some with opioid use disorder choose not to take a medication despite being offeredit, these barriers result in 20% or less of people with an opioid use disorder receiving medication treatment, with engagement and access particularly low among racially minoritized populations.
Mobile programs that provide medications for opioid use disorder using a van or bus may offer one strategy for overcoming barriers to access and implementation, such as geographic location, limited transportation, stigma (preventing people from seeking help in public), and language. This may be due to the flexibility and accessibility of such programs, which can help “meet people where they’re at” and reach populations that have been traditionally underserved (e.g., people experiencing homelessness, people who are uninsured).
The HEALing Communities Study aims to reduce opioid overdose deaths by helping communities implement evidence-based strategies of their choice. During the first wave of the study, 5 programs in Massachusetts and Ohio implemented mobile medication programs, which were defined as ambulatory units that provided same-day access to a prescriber. Researchers in this study assessed these program providers’ experiences with implementing the program. This research can help inform future implementation of mobile medication programs, which can help save lives and improve public health.
HOW WAS THIS STUDY CONDUCTED?
In this qualitative study, the research team conducted semi-structured, in-depth interviews with community providers of 5 mobile medication programs in Massachusetts and Ohio. Interviews were conducted between August 2022 and January 2023 and asked about program characteristics that influenced the implementation process and different barriers and facilitators of implementation, as well as ideas for future directions.
The interviews were video and audio recorded. A transcription service transcribed the recordings word-for-word. The transcripts were then coded by two members of the research team using thematic analysis, which involves categorizing findings into themes. The research team members worked together to reach consensus on the codes.
Participants were recruited by referrals from the HEALing Communities Study or via snowball sampling by other implementing community partners. Of the 24 community providers that were asked to participate, 11 completed an interview. These 11 participants were from 4 programs in Massachusetts and 1 in Ohio, who worked in community health centers and harm reduction programs. Their roles consisted of: Recovery Support Navigator (1); Director of Substance Use Services (1); Family Nurse Practitioner (1); Project Manager (1); Medication Navigator (1); Program Manager or Director (3); Harm Reduction Specialist (1); Medical Director/Associate Medical Director (2).
WHAT DID THIS STUDY FIND?
Program characteristics
Participants reported important physical space considerations that included the need for more space for storage and to see patients, as well as how to set up the space (e.g., where to put a phlebotomy chair, how to set up shelves). Other considerations for the physical space mentioned by participants included locking cabinets, wireless internet, chargers for devices, and restrooms for urine testing.
Participants also reported that offering a variety of services improved engagement. Services offered included harm reduction supplies (e.g., naloxone), nursing (e.g., wound care), insurance enrollment, basic necessities (e.g., snacks, clothes), transportation support, testing and treatment of HIV, Hepatitis C, and sexually transmitted infections, outreach after overdoses, and recovery coaching.
Values and motivation for being engaged in the work
Participants reported their personal values involving the desire to save lives and expand access to medications for opioid use disorder as motivation for program implementation. For example, participants mentioned the program’s ability to overcome barriers to traditional medication treatment (e.g., geographic limitations, transportation) and wanting to reach people who use drugs alone and live outside of areas targeted for overdose prevention resources, as well as people experiencing homelessness, who have been recently incarcerated, who are pregnant, and who work in certain industries (e.g., fisherman).
Participants also cited equity and the need to reach underserved communities as guiding values for program implementation. This involved intentionally hiring diverse staff who can speak other languages, for instance. Other values that were mentioned as important included creativity and flexibility to go where needed, as well as creating an environment free of stigma and judgment.
Community relationships
Engaging and building relationships with the community were mentioned as being important for the success of the program and that it helped the programs better serve patients by learning from each other. Communities also helped programs with outreach. In addition, relationships with organizations both across broad sectors and within specific sectors, such as police, correctional facilities, pharmacies, and local political leaders, were helpful for implementation. Positive relationships with police were especially important when communities’ relationship with police was challenging.
On the other hand, participants also described facing pushback from the communities and other agencies, which they attributed to stigma. For example, one participant described how local politics prohibited them from providing syringes anymore because of a news article that focused only on that and none of the other services offered.
Having adequate staffing and concerns mentioned by staff
Participants described their concerns regarding having a buprenorphine prescriber available. Some programs were able to have a prescriber on-site, while others used telehealth. Having adequate nursing staffing was also important for wound care and related medical problems, in addition to having enough staff who can drive the van to avoid safety issues. Perhaps most important was having staff with lived experience (i.e., harm reduction specialists and recovery coaches) because they have that “personal knowledge of where [they] should be going.”
Within each program, participants described challenges involving the logistics of ordering supplies, managing a mobile unit, and dealing with unexpected emergencies such as flat tires and bad weather. Other difficulties participants mentioned included competing priorities, staffing shortages, coordinating prescriber hours, and staff safety and burnout.
Service delivery and medication decisions
Creatively determining service routes by using overdose data to determine hotspots was seen as helpful for implementation. Doing outreach by foot, consistently being in the same place at the same time each week, and allowing walk-ins were all also described as helpful for reaching patients. Finally, participants described advertising in a discretionary and thoughtful way as important (i.e., having a logo that was not clear about what the programs were; putting out flyers with a barcode that directs people to the programs’ Facebook page), as was advertising via word of mouth.
Participants noted thoughtful decisions about what medications to offer. For instance, programs offered buprenorphine, short-acting naltrexone, and long-acting injectable naltrexone, but not methadone because of regulatory barriers.
Mixed views on participating in the study
Participants had mixed views on being part of the federally-funded Healing Communities Study. Some viewed it as an important facilitator, since study staff could provide training and technical support, be available to answer questions, and help build community relationships. Funding from the study helped with program implementation and staffing.
However, others viewed the study staff as being condescending, disrespectful, and non-collaborative, with burdensome and unreasonable expectations from the study. For example, one participant described how they felt insulted that the study staff was trying to teach them how to provide buprenorphine. Another participant described how they felt that the “goals that [study staff] have set for this van are impossible.”
Sustaining funding and regulatory issues
Funding and financial sustainability were cited as a major concern for continuing the mobile programs. While funding from grants was described as an important financial resource, participants also found that the grants prohibited particular services and purchases (e.g., purchasing syringes and safer smoking supplies).
Participants also mentioned how clinical and regulatory issues served as barriers to implementation. These included how licensing regulations were not designed for mobile programs, how some regulations do not transfer well to a mobile setting, needing a specific certificate to be able to do rapid HIV testing, and obtaining prior authorizations for buprenorphine.
Goals for future implementation
Goals for expanding services included wanting to offer long-acting injectable formulations, such as extended-release naltrexone and buprenorphine (if they did not already) because “people lose their meds all the time. They get stolen at the shelter.” Participants also mentioned the desire to offer HIV pre-exposure prophylaxis (i.e., commonly referred to as PReP; used to prevent the transmission of HIV) and methadone. Beyond medications, other services participants expressed wanting to offer included drug checking (e.g., to detect fentanyl), comprehensive primary care, and infectious disease services.
Participants also expressed a desire to do more program evaluation, such as supplementing data with interviews or surveys from patients. This would allow them to understand the patient’s experience.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
The research team conducted interviews with community providers of mobile programs that provided medications for opioid use disorder to assess important program characteristics, their views on barriers and facilitators to implementation, and their goals for the future. Participants described their considerations for the physical space (e.g., how to set things up) and how offering a variety of services improved patient engagement. While participants reported several barriers to implementing the mobile program involving challenges running the program, pushback from the community and other agencies, tension with the study staff, funding, and regulations, all mobile programs were able to be successfully implemented. Successful implementation was attributed to important facilitators, such as being motivated by personal values of saving lives and expanding access, building relationships with the community, and hiring diverse staff with lived experience.
Participants viewed the mobile programs as an important way of advancing equity because they help reach people where they are – both in terms of physical location and lower/fluctuating motivation for change – and can increase access by providing services to hard-to-reach and under-served populations (e.g., those experiencing homelessness; people in rural locations; people in minoritized populations). Indeed, previous research has shown that mobile programs can increase patients’ probability of using outpatient services and methadone maintenance services due to the advantages they offer over traditional programs. Mobile programs add to the growing number of strategies for removing barriers to medication and capitalizing on patients’ current motivation, such as providing buprenorphine in ambulances to overdose survivors and initiating medication treatment in emergency departments, as well as broader harm reduction approaches, such as the installation of dispensing machines that provide harm reduction supplies. Finally, participants viewed staffing decisions as critical for advancing equity and reducing stigma. This included the decision to hire diverse staff who speak different languages and staff with lived experience.
It is important to note that only 11 of the 24 providers who were asked to participate in the interview completed it. These participants may have had strong views about mobile program implementation that motivated them to participate. It is possible, for example, that staff with especially positive views or especially negative views may have wanted to share their perspective with the research team. Accordingly, the experiences shared by participants in this study may not be representative of all mobile program providers.
Overall, while participants described several barriers to program implementation, participants also viewed the programs as an innovative, equitable strategy to help improve access to medication treatment. Understanding community providers’ experiences with implementing mobile programs is important for informing future implementation. In the midst of the ongoing public health crises related to opioid and other substance use disorders, such innovative programs are critically needed to help save more lives.
The study was conducted in 4 US communities in Massachusetts and 1 in Ohio. Results may not generalize to other communities, states, or countries.
Only 11 of the 24 providers who were asked to participate in the interview completed it. These participants may have had especially strong views that opinions about mobile program implementation that motivated them to participate. Accordingly, the experiences shared by them may not be representative of all mobile program providers.
Mobile programs that provide medication for opioid use disorder can help overcome the barriers to traditional medication treatment. This research found that, despite several challenges noted with program implementation, the study participants who were responsible for providing these services also viewed their programs as an innovative, equitable strategy to help improve access to medication treatment.
For individuals and families seeking recovery: Mobile programs that provide medication for opioid use disorder “meet people where they are” and help reach underserved populations. Individuals who take advantage of mobile medication programs, if available in their area, are likely to benefit from the improved accessibility and may have a greater likelihood of initiating and sustaining recovery.
For treatment professionals and treatment systems: This study demonstrated that community providers of mobile medication programs for opioid use disorder experienced several barriers to program implementation, but were able to successfully implement the program. Professionals who wish to implement similar mobile programs can learn from these experiences and improve future program implementation. Such strategies may include, for example, ensuring an adequate number of drivers, planning for unexpected emergencies such as flat tires and bad weather, and considering needs for wireless internet and enough storage space.
For scientists:Because this study was conducted with a small and somewhat select sample and in only 2 US states, future research that investigates barriers and facilitators of implementing mobile medication programs with more provider/participants in different geographic locations will shed light on whether the experiences shared by the participants in this study generalize or are unique to the study locations. Since only 11 of the 24 providers that were asked to participate completed an interview, additional research with a larger number of providers will provide a broader and more comprehensive understanding of providers’ experiences with mobile program implementation. Finally, research that interviews people in the community who are using this service will allow for an understanding of their experience as well.
For policy makers: This study demonstrated that community providers of mobile medication programs for opioid use disorder experienced several policy-level barriers to program implementation, such as how to sustain funding and issues with regulations translating to a mobile setting. Accordingly, policy makers who support policies to promote funding of mobile medication programs and adjust existing regulations to be better suited within a mobile setting can help improve mobile program implementation. From the prospective of program staff in this study, these programs offer an equitable strategy to help improve access to medication treatment, which can help save lives and improve public health.
Medications used to treat opioid use disorder, such as buprenorphine, naltrexone (often prescribed in a monthly injection), and methadone, are proven treatments that can help prevent fatal overdoses and other causes of mortality. Despite this, there are significant barriers that limit access to these medications among people who may benefit. In combination with the reality that some with opioid use disorder choose not to take a medication despite being offeredit, these barriers result in 20% or less of people with an opioid use disorder receiving medication treatment, with engagement and access particularly low among racially minoritized populations.
Mobile programs that provide medications for opioid use disorder using a van or bus may offer one strategy for overcoming barriers to access and implementation, such as geographic location, limited transportation, stigma (preventing people from seeking help in public), and language. This may be due to the flexibility and accessibility of such programs, which can help “meet people where they’re at” and reach populations that have been traditionally underserved (e.g., people experiencing homelessness, people who are uninsured).
The HEALing Communities Study aims to reduce opioid overdose deaths by helping communities implement evidence-based strategies of their choice. During the first wave of the study, 5 programs in Massachusetts and Ohio implemented mobile medication programs, which were defined as ambulatory units that provided same-day access to a prescriber. Researchers in this study assessed these program providers’ experiences with implementing the program. This research can help inform future implementation of mobile medication programs, which can help save lives and improve public health.
HOW WAS THIS STUDY CONDUCTED?
In this qualitative study, the research team conducted semi-structured, in-depth interviews with community providers of 5 mobile medication programs in Massachusetts and Ohio. Interviews were conducted between August 2022 and January 2023 and asked about program characteristics that influenced the implementation process and different barriers and facilitators of implementation, as well as ideas for future directions.
The interviews were video and audio recorded. A transcription service transcribed the recordings word-for-word. The transcripts were then coded by two members of the research team using thematic analysis, which involves categorizing findings into themes. The research team members worked together to reach consensus on the codes.
Participants were recruited by referrals from the HEALing Communities Study or via snowball sampling by other implementing community partners. Of the 24 community providers that were asked to participate, 11 completed an interview. These 11 participants were from 4 programs in Massachusetts and 1 in Ohio, who worked in community health centers and harm reduction programs. Their roles consisted of: Recovery Support Navigator (1); Director of Substance Use Services (1); Family Nurse Practitioner (1); Project Manager (1); Medication Navigator (1); Program Manager or Director (3); Harm Reduction Specialist (1); Medical Director/Associate Medical Director (2).
WHAT DID THIS STUDY FIND?
Program characteristics
Participants reported important physical space considerations that included the need for more space for storage and to see patients, as well as how to set up the space (e.g., where to put a phlebotomy chair, how to set up shelves). Other considerations for the physical space mentioned by participants included locking cabinets, wireless internet, chargers for devices, and restrooms for urine testing.
Participants also reported that offering a variety of services improved engagement. Services offered included harm reduction supplies (e.g., naloxone), nursing (e.g., wound care), insurance enrollment, basic necessities (e.g., snacks, clothes), transportation support, testing and treatment of HIV, Hepatitis C, and sexually transmitted infections, outreach after overdoses, and recovery coaching.
Values and motivation for being engaged in the work
Participants reported their personal values involving the desire to save lives and expand access to medications for opioid use disorder as motivation for program implementation. For example, participants mentioned the program’s ability to overcome barriers to traditional medication treatment (e.g., geographic limitations, transportation) and wanting to reach people who use drugs alone and live outside of areas targeted for overdose prevention resources, as well as people experiencing homelessness, who have been recently incarcerated, who are pregnant, and who work in certain industries (e.g., fisherman).
Participants also cited equity and the need to reach underserved communities as guiding values for program implementation. This involved intentionally hiring diverse staff who can speak other languages, for instance. Other values that were mentioned as important included creativity and flexibility to go where needed, as well as creating an environment free of stigma and judgment.
Community relationships
Engaging and building relationships with the community were mentioned as being important for the success of the program and that it helped the programs better serve patients by learning from each other. Communities also helped programs with outreach. In addition, relationships with organizations both across broad sectors and within specific sectors, such as police, correctional facilities, pharmacies, and local political leaders, were helpful for implementation. Positive relationships with police were especially important when communities’ relationship with police was challenging.
On the other hand, participants also described facing pushback from the communities and other agencies, which they attributed to stigma. For example, one participant described how local politics prohibited them from providing syringes anymore because of a news article that focused only on that and none of the other services offered.
Having adequate staffing and concerns mentioned by staff
Participants described their concerns regarding having a buprenorphine prescriber available. Some programs were able to have a prescriber on-site, while others used telehealth. Having adequate nursing staffing was also important for wound care and related medical problems, in addition to having enough staff who can drive the van to avoid safety issues. Perhaps most important was having staff with lived experience (i.e., harm reduction specialists and recovery coaches) because they have that “personal knowledge of where [they] should be going.”
Within each program, participants described challenges involving the logistics of ordering supplies, managing a mobile unit, and dealing with unexpected emergencies such as flat tires and bad weather. Other difficulties participants mentioned included competing priorities, staffing shortages, coordinating prescriber hours, and staff safety and burnout.
Service delivery and medication decisions
Creatively determining service routes by using overdose data to determine hotspots was seen as helpful for implementation. Doing outreach by foot, consistently being in the same place at the same time each week, and allowing walk-ins were all also described as helpful for reaching patients. Finally, participants described advertising in a discretionary and thoughtful way as important (i.e., having a logo that was not clear about what the programs were; putting out flyers with a barcode that directs people to the programs’ Facebook page), as was advertising via word of mouth.
Participants noted thoughtful decisions about what medications to offer. For instance, programs offered buprenorphine, short-acting naltrexone, and long-acting injectable naltrexone, but not methadone because of regulatory barriers.
Mixed views on participating in the study
Participants had mixed views on being part of the federally-funded Healing Communities Study. Some viewed it as an important facilitator, since study staff could provide training and technical support, be available to answer questions, and help build community relationships. Funding from the study helped with program implementation and staffing.
However, others viewed the study staff as being condescending, disrespectful, and non-collaborative, with burdensome and unreasonable expectations from the study. For example, one participant described how they felt insulted that the study staff was trying to teach them how to provide buprenorphine. Another participant described how they felt that the “goals that [study staff] have set for this van are impossible.”
Sustaining funding and regulatory issues
Funding and financial sustainability were cited as a major concern for continuing the mobile programs. While funding from grants was described as an important financial resource, participants also found that the grants prohibited particular services and purchases (e.g., purchasing syringes and safer smoking supplies).
Participants also mentioned how clinical and regulatory issues served as barriers to implementation. These included how licensing regulations were not designed for mobile programs, how some regulations do not transfer well to a mobile setting, needing a specific certificate to be able to do rapid HIV testing, and obtaining prior authorizations for buprenorphine.
Goals for future implementation
Goals for expanding services included wanting to offer long-acting injectable formulations, such as extended-release naltrexone and buprenorphine (if they did not already) because “people lose their meds all the time. They get stolen at the shelter.” Participants also mentioned the desire to offer HIV pre-exposure prophylaxis (i.e., commonly referred to as PReP; used to prevent the transmission of HIV) and methadone. Beyond medications, other services participants expressed wanting to offer included drug checking (e.g., to detect fentanyl), comprehensive primary care, and infectious disease services.
Participants also expressed a desire to do more program evaluation, such as supplementing data with interviews or surveys from patients. This would allow them to understand the patient’s experience.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
The research team conducted interviews with community providers of mobile programs that provided medications for opioid use disorder to assess important program characteristics, their views on barriers and facilitators to implementation, and their goals for the future. Participants described their considerations for the physical space (e.g., how to set things up) and how offering a variety of services improved patient engagement. While participants reported several barriers to implementing the mobile program involving challenges running the program, pushback from the community and other agencies, tension with the study staff, funding, and regulations, all mobile programs were able to be successfully implemented. Successful implementation was attributed to important facilitators, such as being motivated by personal values of saving lives and expanding access, building relationships with the community, and hiring diverse staff with lived experience.
Participants viewed the mobile programs as an important way of advancing equity because they help reach people where they are – both in terms of physical location and lower/fluctuating motivation for change – and can increase access by providing services to hard-to-reach and under-served populations (e.g., those experiencing homelessness; people in rural locations; people in minoritized populations). Indeed, previous research has shown that mobile programs can increase patients’ probability of using outpatient services and methadone maintenance services due to the advantages they offer over traditional programs. Mobile programs add to the growing number of strategies for removing barriers to medication and capitalizing on patients’ current motivation, such as providing buprenorphine in ambulances to overdose survivors and initiating medication treatment in emergency departments, as well as broader harm reduction approaches, such as the installation of dispensing machines that provide harm reduction supplies. Finally, participants viewed staffing decisions as critical for advancing equity and reducing stigma. This included the decision to hire diverse staff who speak different languages and staff with lived experience.
It is important to note that only 11 of the 24 providers who were asked to participate in the interview completed it. These participants may have had strong views about mobile program implementation that motivated them to participate. It is possible, for example, that staff with especially positive views or especially negative views may have wanted to share their perspective with the research team. Accordingly, the experiences shared by participants in this study may not be representative of all mobile program providers.
Overall, while participants described several barriers to program implementation, participants also viewed the programs as an innovative, equitable strategy to help improve access to medication treatment. Understanding community providers’ experiences with implementing mobile programs is important for informing future implementation. In the midst of the ongoing public health crises related to opioid and other substance use disorders, such innovative programs are critically needed to help save more lives.
The study was conducted in 4 US communities in Massachusetts and 1 in Ohio. Results may not generalize to other communities, states, or countries.
Only 11 of the 24 providers who were asked to participate in the interview completed it. These participants may have had especially strong views that opinions about mobile program implementation that motivated them to participate. Accordingly, the experiences shared by them may not be representative of all mobile program providers.
Mobile programs that provide medication for opioid use disorder can help overcome the barriers to traditional medication treatment. This research found that, despite several challenges noted with program implementation, the study participants who were responsible for providing these services also viewed their programs as an innovative, equitable strategy to help improve access to medication treatment.
For individuals and families seeking recovery: Mobile programs that provide medication for opioid use disorder “meet people where they are” and help reach underserved populations. Individuals who take advantage of mobile medication programs, if available in their area, are likely to benefit from the improved accessibility and may have a greater likelihood of initiating and sustaining recovery.
For treatment professionals and treatment systems: This study demonstrated that community providers of mobile medication programs for opioid use disorder experienced several barriers to program implementation, but were able to successfully implement the program. Professionals who wish to implement similar mobile programs can learn from these experiences and improve future program implementation. Such strategies may include, for example, ensuring an adequate number of drivers, planning for unexpected emergencies such as flat tires and bad weather, and considering needs for wireless internet and enough storage space.
For scientists:Because this study was conducted with a small and somewhat select sample and in only 2 US states, future research that investigates barriers and facilitators of implementing mobile medication programs with more provider/participants in different geographic locations will shed light on whether the experiences shared by the participants in this study generalize or are unique to the study locations. Since only 11 of the 24 providers that were asked to participate completed an interview, additional research with a larger number of providers will provide a broader and more comprehensive understanding of providers’ experiences with mobile program implementation. Finally, research that interviews people in the community who are using this service will allow for an understanding of their experience as well.
For policy makers: This study demonstrated that community providers of mobile medication programs for opioid use disorder experienced several policy-level barriers to program implementation, such as how to sustain funding and issues with regulations translating to a mobile setting. Accordingly, policy makers who support policies to promote funding of mobile medication programs and adjust existing regulations to be better suited within a mobile setting can help improve mobile program implementation. From the prospective of program staff in this study, these programs offer an equitable strategy to help improve access to medication treatment, which can help save lives and improve public health.
