"Sick and tired of being sick and tired": Exploring initiation of medications for opioid use disorder among people experiencing homelessness

Introduction: People experiencing homelessness (PEH) make up a disproportionate share of opioid overdose fatalities. We set out to identify the facilitators and barriers that shape whether PEH initiate medications for opioid use disorder (MOUDs), both generally and after an overdose.

Methods: We conducted semi-structured interviews with 29 PEH in Boston who had self-reported history of opioid overdose. Seventeen participants had taken prescribed MOUD, and 12 had not. Using NVivo software we then coded transcripts applying the Borkan Immersion Crystallization method to identify individual, social, and structural factors influencing MOUD initiation.

Results: Individual factors: Within the "timing" theme, non-fatal overdoses often led participants to feel sick with naloxone-induced withdrawal, decreasing treatment-seeking. By contrast, chronic opioid use consequences, like daily stress with finding drugs and shelter, increased interest in MOUD. Within the "medication benefits" and "medication concerns" themes, interest in MOUD initiation hinged on whether participants believed in or doubted MOUDs' effectiveness for reducing drug use. In a related theme, participants perceived that individuals must be "ready" in order for MOUDs to be effective. Social factors: Within the "peer influence" theme, peers who use opioids were prominent sources of encouragement or deterrence for starting MOUD. "Family influence" emerged as a theme for participants with MOUD history. Structural factors: Within the "health systems" theme, participants described that experiencing stigma from care providers toward people who use drugs was a barrier to MOUD. Within the "treatment systems" theme, regulations made methadone particularly difficult to access, even though nearly all participants had Medicaid coverage to pay for treatment. Within the "criminal justice systems" theme, participants reported frequent criminal justice involvement, with jails facilitating or preventing MOUD access.

Conclusions: Future interventions should (a) increase MOUD interest by messaging-ideally via peers-that MOUDs are effective for PEH and (b) increase MOUD access by making MOUDs available across health, treatment, and carceral systems. Mobile outreach and MOUD treatment would help reach PEH when they are facing daily opioid use disorder stressors and are more open to MOUD initiation. Future research should explore how racial, ethnic, and linguistic identities affect MOUD engagement among PEH.