Emergent Needs and Interest in New Services among Individuals with Opioid Use Disorder- A Multi-Method Analysis

Abstract

Over 21.9 million people worldwide and 2.5 million in the U.S. alone have opioid use disorder (OUD). The opioid epidemic has been exacerbated by the prevalence of illicitly manufactured fentanyl (IMF), which is associated with significant opioid related morbidity and mortality. In 2023, fentanyl use contributed to 78% of overdose deaths. The standard of care treatment for OUD is medication for OUD (MOUD). However, MOUD is persistently underutilized, and there is a large treatment gap. In 2021, only 22.3% of people with past-year OUD reported receiving past-year MOUD. The increasing prevalence of fentanyl underlines the critical need for people to be connected to MOUD, given fentanyl’s potency and addiction potential. The overall purpose of this study was to identify emergent needs and interest in new services among individuals with OUD. The specific aims of the study were to 1) determine the difference in time to onset of moderate-to-severe OUD, among adults who report using fentanyl versus heroin, 2) examine the association between fentanyl compared to heroin as the primary drug of use and interest in methadone and buprenorphine treatment, and 3) evaluate the acceptability of a low-barrier model of care for clients seeking treatment for opioid use disorder at five community clinical sites, from client and staff perspectives. For the first two papers, I used data from a cross-sectional survey that utilized respondent-driven sampling. For the first paper, I used survival analysis to assess the timing of onset of OUD for people using fentanyl compared to heroin. Using a Cox proportional hazards model, people who used fentanyl were found to have a significantly higher hazard of OUD onset, compared to users of heroin (HR=1.49, 95% CI [ 1.12, 1.98], p=0.006). Findings highlight the potency and rapid addiction potential of fentanyl, underlining the need for rapid initiation of MOUD among this high-risk population. For the second paper, I used descriptive analyses and logistic regression to assess interest in methadone and buprenorphine among people who use fentanyl or heroin. The exposure groups were characterized by primary opioid type (fentanyl or heroin) and route of administration (injected or smoked). A substantial majority of individuals across the three groups reported interest in methadone (59-79%) and in buprenorphine (37-47%). Using logistic regression, individuals who primarily reported injecting fentanyl were found to have significantly higher odds of interest in methadone treatment compared to those who primarily reported injected heroin (aOR=2.81, 95% CI [1.28, 6.50], p = 0.012). Interest in buprenorphine was not found to differ significantly by opioid use pattern. High interest in MOUD highlights the need to expand low-barrier MOUD access. Differences in patient preference by primary opioid type and route of administration should be incorporated during shared decision-making and planning care. For the third paper, I used a qualitative approach that included semi-structured interviews to examine the acceptability of a medication-first low-barrier model of care from 27 clients and 15 staff at 5 clinical sites. Clients and staff both endorsed their acceptability of the low-barrier model of care, citing the relational strengths of the model. Further, the contingency management component of the model was welcomed by people who used stimulants, independently or in combination with opioids. Findings provide evidence for the expansion of medication-first, low-barrier models to increase MOUD access among individuals with OUD and/or stimulant use disorder. Together, findings outline emerging needs and interests in OUD services among individuals with OUD, identify populations most at risk of OUD-related morbidity and mortality, inform improvements, and provide evidence for medication-first low barrier models that can increase uptake and retention in OUD care.