Despite efforts to blanket high-mortality communities with no-cost naloxone, drug checking technologies, and alternatives to using opioids alone, there remains a considerable lack of knowledge about how exposure to these low-threshold interventions may impact rates of naloxone protection. People who used illicit opioids in New York City were surveyed between April 2019 and April 2022. Naloxone protection was defined as the proportion of opioid use events in the past 30 days when opioid use occurred with naloxone present and someone to administer it. Mixed-effect Poisson models examined correlates (syringe service program utilization, behavioral, and experiential factors) of naloxone protection among the overall sample and stratified by gender. Among 428 study participants (mean age 49 years, 64

Despite robust evidence that medications for opioid use disorder (MOUD) reduce overdose and mortality, substantial care gaps remain following opioid-related hospital encounters. The opioid use disorder (OUD) Cascade of Care framework conceptualizes progression from identification to treatment initiation and retention, yet limited research has examined how real-world OUD treatment trajectories unfold, particularly across treatment episodes and multiple care settings. This paper describes an NIH-funded study protocol (1R01DA061367-01A1) to conduct a longitudinal observational study using linked administrative data across New York City to characterize OUD treatment trajectories following opioid-related hospital encounters. Using the OUD Cascade of Care framework, we will apply state sequence analysis to identify common patterns of OUD treatment engagement in the year following hospitalization, including transitions between treatment modalities and periods in and out of care. We will examine how care trajectories vary by individual and neighborhood characteristics, and assess associations between trajectories and key outcomes, including rehospitalization, overdose, and mortality. By applying novel data-driven longitudinal methods, this study will advance understanding of the complex, non-linear nature of OUD treatment engagement. Findings will inform health system and policy efforts to identify populations at elevated risk, hospital-based interventions, and opportunities to address gaps in care to reduce overdose-related harms.

Methadone is a highly effective treatment for opioid use disorder. However, its public health impact in the U.S. has long been constrained by strict regulations requiring dispensing through specialty opioid treatment programs (OTPs). In 2021, the U.S. Drug Enforcement Administration authorized mobile medication units (MMUs) to dispense methadone in community settings, raising hopes that mobile delivery could expand access for underserved populations. This commentary examines New York State's early experience implementing MMUs as a case study of both the opportunities and persistent challenges associated with this care delivery model in the U.S. We discuss how burdensome methadone requirements, high start-up and operating costs, complex staffing and logistical burdens, community opposition, and a continued emphasis on diversion control over patient access have limited the ability to effectively scale MMUs as a low-threshold treatment option. Although MMUs have and will continue to improve convenience and access for some patients, their potential to substantially improve geographic access, provide lower-threshold care, and deliver comprehensive OUD services is inhibited by the broader U.S. "methadone exceptionalism" framework, which silos methadone as a separate and more restrictive treatment modality requiring excessive vigilance and oversight . We argue that without greater regulatory clarity, flexibility, and alignment with patient-centered care goals, MMUs may likely remain a welcomed but modest, rather than transformative, innovation in addressing methadone gaps in the United States.

Introduction: A 2021 federal rule permits opioid treatment programs (OTPs) to provide methadone through mobile medication units (MMUs), creating an opportunity to provide medication for people in residential care facilities. We used simulations to quantify the potential of MMUs to expand methadone access to people residing in residential substance use treatment facilities (RTF), skilled nursing facilities (SNF), and nursing facilities (NF) in New York State under different scenarios. Methods: For each facility (RTF, SNF, and NF), a need score was created using three items: facility opioid use disorder (OUD) population, driving distance to nearest OTP, and county overdose mortality rate. We then demonstrated potential patient reach following the launch of 50 hypothetical MMUs making one stop per day to the highest need facilities. In refinements, we examined three additional scenarios involving more daily stops and prioritizing rural areas. Results: Our sample included 3214 people with OUD estimated to be housed in 1052 facilities in New York, with the majority in RTFs (51.5%). The demonstrated percentage of OUD population served ranged from 23.5% to 35.8%, and the percentage of facilities served ranged from 23.8% to 37.4%. Each scenario reached a large percentage of rural facilities (73-76%). Prioritizing rural facilities decreased the proportion of OUD population served (10% reduction) but did not substantially increase driving time. Allowing multiple stops increased the proportion of OUD population served (32-36% vs. 24-26%). Conclusions: Using methods based on location information and spatial relationships, state officials can develop priorities and assess tradeoffs of MMU deployment and distribution strategies.

Methadone is a highly effective treatment for opioid use disorder (OUD). Yet its impact is constrained by low rates of treatment initiation and retention, driven in part by geographic inequalities in the availability of methadone-providing opioid treatment programs (OTPs) and restrictions on the types of clinical settings where methadone can be dispensed. In response, in July 2021, the Drug Enforcement Administration released a new rule allowing OTPs to dispense medications for OUD—including methadone—through mobile medication units (MMU) without the need for additional treatment waivers. We conducted interviews with 11 participants living in a residential substance use treatment facility in NYC and receiving methadone treatment (MT) from an MMU. Interview data were coded using Dedoose software based on a combination of inductive and deductive coding strategies, and guided by a thematic approach to explore patient’s treatment experiences and perceptions. Participants described MMU as substantially reducing the logistical burden of treatment while also allowing patients to avoid problems associated with brick-and-mortar OTPs. Some raised minor complaints (i.e., additional waiting time on medication delivery days), yet participants framed these concerns within the context of their overall preference for MMU. Participants also expressed uncertainty about how methadone treatment would continue after leaving residential care, highlighting potential challenges in transitioning from mobile services to traditional clinic settings. Our findings provide qualitative evidence from patients’ perspectives on how mobile methadone delivery can potentially reshape the logistical demands, treatment environments, and continuity-of-care challenges associated with methadone treatment in residential settings.

Naloxone remains a critical life-saving intervention, but overdose reversals may also involve withdrawal and stigmatizing encounters with professional responders. Such experiences may shape future willingness to engage with overdose response resources. To understand interpersonal nature of overdose response to inform trainings and develop compassionate response overdose protocols. We conducted a cross-sectional, community-engaged survey of overdose survivors in New York City between June and August 2024. Eligible participants had experienced a naloxone-reversed overdose within the prior 12 months. Measures included overdose context, naloxone dosing, withdrawal experiences, responder interactions, and willingness to engage with naloxone. Descriptive analyses characterized overdose experiences, and hypothesis-driven analyses examined associations between interpersonal quality of professional response and future willingness to receive naloxone, administer naloxone to others, and call 911. Severe or “pretty bad” withdrawal was reported by 62% of participants, and negative treatment by professional responders was common. More favorable EMT/police treatment was associated with greater willingness to administer naloxone to another person (ρ=.267, p=.044) and to call 911 during a future overdose (ρ=.514, p<.001). More favorable hospital treatment was also associated with greater willingness to call 911 (ρ=.359, p=.006). In sensitivity analyses, negative hospital treatment was associated with approximately threefold greater odds of reluctance to administer naloxone to another person (OR=3.13, 95% CI 1.01–9.66). The interpersonal quality of overdose response may have consequences extending beyond the immediate reversal event. Respectful, non-stigmatizing treatment of overdose survivors may help preserve trust and willingness to engage with naloxone and emergency response during subsequent overdoses. Findings support incorporating compassionate care principles into overdose-response training and practice. na

Introduction:People who use drugs (PWUD) in the U.S. are often unable to effectively access social services and medical treatment including harm reduction services. A digital harm reduction support tool (DHRST) that would identify a client's needs and match them to existing community services, is a potential strategy for reducing harms and optimizing access to preferred available services. We examined the feasibility and acceptability of a DHRST among PWUD and its potential for facilitating safer drug use practices and increasing engagement with social and medical services. Methods:We recruited a convenience sample of 37 clients from a community harm reduction service provider to participate in semi-structured interviews. Participants were required to be at least 18 years old; speak English; and be able to understand and provide informed consent. Interviews lasted approximately 30 minutes and focused primarily on individuals' perspectives of a DHRST. Results:Most participants expressed enthusiasm for a DHRST. They described it as potentially filling a number of needs including providing information about local harm reduction services and as a platform to exchange information about the safety/quality of local drugs. Participants shared uncertainly about whether a DHRST was needed, fears about privacy, and perceived some risks of providing information about drugs. Conclusions:Although participants raised important concerns that would need to be addressed during DHRST development, findings were mostly supportive of DHRST acceptability and feasibility and underscored PWUD's belief in its potential and willingness to use one.

BACKGROUND:Methadone is the gold standard treatment for opioid use disorder (OUD). In the U.S., methadone is usually only available through licensed opioid treatment programs (OTPs), but a 2021 federal rule provided an opportunity for OTPs to provide methadone on mobile medication units (MMUs). MMUs operate under the license of an OTP and are subject to complex regulatory requirements. New York State provided grant funding to support OTPs to adopt MMUs, aligned with the broader goal to improve methadone access statewide. This study explored barriers and facilitators to MMU implementation across New York State from the perspectives of treatment staff and administrators. METHODS:We conducted semi-structured interviews between June 2024 and June 2025 with 16 staff from four OTPs that adopted MMUs and one residential treatment program served by an MMU. Interviews were audio-recorded, transcribed, and analyzed using a hybrid deductive-inductive thematic analysis approach to identify implementation barriers and facilitators. RESULTS:Staff described a variety of potential models for using MMUs to expand access. In New York City, MMUs were used to serve a residential substance use program. In upstate NY, MMUs were deployed to reduce travel distance in counties with few OTP options. Key facilitators of MMU implementation included leadership persistence in the face of community pushback, creativity and workarounds in the face of logistical hurdles, and support from the state agency. Key barriers included community resistance to MMUs, unclear or inconsistent guidance from the Drug Enforcement Administration, and a variety of operational challenges, such as vehicle maintenance and workforce shortages. Staff generally were positive about the opportunity to use MMUs to address access challenges. CONCLUSIONS:MMUs provide a novel approach to expand methadone access, particularly to populations not currently served by brick-and-mortar OTPs. Early implementers can provide important lessons about how to manage start-up challenges, which can guide later adopters.

BACKGROUND:Substandard practices in opioid treatment programs (OTPs) contribute to missed doses and treatment discontinuation. Training OTP staff to deliver trauma-informed methadone treatment can facilitate the adoption of patient-centered practices and improve patient methadone access and use. A clinic-level, multimodal intervention to promote patient-centered methadone care was pilot-tested in 2 Arizona OTP clinics. METHODS:A single-arm, repeated measures pilot trial consisting of 1.5 months preintervention onboarding and 4 months intervention and data collection was conducted from September 2024 to March 2025. Consistent daily methadone adherence was the primary outcome. Data were collected from patients (n = 91) in surveys at baseline and monthly thereafter. Bayesian multilevel generalized linear mixed models estimated the changes in consistent daily dosing from baseline (preintervention) to study conclusion (postintervention). RESULTS:Patients had a greater likelihood of consistent daily methadone adherence in the past 30 days at study endpoint compared to baseline (adjusted odds ratio 3.63 [95% credible interval 1.27-10.60]). CONCLUSIONS:Findings from this exploratory study indicate the potential of this clinic-level intervention to support more consistent methadone use. Interpretive caution is advised as this is a single-arm design with study attrition, and limited follow-up period. Future studies will assess the effectiveness of this intervention in a large-scale, multisite randomized controlled trial.

Staff in opioid treatment programs (OTPs) face elevated risk of secondary traumatic stress, yet the availability and effectiveness of training and clinical supervision to address this risk remain unclear. This study characterized current OTP training and supervision practices and examined their associations with staff vicarious trauma (VT) and burn-out. In a cross-sectional survey of OTPs, administrators (N = 44, 21 U.S. states) reported on staff training. Staff (N = 83) completed validated measures of VT and burnout. Counselors (n = 30) reported on clinical supervision. Training in VT and burnout was widely available, and most administrators (83.3%) and staff (89.6%) expressed interest in reflective supervision tailored to OTPs. In regression models, clinical supervision was associated with lower VT and burnout, whereas training availability was associated with higher VT and burnout. Findings suggest existing training models may be insufficient to address OTP staff stress. Expanding relationally-focused supervision may buffer the emotional toll of substance use treatment work.

Permanent supportive housing (PSH) is an evidence-based intervention for people experiencing homelessness which integrates permanent housing with voluntary support services. PSH tenants are at high risk for overdose death, yet little research to date has examined overdose in PSH. We sought to examine overdose risk and existing responses in PSH, which can shed light on opportunities for future overdose prevention efforts. We conducted focus groups with PSH tenants, staff, and leaders in New York City and New York’s Capital Region. Focus groups were recorded and professionally transcribed. Two investigators independently completed rapid turnaround qualitative analysis, completing templated summaries of each focus group and compiling key content in an analysis matrix, which a third investigator reviewed; discrepancies were resolved by consensus. From October to December 2022, we held 8 focus group sessions with PSH tenants (3 focus groups, n = 10 total participants), staff (3 focus groups, n = 13), and leaders (2 focus groups, n = 11) grouped by role and region. Participants were diverse in age (26–67 years), gender (18 women, 16 men), race (3 Asian, 12 Black, 11 White, 5 multiracial, 3 other), and ethnicity (5 Latinx, 29 not Latinx). Analysis revealed four main themes: (1) Overdose was a large concern in PSH and created significant trauma for tenants and staff; (2) Environmental factors in PSH contributed to overdose risk; (3) There was heterogeneity in PSH buildings’ current overdose prevention efforts and adoption of harm reduction principles; and (4) Multifactorial barriers resulted in limited tenant use of opioid agonist treatment. Overdose is a major concern for PSH tenants, staff, and leaders. Our findings shed new light on overdose in PSH settings, providing insight into risk factors, existing responses, and barriers and facilitators to future overdose prevention efforts. These findings can inform future overdose prevention interventions within PSH. ClinicalTrials.gov, NCT05786222, registered 27 March 2023.

Objective To apply risk compensation theory to naloxone peer access and evaluate whether reported naloxone protection—having naloxone and someone to administer it present when using unprescribed opioids—correlated with greater opioid overdose risk behaviors. Methods Longitudinal cohort of 422 NYC residents using unprescribed opioids who completed at least three monthly surveys over 24 months. Mixed-effects models estimated unadjusted and adjusted associations between naloxone protection and both opioid risk and overdose events and were used to test whether race/ethnicity and gender modified the relationship between naloxone protection and risk behaviors. Results Being protected 75% of the time or more was identified as a meaningful cutoff in the sample and was associated with fewer opioid risk behaviors and overdose events. Race/ethnicity, but not gender, was found to be a significant effect modifier of naloxone protection. Conclusions Findings indicate no support for the risk compensation-derived hypothesis that people who use opioids while protected by naloxone pursue more overdose-associated risk behaviors than those unprotected. Policy Implications Concerns about how naloxone may disinhibit people who use opioids, leading to greater risk-taking, appear unfounded, reaffirming the importance of universal naloxone access.

BACKGROUND AND AIMS:Better understanding the challenges faced by patients on medications for opioid use disorder (MOUD), including methadone and buprenorphine, is critical to increasing their use/retention. Social media platforms such as Reddit offer a space for patients to share their experiences with medications. We aimed to identify and characterize challenges faced by patients taking MOUD through analysis of discussions from the r/Methadone and r/suboxone subreddits. DESIGN, SETTING AND PARTICIPANTS:Mixed methods study applying natural language processing methods to 37 278 posts from both subreddits from their origin in 2011 until 31 December 2022. Independent topic analyses used Correlated Topic Models to extract the main themes discussed. MEASUREMENTS:We labeled, validated and grouped the topics into macro classes and computed topic shares. We interpreted and compared topics across subreddits informed by the patient-centered medication experience framework. FINDINGS:We found 27 and 34 challenge-related topics for the r/Methadone and r/suboxone subreddits, respectively. Topics were grouped into three macro-topics: (i) healthcare-related issues, including misunderstandings/confusion around appointments, prescriptions, bottle checks, telehealth technology and health insurance coverage; (ii) medication-related issues, including withdrawal, cravings, dosage, side effects, mixing with other medications/drugs; and (iii) treatment discontinuation, including tapering protocols. Patients conveyed highly specialized knowledge about dosage and tapering strategies and spoke from experience. Key differences between r/Methadone and r/suboxone were driven by their dispensing requirements (clinic-based vs. take-home), with 20.05% vs 14.74% of posts related to healthcare service, primarily for logistic and interpersonal issues with healthcare providers. CONCLUSION:People who post on the r/Methadone and r/suboxone subreddits appear to have detailed knowledge of medications for opioid use disorder and want more control over their dosing, effects, side effects and discontinuation. Acknowledging this expertise and establishing stronger patients' partnerships with the healthcare team and system might result in better treatment outcomes.

INTRODUCTION:Methadone maintenance treatment (MMT) is among the best strategies for reducing harms associated with illegal opioid use, yet it is hindered by low rates of treatment initiation and retention that limit its impact. There has been a lack of studies that describe how people who use illegal opioids use methadone-both from opioid treatment programs, and bought illegally-over time, or what factors correlate with long-term participation in MMT. METHODS:We collected monthly survey data from N = 412 people who use illicit opioids in New York City from April 2019-2022. We used bivariate analyses to estimate the distribution of baseline sociodemographic and background characteristics. Multinomial logistic regression was then used to estimate the association between those characteristics and methadone use over time. RESULTS:Findings show that people who are older, who used heroin for longer amounts of time, and who had multiple episodes of substance use disorder treatment other than medication for opioid use disorder are more likely to use MMT consistently over time. DISCUSSION:Our findings may be related to the many barriers to long-term participation in MMT, such as travel distance, the need for regular attendance, and patients' dissatisfaction with opioid treatment programs. Consistent participation in MMT may become acceptable only when the difficulties and burdens of criminalized drug use begin to outweigh those of MMT participation, and after non-medication-using treatments have already been tried. Efforts to make MMT less burdensome could reduce the tendency to avoid MMT until later in life and improve people's consistency of participation over time.

Background:The quality of methadone treatment for opioid use disorder varies across the U.S., affecting patient retention and overdose. Staff stress, trauma exposure, vicarious trauma (VT), burnout, and empowerment are important yet understudied factors that influence workforce well-being and performance. Objectives:This study aimed to characterize trauma-related well-being among staff in a national sample of opioid treatment programs (OTPs) and to explore potential correlates of resilience. Design:A cross-sectional survey was conducted from June to August 2024 with OTP staff from clinics participating in a parent national study. Methods:The survey combined validated instruments and tailored questions to assess work experience, lifetime trauma exposure, trauma and stress-related symptoms, VT, burnout, and multiple dimensions of empowerment. Exploratory factor analysis was used to identify domains of staff well-being. Results:The sample (N = 86) included medical staff, counselors, and non-medical/counseling staff from OTPs across 16 states. Thirteen percent of staff met preliminary criteria for posttraumatic stress disorder, 89.2% reported VT exposure at work, and 63.8% reported moderate to severe VT symptoms. Medical staff reported the highest VT and stress scores. Overall, 19.8% of staff met criteria for burnout, with counselors reporting the highest rates (30%). VT symptoms were positively correlated with burnout among counselors, medical, and other staff (r = 0.413-0.650, P < .05). Empowerment subscales were strongly correlated. Two distinct, uncorrelated domains of staff well-being emerged: VT resilience (low VT symptoms and burnout) and empowerment (high perceived control and influence), reflecting distinct aspects of trauma-related functioning. Despite high exposure to lifetime trauma and VT, staff demonstrated moderate resilience and moderate-to-high levels of empowerment. Conclusion:Staff of OTPs experience high levels of trauma exposure and symptomatology, VT, and burnout, with notable differences by clinic role. Resilience and empowerment domains suggest opportunities to improve staff wellness.

BACKGROUND:Despite the growing relevance of rural areas in the overdose crisis, research on rural people who inject drugs and their experiences with law enforcement remains limited. This research examines how rural policing and stigma uniquely shape the lives of people who inject drugs. METHODS:Forty-one semi-structured qualitative interviews were conducted with people who inject drugs in southern Illinois. For this analysis, we focused on participants who mentioned police in response to the question, "Have you ever been treated differently because you used drugs?" RESULTS:We identified three interrelated manifestations of stigma in rural people who inject drugs' interactions with police-verbal degradation and discrediting, unwarranted searches, and dehumanization-that align with Earnshaw's (2020) model distinguishing between stigma components (stereotypes, prejudice, discrimination) and health impact pathways. CONCLUSION:This study emphasizes the impact of stigma on people who use drugs, particularly in their interactions with law enforcement.

BackgroundAccess to methadone treatment can reduce opioid overdose death by up to 60%, but US patient outcomes are suboptimal. Federally allowed methadone treatment accommodations during the COVID-19 public health emergency were not widely adopted. It is likely that staff-level characteristics such as trauma symptoms influence the adoption of treatment innovation. ObjectiveMethadone Patient Access to Collaborative Treatment (MPACT) is a 2-phased project (pilot and field trial) to develop and test a staff-level, multimodal intervention to increase staff adoption of low-barrier, patient-centered methadone treatment practices and ultimately improve treatment retention and patient outcomes. MethodsA pilot and national trial will measure implementation feasibility, acceptability, and effects of the MPACT intervention on treatment practice change, clinic culture, patient retention, and patient posttraumatic stress symptoms (PTSS). The pilot will be a single-arm 5.5-month pilot study of MPACT conducted in 2 Arizona methadone treatment clinics (rural and urban) among 100 patients and 22 staff. The national trial will be a 20-month cluster randomized trial conducted among 30 clinics, 600 patients (20 per clinic), and 480 staff (18 per clinic). Data will be gathered by staff and patient surveys and patient chart review. The primary study outcome is increased patient methadone treatment retention measured as (1) time to first treatment interruption from study enrollment; (2) active in treatment at enrollment, day 30, 60, 90, and 120; and (3) continuous days in treatment during the study period. Secondary study outcomes include reductions in vicarious trauma and PTSS among enrolled opioid treatment program staff and PTSS among enrolled patients. ResultsThe pilot study was funded by the National Institute on Drug Abuse (award R61DA059889, funded September 2023), and the field trial will be funded under the associated R33 mechanism in September 2025. The pilot study was completed in March 2025. The randomized controlled trial will begin in December 2025. Both the pilot and trial have been approved by the University of Arizona Human Subjects Protection Program and have been registered with the clinical trials network. ConclusionsThe MPACT study will provide a foundation for an evidence-based, staff-level intervention aimed at improving patient retention in methadone treatment. Future studies should examine the individual components of MPACT to determine their differential contributions to the primary outcome of patient methadone treatment retention and to secondary outcomes of staff and patient reduction in stress symptoms. Trial RegistrationClinicalTrials.gov NCT06513728; https://clinicaltrials.gov/study/NCT06513728 and ClinicalTrials.gov NCT06556602; https://clinicaltrials.gov/study/NCT06556602 International Registered Report Identifier (IRRID)DERR1-10.2196/69829