Scaling up medications for opioid use disorder in Kentucky: Qualitative perspectives of treatment organizations.

Background: Underutilization of medications for opioid use disorder (MOUD), which reflects the limited number of patients initiating treatment and being retained in treatment, remains a persistent barrier to addressing the opioid epidemic. Using an adapted PRISM (Practical, Robust Implementation and Sustainability Model) framework, this study describes multi-level barriers and facilitators to expanding MOUD as part of the HEALing (Helping to End Addiction Long-term Methods: Cross-sectional small group and individual semi-structured interviews were conducted with 60 employees representing 30 MOUD agencies in eight Kentucky counties from December 2022 to June 2023. A deductive-dominant approach to interviewing, with all interviews recorded and transcribed. Using a codebook informed by the adapted PRISM framework, a directed consensus-based approach to coding and thematic analysis was used. Results: Although some agencies had a fairly static number of patients, most described recent experiences with modestgrowth in MOUD census and the ability to provide same day/next day MOUD. Multi-level factors, includingorganizational, patient-level, and community characteristics and perspectives, were perceived to impact MOUDcensus. Organizational characteristics impacting growth included the physical space of the clinic and staffing. Organizational policies in some agencies constrained treatment retention, while other agencies implementedinnovations to better meet patients' needs. Patients often encountered numerous challenges to treatmentinitiation and retention, including limited access to transportation, technology, safe and stable housing, and childcare. These patient-level barriers often reflected community characteristics, while community stigma alsoimpeded MOUD growth. Conclusions: These qualitative data revealed that some degree of growth in MOUD has occurred, but multi-level barriers are impeding further increases in treatment initiation and retention. Some barriers likely require policy changes related to financing and regulation, while other barriers require community-level efforts to decrease stigma and greater community investment in infrastructure, such as transportation and housing. Trial registration: ClinicalTrials.gov, NCT04111939. Registered 30 September 2019.