Low Threshold Buprenorphine Induction at Harm Reduction Centers Grant

Low Threshold Buprenorphine Induction at Harm Reduction Centers Grant is sponsored by New Jersey Department of Health. Supports harm reduction centers in New Jersey to enhance access to medication-assisted treatment for opioid use disorder.

Low-Threshold Buprenorphine in Non-Traditional Settings: A Scoping Review - PMC As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. .

2025 Sep 27;19:29768357251371854. doi: 10.

1177/29768357251371854 Low-Threshold Buprenorphine in Non-Traditional Settings: A Scoping Review 1 College of Medicine, University of Illinois Chicago, IL, USA Find articles by Anna Patterson 1 College of Medicine, University of Illinois Chicago, IL, USA Find articles by Zachary Davis 1 College of Medicine, University of Illinois Chicago, IL, USA Find articles by Mackenzie Smith 1 College of Medicine, University of Illinois Chicago, IL, USA Find articles by Nihmotallahi Adebayo 1 College of Medicine, University of Illinois Chicago, IL, USA Find articles by Madelyn Perez 1 College of Medicine, University of Illinois Chicago, IL, USA Find articles by Miriam Guzman 2 University Library, Information Services & Research, University of Illinois Chicago, IL, USA Find articles by Tina Griffin 3 Chestnut Health Systems, Lighthouse Institute, Chicago, IL, USA Find articles by Dennis Watson 4 College of Medicine, University of Illinois Chicago, Jesse Brown, VA, USA Find articles by Elisabeth Poorman 5 Department of Psychiatry & Institute for Research on Addictions, University of Illinois Chicago, IL, USA Find articles by Niranjan S Karnik 6 Department of Medicine & Institute for Research on Addictions.

University of Illinois Chicago, IL, USA Find articles by Sarah Messmer 1 College of Medicine, University of Illinois Chicago, IL, USA 2 University Library, Information Services & Research, University of Illinois Chicago, IL, USA 3 Chestnut Health Systems, Lighthouse Institute, Chicago, IL, USA 4 College of Medicine, University of Illinois Chicago, Jesse Brown, VA, USA 5 Department of Psychiatry & Institute for Research on Addictions, University of Illinois Chicago, IL, USA 6 Department of Medicine & Institute for Research on Addictions.

University of Illinois Chicago, IL, USA ✉ Anna Patterson, College of Medicine, University of Illinois at Chicago, 1854 W Polk St, Chicago, IL 60612, USA. Email: apatte21@uic. edu Received 2025 May 27; Accepted 2025 Jul 15; Collection date 2025 Jan-Dec.

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4. 0 License ( https://creativecommons. org/licenses/by-nc/4.

0/ ) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us. sagepub. com/en-us/nam/open-access-at-sage ).

PMCID: PMC12476501 PMID: 41024774 Despite the continuing opioid overdose crisis, the majority of those diagnosed with opioid use disorder (OUD) are not engaged in treatment due to various barriers. Low-threshold buprenorphine programs are designed to reduce treatment barriers. Key tenets of these programs are a harm reduction approach, same-day entry, flexibility, and accessibility.

The development of novel programs has expanded low-threshold treatment into mobile units, syringe service programs, and community centers. This scoping review aims to describe approaches taken by programs in non-clinical settings by identifying key components of delivery models, implementation barriers and facilitators, and outcomes.

Given the diverse nature of the literature on these programs, a scoping review was selected to review outcomes and to identify gaps. A protocol following the PRISMA-ScR guidelines was developed to systematically search 5 databases: Medline, Embase, CINAHL, PsycInfo, and Web of Science. Articles published prior to January 31, 2024 that described buprenorphine programs operating outside traditional healthcare settings were included.

The search identified 18 784 articles, including 147 in full-text review, with 41 meeting eligibility criteria. Common program types encompassed syringe service, mobile, community center, and street medicine. All programs emphasized community partnerships as key implementation facilitators and noted funding is urgently needed.

Low-threshold buprenorphine programs are an innovative way to deliver OUD treatment to people who otherwise may not have access to and/or engage in treatment. Future efforts should determine which outcomes are most important to people who use drugs, standardize outcome measurements, and implement programs tailored to help communities meet those outcomes.

Keywords: opioid use disorder, buprenorphine, low-threshold treatment, implementation The U.S. Department of Health and Human Services declared the ongoing opioid epidemic a public health emergency in 2017. In 2022, 6. 1 million people in the U.S. had an opioid use disorder (OUD), affecting 2.

2% of the population over the age of 12. The number of opioid-involved overdose deaths has risen dramatically in recent years, climbing from 47 600 in 2017 to 81 806 in 2022. The epidemic is not restricted to the United States: globally, an estimated 60 million people engaged in non-medical opioid use in 2021, 1.

23% of the world population aged 15 to 64. Expanding access to medications for opioid use disorder (MOUD) has transformed the treatment landscape, as MOUD is demonstrated to increase treatment engagement and retention while decreasing overdose rates, illicit opioid use, all-cause hospitalizations, all-cause mortality, and opioid-related mortality.

5 - 7 The number needed to treat with buprenorphine to prevent 1 death per year after overdose (52. 6) is lower than most commonly-prescribed medications. Additionally, one meta-analysis found all-cause mortality decreased by half with engagement in buprenorphine or methadone treatment.

Despite the efficacy of MOUD, there are still many barriers to treatment access, as only 22% of adults in the U.S. with an OUD received any kind of MOUD in 2021. Some of these barriers result from controlled substance prescribing regulations. For example, methadone is only available through strictly regulated opioid treatment programs (OTPs).

Until 2022, providers in the U.S. were legally required to obtain an “X-waiver” to prescribe buprenorphine and were limited to 30 patients in the first year. Other prescribing barriers exist at the insurance and pharmacy levels.

While most insurers cover at least 1 buprenorphine formulation, extended-release injectable buprenorphine is often considered non-formulary and additional requirements such as prior authorizations and quantity limits are common. Once insurance coverage has been assured, clients may find their preferred pharmacy does not carry buprenorphine.

Among U.S. counties with greater-than-average opioid-related mortality, 1 in 5 pharmacies indicated they do not dispense buprenorphine, according to an analysis of randomly selected pharmacies. Other barriers stem directly from the healthcare system.

These include but are not limited to long wait times, restricting intake hours, not allowing distribution of buprenorphine/methadone on the first visit, requiring in-person dosing (especially at OTPs), strict restrictions on maximum dosage or time in treatment, requiring clients to participate in counseling, requiring frequent urine drug tests, and/or mandating abstinence from all substances.

Clients often experience stigmatizing events when they interact with the healthcare system, which erodes trust in traditional healthcare settings. 14 , 15 Low-threshold treatment models seek to reduce barriers and build treatment programs that better address the needs of the people who access their services. Due to legal restrictions surrounding methadone, low-threshold programs in the U.S. almost exclusively utilize buprenorphine.

synthesized prior low-threshold approaches and defined a low-threshold buprenorphine model as including 4 overarching principles: (1) a harm reduction approach, (2) same-day treatment entry, (3) flexibility, and (4) wide availability in places frequented by people with opioid use disorder.

A harm reduction approach generally encompasses operating in a non-stigmatizing, welcoming environment, not stopping treatment due to opioid or other substance use, and working toward patient-centered goals such as reduced overdose risk or use reduction. Most low-threshold buprenorphine programs have been implemented in primary care and hospital settings.

Even so, models are wide-ranging, including emergency department bridge programs, telemedicine, 20 , 21 and coordination with both syringe service programs, and clinics focusing on the Hepatitis C Virus (HCV).

Additionally, the literature on low-threshold programs can be challenging in that not all programs explicitly state their low-threshold approach, but rather imply it by their description, and what is considered low-threshold has evolved throughout the years. In light of the literature’s heterogenous nature, we considered program context, and the programs’ definitions of what is low threshold for inclusion into this review.

Finally, as compared to standard, high-threshold approaches, results for low-threshold treatment are promising with higher initiation, increased buprenorphine adherence among retained participants, and similar retention rates. There is significant potential in developing low-threshold programs in non-traditional settings outside of primary care clinics or hospitals.

One cost-effectiveness model of low-threshold buprenorphine in syringe service programs predicted a 20% decrease in fatal opioid-involved overdoses. Low-threshold programs in non-traditional settings may be particularly effective for reaching people with OUD who are not otherwise engaged with the healthcare system.

Many such clients express a preference for receiving care in environments perceived as less judgmental and stigmatizing, such as programs operating out of a mobile unit. Despite the promise of these low-threshold programs within existing, non-clinical infrastructures, multiple barriers hinder their development, such as staff training, limited financial support, and appropriate medical provider placement.

This scoping review seeks to identify key characteristics, measurement methods, and outcomes of low-threshold buprenorphine programs operating in non-traditional settings. Given the diverse nature of the literature describing these programs, a scoping review was selected rather than a systematic review to identify knowledge gaps and provide a scope of the literature.

This study seeks to describe the approaches taken by these programs, elements of their delivery models, obstacles and support during implementation, measures of success, and reported outcomes. Question 1: What models of low-threshold buprenorphine care have been developed for non-traditional settings? Question 2: What are the key components of these low-threshold buprenorphine models of care?

Question 3: What determinants of implementation (barriers and facilitators) have been described for these models of care? Question 4: What service and clinical outcomes have been associated with these models of care? Prior to conducting this scoping review, a protocol was developed based on the PRISMA-SCR guidelines.

This protocol is registered and on Open Science Framework at https://osf. io/7rshq Peer-reviewed articles focused on low-threshold buprenorphine treatment programs in non-traditional settings were included in this review while conference abstracts, reports, and dissertations were excluded.

Population, Concept, and Context: Inclusion and Exclusion Criteria Given the broad range of opioid use disorder treatment programs described in the literature, the following inclusion/exclusion criteria were developed to focus the review. Programs providing care to adult or adolescent clients (ages 15 and older) with opioid use disorder. Programs primarily providing care to clients under age 15.

Low-threshold or low-barrier programs providing medication for opioid use disorder (MOUD) in the form of buprenorphine. Given the evolving landscape regarding telehealth-based delivery methods, exclusively telehealth-based programs were excluded.

Additionally, as the review seeks to focus on highlighting novel, sustainable settings that can provide buprenorphine treatment directly, rather than initiating treatment or bridging into traditional programs, programs that did not provide ongoing buprenorphine care were excluded. Both telehealth and bridge programs have been recently reviewed elsewhere.

31 - 33 Community-based programs operating outside traditional health and substance use disorder care settings. Programs where care had previously been established generally: those operating in a hospital, outpatient primary care clinic, federally qualified health center, or jail/prison.

A search of literature databases was performed in Medline (via PubMed), Embase (Elsevier), CINAHL (via EBSCO), PsycInfo (ProQuest), and Web of Science (Clarivate). Source selection was made based on recommendations by Brahmer. All dates were searched through January 31, 2024.

Search string vocabulary terms were grouped into 2 concepts: (1) buprenorphine and its drug synonyms and (2) opiate addiction treatment including safe supply, harm reduction, low-barrier/low-threshold, and medication-assisted treatment. Full search strings, reported in Supplemental Appendix A , were developed with the assistance of the search string development tool created by Brunskill.

Covidence software was used for citation screening and data extraction (Veritas Health Innovation, Melbourne, Australia, www. covidence. org ).

Selection of Sources of Evidence Abstracts identified through the described search were imported into Covidence and duplicates were removed. Titles and abstracts were screened independently by 2 reviewers, and any conflicts between the 2 reviewers were resolved by a separate reviewer. Next, full text review was completed by 2 independent reviewers, with a third reviewer resolving conflicts based on the previously defined protocol.

Articles not meeting the above inclusion criteria were excluded. A team of reviewers developed a data extraction template in Covidence to address the study questions.

Extracted data included: (1) article title and first author; (2) total number of participants and participant details (age, gender, race/ethnicity, substance use history, prior treatment attempts, co-morbid conditions); (3) study location, aim, design, start/end dates, funding sources, and conflict(s) of interest; (4) program name and components including type of program, setting (city and type of non-traditional program), treatment entry, harm reduction approach, flexibility, staffing, participant engagement, type, dose, and range/duration of medication provided, requirements for participation (including management of those not meetings program goals), urine drug screen usage, telehealth inclusion, additional services provided, implementation barriers and facilitators, program outcomes (service and clinical outcomes, retention in care, qualitative outcomes), and adverse events; and (5) this study’s inclusion/exclusion criteria.

These data points were selected to provide a broad overview of the types of programs, services provided, and implementation facilitators and barriers associated with programs. Data regarding implementation facilitators and barriers in included articles were extracted using a structure based on the Consolidated Framework for Implementation Research (CFIR).

CFIR is a practical framework developed to guide systematic assessment of barriers and facilitators to implementation, categorizing these factors by domains (innovation, inner setting, outer setting, individuals, and implementation process). Based on these domains, data were extracted by 2 independent reviewers then consolidated by a third reviewer. The full spreadsheet of extracted data can be found in Supplemental Appendix B .

A total of 41 articles met criteria and were included in this scoping review. 18 , 19 , 22 , 24 , 28 , 37 - 72 The PRISMA flow diagram provided in Figure 1 details inclusion and exclusion decisions. Figure 2 details the types of articles included.

Of these, 35 were based in the United States, 2 in Canada, 2 in the United Kingdom, 1 in Norway, and 1 in India. Most studies in the U.S. occurred in urban communities, most commonly in Baltimore, MD, and Philadelphia, PA. The following results are organized to respond to each of the review’s 4 guiding questions.

PRISMA flow diagram of the study selection process. Each of the identified studies were screened, retrieved, assessed for eligibility, and examined by 2 independent reviewers. Included Studies.

Retrospective chart reviews were most frequently deemed as acceptable to include, followed by qualitative research studies. Models of Low-Threshold Buprenorphine Care in Non-Traditional Settings We reviewed the following aspects of the identified program models: location/setting, buprenorphine prescribing and dispensation modalities, and target population.

In terms of program setting, the programs described in the 41 included articles can be largely categorized into 4 groups: syringe service programs (SSP), mobile programs, community centers, and street medicine. Regarding prescribing and dispensation modalities, the ability to prescribe and/or dispense buprenorphine was added to these programs’ existing services in most cases.

Other program designs included pharmacy-based programs, 47 , 56 an integrated obstetric/addiction clinic, and a medication delivery program designed to reach people living in shelters. Thirteen of the 41 programs did not detail how buprenorphine was prescribed or dispensed to patients.

Of the 28 that provided details, 8 dispensed buprenorphine directly to patients while 21 provided buprenorphine prescriptions for the patients to fill later at a pharmacy. While initial prescriptions were typically for 1 to 2 weeks of medication, there were dosing inconsistencies with the starting dose ranging from as little as 2 to 16 mg 24 , 37 and the maximum dose ranging from 16 to 32 mg.

One program specifically offered micro-dosing regimens to enable same day induction. Lastly, the primary target population for each program was individuals with OUD and other substance use disorders. Many programs focused on unique subpopulations, particularly those experiencing homelessness.

A few programs targeted even more specific populations, such as individuals involved in the criminal legal system, women experiencing homelessness, Components of Low-Threshold, Non-Traditional Models of Care The vast majority of the 41 programs included all 4 overarching principles of low-threshold buprenorphine care as outlined previously in Jakubowski and Fox.

Namely, all of the 41 programs utilized a harm reduction approach, 85% (35 yes, 1 no, 5 unknown) had the option of same-day treatment entry, 83% (34 yes, 1 no, 6 unknown) incorporated flexibility into their care, and 83% (34 yes, 1 no, 6 unknown) were located in places frequented by people with opioid use disorder.

Program descriptions and other key components are included in Table 1 , with additional qualitative themes highlighted in Supplemental Table 1 . Program Descriptions Final.

Program description and target population How medication is provided/dosage Harm Reduction Coalition (HRC) Cohort study, November 2005 to July 2008 Clients referred by SSP; Target population: marginalized populations, younger clients, long-term heroin use, no prior treatment history Prescriptions provided; average daily dose 16 mg; 1 wk initial Rx Stepped Treatment and Engagement Program (STEP) Non-randomized experimental study, dates not specified Pilot study; enrolled clients of the SSP with current heroin use Buprenorphine directly dispensed twice weekly; doses not specified Pilot study; self-described as low-threshold but with did require counseling/frequent visits Stabilization, Treatment, and Engagement Program (STEP) Retrospective chart review, October 2011 to August 2014 Low-barrier buprenorphine treatment integrated into an SSP Prescriptions provided; average daily dose 16 mg; 1 wk initial Rx and can space to 4 wk King County Public Health Syringe Services Program Retrospective chart review, 2017 to 2018 Low-barrier buprenorphine treatment integrated into an SSP Prescriptions provided and can be dispensed from co-located pharmacy; initial 3-4 d supply, can be increased to 1-2 wk once dose is stable Homeless Health Care Los Angeles (HHCLA) clinic Descriptive/implementation study, January 2020 to June 2020 Designed to reach high-risk population during COVID-19; developed telephone booth model to allow for social distancing; target population was clients of syringe service program Initially majority of patients (86%) were directly dispensed buprenorphine; eventually switched to prescription via coordinated pharmacies Describes adaptations during COVID: telephone booth development and partnership with pharmacies to coordinate buprenorphine prescriptions Case Report, 2017 to 2020 Low-threshold buprenorphine provided by city’s syringe service program to clients seeking treatment for OUD Led by the police department but not enforcement-oriented; focused on harm reduction Retrospective chart review, February 2019 to October 2020 SSP-based low-threshold buprenorphine treatment program to engage people with opioid use disorder who may be reluctant to seek treatment elsewhere Prescriptiosn provided; daily dose 16 mg; 1 wk initial Rx Qualitative research, April 2019 to November 2019 SSP-based low-threshold buprenorphine treatment program to engage people with OUD who may be reluctant to seek treatment elsewhere Prescription typically given for 1-2 wk, could progress to monthly once patients were stabilized Describes 6 low-threshold buprenorphine programs in NYC: stage of development, location, availability, provider, SSP staff, documentation, urine toxicology testing Descriptive study, August 2020 to August 2021 Full spectrum care for people with opioid use disorder integrated in harm reduction site Cohort study, May 2017 to May 2018 Buprenorphine clinic co-located with Hepatitis C treatment clinic Initial prescriptions 16 mg/d for 1 wk, spaced out per physician discretion Offered legal support, laundry, showers, community lunch New Jersey Medication Assisted Treatment Initiative Retrospective chart review, January 2008 to September 2010 Mobile vans that provided buprenorphine and methadone; 6 state-funded sites in different NJ municipalities; 5 had mobile medical units and 1 had an office-based program with a passenger van to transport clients to the office Only 25% of clients chose buprenorphine, remainder were treated with methadone Project Connections at Re-Entry (PCARE) Retrospective chart review, November 2017 to November 2018 A mobile low-threshold buprenorphine program located outside of Baltimore City Jail; designed to reach recently incarcerated individuals but sees anyone from the community Prescriptions provided; dose up to 16 mg/d, initial Rx 2-7 d Project Connections at Re-Entry (PCARE) Retrospective chart review, January 2021 to July 2021 A mobile low-threshold buprenorphine program located outside of Baltimore City Jail; designed to reach recently incarcerated individuals but sees anyone from the community Prescriptions provided; dosage of buprenorphine varies across patients (up to 32 mg/d); initial Rx up to 1 wk, can space to 4 wk Study examines retention rates at higher vs lower buprenorphine doses and found higher retention with higher doses British Columbia Ambulance Services Retrospective chart review, December 2016 to March 2017 Ambulances could bring patients to a specialized trailer for opioid use disorder treatment rather than an emergency room Medications (methadone and buprenorphine) are prescribed and dispensed; take home doses of buprenorphine with follow up next day for new starts; methadone given for 3 d Outreach team available and helps with resources Community Care in Reach Mobile Health Initiative Mixed methods evaluation, January 2018 to December 2019 Seeks to engage individuals with opioid use disorder not currently in care; staffed by clinician with expertise in caring for individuals experiencing homelessness and harm reduction specialists Prescriptions provided; observed induction on the first day of treatment Mixture of street outreach and mobile care Safe Healthy Empowered (SHE) clinic Retrospective chart review, July 2018 to October 2018 Program designed to reach women experiencing homelessness; served patients with high rates of homelessness, individuals engaged in sex work; provided wraparound care which included buprenorphine for opioid use disorder when needed Access, Harm Reduction, Overdose Prevention, and Education (AHOPE) Qualitative research, December 2019 to March 2020 Mobile outreach program offering harm reduction services, primary care, and addiction treatment Offered escort to pharmacy for clients Retrospective chart review, July 2019 to December 2019 Low-barrier, multidisciplinary mobile care unit targeting fatal overdose hot spots Prescriptions provided; 1 wk initial Rx, can space to 4 wk pending progress and UDS results Qualitative study embedded into a cluster randomized trial, March 2019 to October 2019 Mobile van-based program co-located with SSP vans, offering an array of services including buprenorphine-based MOUD Prescriptions provided; 1 wk supply Offered overdose prevention and response training, health insurance enrollment Cohort study, September 2018 to November 2019 Mobile van-based program co-located with SSP vans, offering an array of services including buprenorphine-based MOUD Prescriptions provided; 1 wk supply Prevention Point Philadelphia (PPP) Qualitative research, July 2021 to December 2021 Multiple mobile, low-barrier buprenorphine programs designed to increase treatment access among marginalized individuals at high risk of overdose Prescriptions provided; max dose 24 mg/d; generally 1 wk Rx Interviews with patients of the mobile units Prevention Point Philadelphia (PPP) Qualitative research, May 2022 to August 2022 Participants of the research were leaders of 7 mobile units that provideor link to MOUD and were in operation in Philadelphia County as of February 2022 Practice varies across mobile units, some prescribe and some dispense medications Interviews with leaders of 7 different mobile units Community Outreach Intervention Projects (COIP) Retrospective chart reviewy, July 2021 to June 2022 Mobile medical unit integrated into community-based harm reduction organization targeting opioid overdose hot spots in Chicago, offering primary care and low-threshold buprenorphine Prescriptions provided; dispensing model under development Offering post-use monitoring with buprenorphine initiation Community case study, May 2021 to April 2023 A mobile team rooted in emergency medicine and family medicine for patients with opioid use disorders who may also be experiencing homelessnes Communities that HEAL (Helping to End Addiction Long-term) intervention Massachusetts and Ohio, USA Qualitative research, August 2022 to January 2023 Mobile units that provide same-day access to MOUD prescriber at an outreach site, either in-person or via tele Not specified, “traditional induction” vs low-dose induction (site dependent) Prevention Point Pittsburgh Quasi-experimental study, January 2018 to September 2022 Four low-threshold buprenorphine mobile vans colocated with a mobile SSP Examines impact of mobile units on neighborhood arrest rates The Great Circle Mobile Medication Unit (MMU) Grande Ronde, Oregon, USA Qualitative Research, February 2023 to March 2023 Dispenses methadone or buprenorphine from a mobile van on the lands of the Confederated Tribes of Grande Ronde; target population is American Indian/Alaskan Native communities Medications dispensed from the mobile unit Only known Tribally operated mobile medical unit in the United States Case series, March 2020 to October 2020 Self-described low-threshold drop-in program with assertive outreach; describes cases of patients with OUD who wished to transition to injectable buprenorphine and for whom conventional induction were unlikely to be tolerated Medications dispensed and administered on site; range of micro-dosing regimen start to first injectable buprenorphine is 8-19 d; prescription length varied depending on the point in the program but goal to reach monthly visits Participants were provided a micro-dosing regimen to enable same day induction of oral buprenorphine; case series of 5 individuals Project ORCHID (Organised Response for Comprehensive HIV Interventions in the Districts of Nagaland and Manipur) Manipur and Nagaland, India Retrospective chart review, May 2006 to December 2007 Buprenorphine treatment program based in community drop in centers for people who inject drugs Averaged daily dose varies among the drop in centers Project Connections Buprenorphine Program (PCBP) Qualitative research, February 2017 to June 2017 Clinic located at peer recovery center in Baltimore that hosts peer recovery meetings and offers referrals/supports Program is largely focused on peer support Respectful, Equitable Access to Compassionate Healthcare (REACH) Qualitative research, dates not specified Harm-reduction based, low-threshold, nurse-led model of buprenorphine therapy in a community-based medical practice Qualitative research, April 2017 to December 2017 Private, community based non-profit organization that primarily treats those who are underinsured or uninsured RAAM (Rapid Access Addiction Medicine) model Retrospective chart review, October 2017 to October 2019 RAAM model integrates pharmacologic treatments, psychosocial and behavioral treatments, addiction medicine, and primary care into 1 team to address substance use issues Prescriptions provided for buprenorphine; methadone referrals offered Cohort study, March 2021 to February 2022 Program designed to reach individuals engaged in sex work in Leeds with a focus on informed choices about buprenorphine prolonged-release injection Low Threshold Substitution Treatment in Oslo Retrospective chart review, September 2010 to December 2016 Daily free, supervised buprenorphine offered from a street clinic Daily observed doses dispensed directly from program.

Initial dose 4 mg, up to 16 mg.

San Francisco Street Medicine Retrospective chart review, November 2016 to October 2017 Low barrier buprenorphine program with the primary goal of engaging and retaining people experiencing homelessness with OUD in care Prescriptions provided; typical initial dose of 16 mg/d; initial Rx for 3-7 d The Connecticut Mental Health Center Retrospective chart review, July 2019 to April 2021 Provides care to unsheltered individuals; offering buprenorphine for those who wanted to reduce their opioid use.

Prescriptions provided; initial 1 wk Rx, can space to 30 d supply unnamed (pharmacy integrated) Feasibility pilot study, February 2021 to April 2022 Prescribers allowed to delegate evaluation and some treatment decisions to pharmacists; pharmacists see patients in the pharmacy and dispense buprenorphine; patients recruited through self-referral, emergency department outreach, or community outreach Medications dispensed from pharmacy; dose 4-24 mg/d; initial Rx 3-7 d supply, can space to 2 wk unnamed (pharmacist outreach program) Retrospective chart review, August 2022 to November 2022 Pharmacist-led outreach pilot program to provide buprenorphine treatment to individuals residing in permanent supportive housing Prescriptions provided; different dosing protocols offered; 1-2 wk Rx Pharmacist led outreach program Other: Integrated Obstetric/Addiction clinic Obstetric/Addiction Clinic Retrospective chart review, June 2019 to June 2021 Pregnancy-to-postpartum services provided alongside buprenorphine treatment Prescriptions provided; mean daily dose 18.

5 mg/d Offered prenatal care, NOWS education, anesthesia birth pain management consultation, lactation consultation, group therapy Other: Medication delivery to patients in shelters Community Behavioral Health Services Pharmacy Developed to delivery buprenorphine to patients who have residence at a shelter in place (SIP) hotel for homeless individuals in San Francisco Prescription either delivered by pharmacy staff or picked up at pharmacy Program offered the ability to personalize prescription delivery to accommodate patient’s schedule Many programs provided additional services, the most common being general harm reduction support (ie, fentanyl test strips, education, supplies, naloxone kits) (83%), naloxone distribution (51%), referrals to additional services (51%), such as Federally Qualified Health center care, and syringe exchange (44%).

The program described in Ellis et al provided prenatal care, anesthesia-birth pain management consultation, and lactation consultation. Another program provided overdose prevention, response training, and assistance with health insurance enrollment. Other services, as described in Samuel et al, included legal case work, access to laundry and showers, community lunch, and prescription delivery.

No client participation requirements were specified for 29 of the 41 programs. Nine programs required drug testing, typically through a urine drug test. Of these 9 programs, 5 explicitly stated that drug testing was required at each appointment, whereas the frequency of drug testing for the remaining 4 was unspecified.

Bachhuber et al had an orientation with a case manager upon enrollment, but the remaining principles were described as low barrier. Another program, Tringale et al, required participation in a peer support group as part of the pilot program but was self-described as utilizing a low-threshold approach. We also evaluated what was offered to program clients not progressing in their treatment goals.

Of the 41 reviewed programs, 25 did not specify protocols for supporting clients who do not meet goals. Twelve programs referred clients to healthcare providers offering different treatment modalities or more individualized care (eg, methadone programs, inpatient/intensive outpatient programs, FQHC/primary care).

Hill et al required 3 consecutive days of directly observed therapy for clients with 2 consecutive urine screens that were negative for buprenorphine; otherwise, they were discharged from the program. If a client missed an appointment in the program described in Tay Wee Teck et al, the client was offered re-initiation into treatment.

For clients not meeting treatment goals, another 5 programs offered multiple next-step options, often determined by provider discretion or client preference. For instance, the STEP program (Stabilization, Treatment, and Engagement) noted an expectation of cessation of heroin use within 4 weeks of treatment initiation, monitored by urine screens each visit.

A client still using heroin at week 3 was evaluated for either intensified treatment or increased buprenorphine dosage. Some programs prompted clients not meeting goals to either demonstrate dosing(s), 25 , 37 or increase the frequency of their provider visits. 24 , 57 , 72 Approximately one-third of studies noted referring those not meeting treatment goals to alternative programs for further treatment.

Determinants of Implementation Barriers and facilitators of program implementation are presented in Table 2 and discussed separately below. Barriers and Facilitators to Program Implementation. Key barriers and facilitators to program creation and execution were identified across settings.

Barriers to implementation