Abstract
Introduction
The opioid overdose crisis necessitates the development of effective treatment and harm reduction practices. Recent increases in opioid use disorder (OUD) and overdose rates among women in tandem with lower medications for opioid use disorder (MOUD) treatment utilization rates make a case for investigating the barriers faced by women with OUD in accessing MOUD treatment. To inform future interventions, this study examines factors that impede access to MOUD treatment and explores evidence-based solutions through triangulating the perspectives of affected women as well as criminal legal and health professionals who work with women with OUD.
Methods
Semi-structured interviews (N = 42) were conducted from May to June 2022 to assess participants’ lived experiences with MOUD treatment. Participants included criminal-legal involved women with a lifetime history of OUD and MOUD use (N = 20), criminal legal professionals (N = 10), and substance use disorder (SUD) treatment professionals (N = 12) who work with women with OUD. We used a thematic qualitative data analysis process to identify common barriers to accessing MOUD treatment.
Results
The thematic analysis identified three categories of factors impeding MOUD treatment accessibility: (1) financial barriers (including program difficulties procuring grant funding and individuals’ concerns regarding insurance coverage), (2) travel hardships (including inadequate public transportation infrastructure and lack of access to personal vehicles), and (3) insufficient provider availability (including demand that exceeds the supply of open spots in MOUD treatment programs and a limited number of treatment facilities).
Conclusion
There was substantial consensus among the three groups, and participants identified financial barriers, travel hardships, and insufficient provider availability as barriers to accessing MOUD treatment. Our study's results make a strong case for addressing travel-related hardships. To best serve affected women, solutions such as allocated transportation, gas mileage reimbursement, bus passes, flexible take-home treatment options, and alternative medication dispensing settings should be implemented to mitigate transportation-related barriers to accessibility.
Introduction
Opioid Use Trends and MOUD Treatment
The drug overdose crisis in the USA, primarily fueled by opioids, necessitates the development and expansion of effective treatment and harm reduction practices (Saloner et al., 2018; Volkow & Blanco, 2021). In 2021, an estimated 5.7 million Americans over the age of 11 met the criteria for opioid use disorder (OUD)—an increase of approximately 171% from roughly 2.1 million in 2016 [Substance Abuse and Mental Health Services Administration (SAMHSA), 2017, 2022]. Coupled with opioid-related overdose deaths doubling from around 40,000 in 2016 to over 80,000 in 2021 [Centers for Disease Control and Prevention (CDC), 2023], the ongoing drug overdose crisis is worsening in prevalence and severity (Jones et al., 2023), highlighting the need for more accessible interventions and treatment practices.
One evidence-based method of treatment for OUD is the use of medication for OUD (MOUD). Methadone, extended-release naltrexone, and buprenorphine are three medications approved by the U.S. Food and Drug Administration for MOUD treatment and demonstrate significant reductions in opioid use (Koehl et al., 2019; Mancher & Leshner, 2019; Volkow et al., 2019). Extensive research has identified the health-related benefits of MOUD treatment to include reduced likelihood of overdose and opioid-related mortality (Larochelle et al., 2018; Wakeman et al., 2020), decreased risk of infectious diseases (Springer, 2020; Volkow & Blanco, 2020), and improved quality of life (Bell & Strang, 2020; Ma et al., 2019). Taken together, such findings illustrate the value of MOUD and underscore the importance of increasing accessibility to MOUD treatment.
Barriers to the Physical Accessibility of OUD Treatment and MOUD
While MOUD treatment bolsters positive health outcomes in individuals with OUD, low rates of utilization indicate that not all who could benefit from MOUD treatment are able to access it. Specifically, as of 2021, only an estimated 22% of those diagnosed with OUD received MOUD treatment (SAMHSA, 2022). One significant impediment to receiving OUD treatment generally involves physical accessibility barriers (Cernasev et al., 2021). In the context of this study, physical accessibility refers to the constraints on an individual's ability to reach clinics and/or obtain treatment for OUD. From this definition, there is ample evidence that financial costs (Elmore et al., 2023; Winiker et al., 2023), travel hardships (Andrilla & Patterson, 2022; Pasman et al., 2022), and insufficient clinic availability (Drainoni et al., 2022; Miles et al., 2020) extend beyond their impacts to general OUD treatment to contribute to low rates of MOUD treatment uptake and retention.
Studies of individuals with OUD, as well as the professionals who serve them, such as criminal justice and substance use disorder (SUD) treatment professionals, have all documented these issues. For example, in 2021, results from the National Survey on Drug Use and Health identified insurance-based financial barriers, including a lack of health insurance, denial or only partial coverage of SUD treatment, and resulting unaffordability as prevalent reasons why individuals with SUD were unable to access treatment in general (SAMHSA, 2022). Speaking to physical accessibility barriers further, in one recent study, drug court staff discussed how insurance requirements or lack of coverage caused significant delays in MOUD treatment access (Pivovarova et al., 2023); in another, MOUD providers emphasized that there are more potential patients than available MOUD providers to treat them (Bridges et al., 2023); and a third study interviewing individuals with a history of opioid use found that many lacked driver's licenses and faced transportation-related issues in accessing MOUD treatment (Staton et al., 2024).
The Need for Investigating Accessibility Barriers for Criminal-Legal Involved Women with OUD
Recent trends reflect alarming increases in OUD, overdose, and opioid-related mortality among women, with the mortality rate for opioid overdose rising by 492% between 1999 and 2017 (Barbosa-Leiker et al., 2021; CDC, 2023; VanHouten et al., 2019). Rates of OUD and overdose are also disproportionately high among criminal-legal involved individuals, a trend that often worsens following experiences of incarceration and treatment disruptions related to criminal legal system involvement (Blanco et al., 2020; SAMHSA, 2017; Scott et al., 2021). Although there is a lack of research focusing specifically on the prevalence of OUD among criminal-legal involved women, considering these trends in connection with the jarring rates of increase (525%) in women's incarceration over the past 30 years and the roughly 976,000 women either incarcerated, on probation, or on parole as of 2021 (The Sentencing Project, 2022), it is likely that OUD, overdose, and opioid-related mortality affect a substantial number of criminal-legal involved women.
Additional evidence suggests that rates of OUD treatment utilization are lower among individuals who are criminal-legal involved (Grella et al., 2020) and women (Mauro et al., 2022; Morgan et al., 2018), which is likely indicative of low utilization rates among criminal-legal involved women. In this regard, criminal-legal involved women are a subset of individuals likely more significantly impacted by physical accessibility barriers to MOUD treatment (Smith et al., 2020). Compared to those in the general population, women with a history of involvement in the criminal justice system are more likely to be without reliable transportation, lack stable housing, have greater rates of unemployment and fewer job opportunities, and experience constraints on insurance coverage or not have any altogether (Bohmert & DeMaris, 2018; Sheely, 2020; Smith et al., 2020).
The interplay between gender and criminal legal system involvement likely exacerbates physical accessibility barriers to MOUD treatment. There is great stigma attached to women with OUD or criminal legal system involvement, stemming from societal associations between OUD or criminal legal system involvement and being a neglectful mother, failing in their patriarchal role as a caregiver, and sex work (Fiddian-Green et al., 2022; Rutter & Barr, 2021). When an individual is both a woman with OUD and has a history of criminal legal system involvement, it is probable that compounding discriminatory manifestations of this stigma complicate MOUD treatment accessibility. This likelihood highlights the need for research that centers their perspectives of criminal-legal involved women and draws on them to inform future directions in addressing barriers to MOUD treatment.
Present Study
A rich body of literature examines accessibility barriers to OUD treatment utilization in general; however, few studies triangulate the perspectives of multiple groups with lived experience with MOUD treatment specifically. Moreover, to our knowledge, none focus specifically on criminal-legal involved individuals with OUD, who are much less likely to be referred to MOUD treatment by the criminal legal system compared to individuals with OUD referred to treatment by non-criminal legal referrals (Krawczyk et al., 2017; Shearer et al., 2022; Stahler et al., 2022). The current study contributes to the literature by triangulating the lived experiences of women with a lifetime history of MOUD use, along with the perspectives and experiences of criminal legal and SUD treatment professionals who work with women using MOUD. Additionally, this research seeks to extend the identified general OUD treatment accessibility barriers to MOUD treatment specifically, while also further analyzing why some of these barriers may be intensified for criminal-legal involved women. Furthermore, we focus here, specifically, on factors that impede accessibility to MOUD treatment and explore related evidence-based solutions in the discussion. This approach can shed light on the experiences of affected women and those in their nested social contexts; such insights can guide developing solutions both through practice and policy to increase MOUD uptake and retention among women and sustain positive health outcomes overall.
Methods
This study uses semi-structured telephone interviews (N = 42) conducted between May and July 2022 to assess participants’ lived experiences regarding factors impeding access to MOUD treatment. Participants included individuals from the following groups: criminal-legal involved women with a lifetime history of MOUD use (N = 20), criminal legal professionals who worked with women who use opioids (N = 10), and SUD treatment professionals (N = 12). When referring to women who use opioids, the term ‘opioids’ encompasses prescription and illicit opioid use, as some only used illicit opioids, others only misused prescription opioids, and a few used a combination of both. This study received approval from the Pennsylvania State University Institutional Review Board.
Participant Recruitment
The criteria for recruitment and eligibility differed by group: the affected women, the criminal legal workers, and the SUD treatment professionals. For the 20 women with a lifetime history of MOUD treatment, our sampling strategy was targeted and involved the use of chain referrals and social media advertisements. We also mailed flyers to MOUD treatment programs across Pennsylvania (P.A.). Interview eligibility criteria included informed consent; be over the age of 18; live in P.A.; have a lifetime history of criminal legal system involvement through either incarceration, probation, or parole; and have been enrolled in an MOUD program at one point in their lives.
Recruitment of the 10 criminal legal professionals involved posting online advertisements, calling P.A. women's prisons directly, and conducting chain referrals. Eligibility criteria required that these professionals provide informed consent; hold the position of a prosecutor, treatment court professional, law enforcement officer, or corrections officer; engage in work with criminal-legal involved women who used substances; and work in P.A.
Finally, to recruit the 12 SUD treatment professionals, we utilized a directory listing all of the Pennsylvania Department of Drug and Alcohol Programs’ licensed Opioid Treatment Programs (OTPs) to place direct calls and make chain referrals. Participation criteria stipulated that the SUD treatment professionals must either prescribe MOUD as healthcare workers, offer counseling as a component of an MOUD treatment program, or provide care for those being treated with MOUD. They also had to give informed consent, work with female-identifying clients with OUD, and work in P.A.
To ensure all individuals interested in the study were eligible, we provided a brief web screening. The screening took the form of a REDCap information survey about demographic characteristics such as age and sex as well as contact information.
Interviews
After the recruitment process, trained study staff contacted eligible participants by phone to schedule interviews. All interviewers were female employed research staff, had experience conducting qualitative interviews, held post-secondary degrees, and shared similar sociodemographic characteristics with the women with a lifetime history of OUD. During these calls, study staff scheduled each interview to take place by phone in the span of one hour on the scheduled day.
Thirteen key questions were asked in each interview, and they focused on either the participants’ work with women who use drugs or the women's own experiences using MOUD treatment. For example, one of the questions in women's interviews that elicited themes we discuss in this manuscript was “What was the least helpful when you were in drug treatment? What do you think is the main reason women drop out of drug treatment?.” The corollary question in the interviews with SUD treatment professionals was “What have you noticed to be the least helpful to women in drug treatment for opioid use and other substances? What do you think is the main reason women drop out of drug treatment?.” For criminal legal professionals, the corresponding question was “From your viewpoint, what are the biggest challenges in the lives of the women who use drugs and are involved in the criminal justice system?.” When discussing “MOUD treatment” in this context, women referred to the use of MOUD across various types of settings—outpatient facilities, inpatient facilities, medication-assisted treatment clinics, and others—and pointed to the challenges and successes they faced across such settings. We compensated participants for their time with a $50 gift card.
After providing verbal consent, the interview started. Additionally, interview staff clarified that participants were free to decline to answer any questions.
Data Analysis
Interviews were conducted, audio-recorded, and transcribed by trained study staff using NVivo 14 software. Transcripts were de-identified using pseudonyms to protect participant confidentiality. The research team then analyzed the transcripts through a thematic analysis process (Glaser & Strauss, 1967; Khan, 2014). Given that the interview questions were open-ended, codes regarding barriers to MOUD treatment were generated inductively after reading a sample of the transcripts. This iterative process involved three researchers reading the transcripts carefully to generate an initial inductive list of primary codes. Specifically, to develop the primary codes, the researchers continued to review the transcripts closely until the content of the new transcripts no longer necessitated adding any further primary codes in the codebook. Then, to generate secondary codes, the three researchers went on to repeat this process within each primary code, further aligning with thematic analysis through theme development and refinement (Glaser & Strauss, 1967; Khan, 2014).
With interviewers asking similarly structured questions to the affected women, criminal legal professionals, and SUD treatment professionals to examine areas of convergence and divergence, the research team created a single codebook to employ with all groups. Four different members of the research team, including the P.I., utilized the codebook during the coding process, with each transcript initially coded by one team member and then double-checked by the P.I. for consistency. Through cross-checking, the P.I. identified any differences in coding, which were then discussed and resolved. This paper utilizes the primary code “Barriers to Treatment Success.”
Results
Participant Characteristics
This study recruited a total of 42 participants: 20 women with a lifetime history of MOUD use, 10 criminal legal professionals, and 12 SUD treatment professionals. The women with MOUD history mostly identified as white, non-Hispanic (n = 14, 70%), and ranged in age from 24 to 54 (mean = 37 years). Among the SUD treatment professionals, the majority identified as white, non-Hispanic (n = 8, 66.7%), and their ages ranged from 38 to 54 (mean 48 years). Two identified as male, and the remaining were female. Of the criminal legal professionals, one participant identified as Black, while the majority identified as white, non-Hispanic (n = 9, 90%). Three identified as male, and the remaining identified as female. Their ages ranged from 34 to 56 (mean = 44 years).
Themes
In interviews, we asked each participant group specifically about barriers to women's access to MOUD treatment and retention. Responses from participants encompassed three factors impeding MOUD treatment accessibility: financial barriers, lack of transportation access, and insufficient availability.
Financial Barriers
When asked about perceived obstacles to MOUD treatment, SUD treatment professionals and women with OUD both mentioned financial barriers. Participants not only addressed obstacles related to insurance but also, from the SUD treatment professionals’ perspectives, grants, which can be another important funding source for MOUD treatment programs. Taken together, grant funding and insurance comprise two subtopics of financial barriers worthy of further examination regarding their influence on the accessibility of MOUD treatment.
Grant funding
Local and state-level grants are an important funding source for MOUD treatment programs (Dickson-Gomez et al., 2022). Yet despite their great utility, it can be difficult to procure an amount of funding that will meet a given county's MOUD treatment expenses, which may further impede accessibility. One SUD treatment professional (participant #5), an executive director of a recovery program, spoke to this when discussing financial barriers that stand in the way of MOUD treatment program success, specifically addressing the procurement of funding from her county: Drug and Alcohol, our local SCAs [Single County Authorities], that are supposed to be funding these people, that's what makes them not successful. Because the funding that's available isn’t enough. I fought for funding here in this county for my ladies and I was granted $1,250 for a lifetime. That's it, that's all.
In Pennsylvania, local Drug and Alcohol offices can provide funding for MOUD treatment for individuals with OUD who are uninsured. But as this participant points out, there may be a funding cap in some counties that is low. People's MOUD needs may only be covered for a short period in those counties with funding caps.
When asked about how much funding would ideally be provided for each person, the recovery program executive director (participant #5) continued, saying “I can’t really put a cap on that, because we don’t know how far down these people are. How can we put a cap on that? We wouldn’t do that somebody with cancer.” Because MOUD treatment can last for several years, depending on an individual's needs, a funding cap could limit MOUD treatment retention in more extreme ways than retention in a time-limited, 30-day inpatient program. A lack of funding acts as an accessibility barrier in this regard; MOUD treatment programs that cannot procure a sufficient amount of funding likely cannot support those with great financial need, which decreases MOUD treatment retention overall.
Insurance
Beyond lacking grant funding, insurance can act as a financial barrier to accessing MOUD treatment programs. One woman with OUD (participant #34) discussed an experience she had with her insurance provider:
Oh, yes, I feel like that [financial cost as a barrier to treatment access] is a definite thing, because I almost got switched off of my insurance, and it would have been $180 just to continue for six months. It would have been a lot of money. I feel like financial stuff, it has a lot to do with it.
SUD treatment professionals held a similar perspective, albeit from a different angle. For example, when discussing difficulties trying to place a patient into a residential treatment program where she could begin using MOUD, one nurse (participant #7) told us: It was just like, there was always a waiting list, and like I said, insurance wouldn't cover it. I think that yes, insurance has to recognize that it is as necessary as skilled nursing care is for some people or hospice or whatever, or home health nursing. They need to accept it more rapidly, I think.
Taken together, insights from both perspectives identify insurance, whether through costs associated with a lack of coverage or delays in coverage decisions, as a barrier to MOUD treatment access.
Travel Hardships
Travel hardships stood out as the most commonly cited barrier to accessing MOUD treatment across all three groups of participants’ accounts. Two travel hardships recurred frequently in the interviews: inadequate infrastructure and a lack of transportation.
Inadequate infrastructure
Regarding travel hardships, participants discussed obstacles associated with the routes people seeking treatment must sometimes take to get to MOUD clinics and treatment facilities. Affected women spoke the most to these difficulties during their interviews, detailing their experiences in traveling to seek treatment. One woman (participant #33), a methadone patient, told us about her experience with the bus: Taking the bus, that's an extra 20-minute walk from going there and then getting dropped off, and then it's an hour and a half. That's the last stop on their route. That's an hour and a half, an hour and a half and then 40 minutes of walking takes 3 hours just to get dosed, something that takes not even 30 seconds … I think a lot more people would be getting help going if it was in walkable distance.
She mentions how receiving methadone is a relatively quick process in and of itself, which stands in a sharp contrast to the three-hour journey it took to get to the nearest facility. If treatment access points were more common and located within a reasonable walking distance of those that needed to access them, then it would likely increase overall accessibility in addition to lessening travel time.
For some women seeking treatment, the route to the nearest facility itself is a significant barrier to access. One woman (participant #35) detailed her experience walking the path to the clinic she goes to: The only way they get from the bus stop to the clinic is walking on Route 51 on a path that's not a path. It was a service path that hasn't been paved. Basically, they're walking on the side of 51 where people have fell off the cliff into the creek. I'm talking about a 15, 20-foot drop into the creek. People have been hit and killed there.
When asked about this path further, the woman continued, telling us, “There's been people that have been hit with eggs, cartons of eggs. … People would come in and be covered in eggs, because people would leave their house and come throw that at people there.” When asked if this was specifically because people nearby knew that they were traveling to a treatment facility, the woman elaborated further: “Oh yes, because even my father-in-law will say, ‘Oh, there goes the people making the walk of shame’, and he doesn't even know I go there. Everybody knows what that place is because it stands out.”
The conditions that this participant and others in her area face in trying to access treatment are highly unsafe, both regarding the route itself and the actions of others along it—actions that may further contribute to the stigma felt and experienced by individuals seeking MOUD treatment. Taken together, the perspectives of both women shine a light on how insufficient infrastructure acts as an accessibility barrier.
Lack of transportation
In addition to mentioning barriers related to inadequate infrastructure, all participant groups asserted that the lack of transportation to and from MOUD treatment was a massive barrier to accessibility. When asked about barriers to MOUD treatment access, one criminal legal professional (participant #15), a state prosecutor, relayed some of her conversations with individuals with OUD: I know transportation has been talked about, ‘Oh, it's hard for me to get to the meetings. It's hard for me to get to the facility’. There's definitely difficulties depending on if you're in or outside the facility that I've heard of.
Responses across participants found that the loss of or restrictions on driver's licenses, inconsistent public transportation, and unreliable ride access emerged frequently as the root causes of the lack of transportation.
Grounding the issue of lacking transportation in personal experience, multiple women with OUD gave examples from their lives. One woman (participant #31) commented on the difficulty of making it to the clinic where she obtained MOUD, telling us, “This clinic is an hour away. I don't have a car. I don't have babysitters. It's been a real struggle for me, but I've been making it happen.” Another participant (#28) shared similar experiences: You have to be able to get to a clinic. In my experience, a lot of times what ends up happening is, you get in trouble, you lose your license, you can't drive 30 minutes to a clinic every day.
The second woman went on to specifically explain that these challenges had kept her from successfully completing MOUD treatment to reach recovery multiple times in the past. Together, these perspectives speak to lacking transportation as a barrier to MOUD treatment program access.
To try to navigate such barriers, many women discussed turning to unconventional travel arrangements, like driving illegally or calling on friends and family for help. One woman (participant #30) described her experience getting herself to her program: He [her boyfriend] would sit out in the car for freaking 90 minutes waiting on me in the dark, waiting for me to come out of those stupid things … I started driving illegally to them and just parking a few blocks away, even though I was under a suspension, because I didn't want to have to ask him to do that.
Another woman (participant #21) shared a similar perspective about seeking outside help in traveling to her treatment: If a friend drove me, I would try to give them like $5 in gas money if I had it. I did have help sometimes from my father. He was very restrictive in the beginning of sobriety. Financially, one, I was embarrassed at 33 years old to have to ask him for help. Sometimes my dad would help me financially if I could get an Uber or a Lyft or anything like that.
Both responses converge on how transportation shortcomings stand in the way of MOUD treatment access and point to potential negative feelings that may accompany having to make unconventional travel arrangements.
SUD treatment professionals also saw a lack of transportation impede the success of their own patients. One SUD treatment professional (participant #11), a counselor, shared: We had a patient in our facility where she struggled to be able to show up every day. We did get her connected with county transportation, but that doesn't run on Saturdays. She was missing her treatment on the weekends because she wasn't able to get here consistently. When she wasn't able to get to treatment, she was using to keep herself from going through withdrawal.
This counselor's response illustrates that unreliable, inconsistent, and limited transportation options not only prevent women seeking treatment from obtaining it, but they may also negatively influence overall health and wellbeing as a result.
Insufficient Availability
Finally, the severe lack of availability of MOUD treatment programs emerged as an important theme touched on by women as well as SUD treatment and criminal legal professionals. This topic differentiates itself from the others through its focus on the physical and material capacity of treatment programs as contributing to inaccessibility. Participants described both a demand far exceeding the supply of open spots in MOUD treatment programs as well as a limited number of existing treatment program facilities in general.
Limited options for treatment program placement
Participants from all groups highlighted limited options for placement in treatment programs as a significant barrier to MOUD treatment accessibility. The affected women, SUD treatment professionals, and criminal legal professionals described these constraints as treatment programs having long waitlists and few available spots at both the individual facility and county levels. One criminal legal professional (participant #13), a state prosecutor, told us, “I don't think that people realize how hard it is to get a bed at a treatment facility and how difficult it is to get involved in a reputable and productive intensive outpatient program.”
This point was further corroborated by the experience of a different criminal legal professional (participant #20), also a state prosecutor, when recounting trying to access treatment for a family member: I just note from my personal life, I was trying to find a facility for my brother-in-law, and I had to call so many people, and it was like, “Well, there's no bed. There's nothing. There's nothing. There's nothing.” He ended up needing to travel an hour away from the house to find this place that did dual diagnosis.
Even when individuals seeking treatment may have the financial means and the transportation required to partake in their respective programs, without open placements, they may be unable to access the care they desire. Moreover, when placements are found, individuals express feeling ‘lucky.’ One woman (participant #28) told us, “It was just by chance and luck that we were able to get him into this place,” when sharing how she helped get someone she knew into a treatment facility.
The perspective from SUD treatment professionals further supports the argument that limited options for program placements are standing in the way of MOUD treatment access. One SUD treatment professional (participant #5), a case manager, described these difficulties in greater detail: Right now in our county, we have 100 beds. That's it, that's all and that's a dual diagnosis facility. You take 50 and 50, you've got 50 drug and alcohol beds and 50 mental health beds. That's not enough. A lot of our people when they call to make appointments, it's a six to eight-month waitlist just to see a therapist or a psychiatrist.
A lack of spots in inpatient and outpatient treatment facilities does not just affect MOUD access because it is a potential route to MOUD. MOUD clinics themselves may also refer patients to inpatient and outpatient treatment facilities when they feel that their patients need a higher level of care. For some women, then, being able to continue MOUD hinges on being able to access that higher level of care. Being unable to find an inpatient bed may render them unable to continue at the MOUD clinic as well. One methadone clinic counselor (participant #8) told us how they “tried to get someone in treatment today, and there was a three-month waiting list to get in one facility.” Insufficient treatment facilities, then, can threaten women's ability to access MOUD not just through those facilities but through MOUD clinics as well.
Discussion
Overall Findings
Utilizing in-depth interviews from multiple perspectives, this study identified accessibility barriers to MOUD treatment uptake and retention. Emergent themes fell into three domains: financial barriers, travel hardships, and insufficient availability. Of these, travel hardships were the most prominent, with the lack of transportation discussed especially in detail by affected women, criminal legal professionals, and SUD treatment professionals alike. Participants discussed the role of insufficient availability of treatment facilities in hampering MOUD treatment access and retention, and SUD treatment professionals and affected women discussed the influence of financial barriers.
Financial Barriers and Potential Solutions to MOUD Treatment Access
Even with a massive opioid epidemic, funding continues to be an issue. SUD treatment professionals and women with a lifetime history of MOUD use described financial barriers as impeding treatment access, with both groups discussing the negative impacts of limited coverage, high out-of-pocket costs, and consequences associated with slow rates of treatment authorization as obstacles to uptake and retention. If insurance-related barriers to MOUD treatment accessibility are minimized, then the gap between women who need MOUD treatment and those who receive it may shrink. On a broad scale, existing research makes a case for public and private insurance plans recognizing evidence-based MOUD treatment as an essential health benefit and requiring its coverage (Haffajee et al., 2018; Madras et al., 2020) to increase overall accessibility and likely aid in faster acceptance times to help close the gap between needing and receiving care.
Targeting affordability itself, another solution is to lower out-of-pocket MOUD costs. One study examining the relationship between out-of-pocket costs of buprenorphine and treatment retention found that when patient cost-sharing was lower, MOUD retention and adherence rates were higher among insured patients (Dunphy et al., 2021). Methods like telemedicine and dispensing medications at pharmacies may also be effective approaches to reduce costs, increase access, and address barriers connected to transportation (Ostrach et al., 2022; Riedel et al., 2021). Ultimately, to aid in developing more accessible, effective interventions, future work in addressing these issues should advocate for greater coverage at the policy level as well as investigate the feasibility of lowering MOUD treatment costs.
The interplay between gender, justice involvement, and financial barriers
Regarding financial barriers, some of the affected women spoke about high out-of-pocket costs should insurance delay or refuse to cover their MOUD treatment. This can place a great burden on a subset of the population that earns less than men on average (Aragão, 2023) in tandem with increased difficulties in obtaining and maintaining employment following criminal legal system involvement compared to men (Curcio & Pattavina, 2018). The financial cost of criminal legal system involvement itself compounds this issue; on top of paying for everyday expenses, affected women often must pay off fines, court fees, cash bail, and other applicable bills from the criminal legal system (Servon et al., 2021). While men can and do also experience financial barriers to MOUD treatment, employment and monetary disparities arising from the intersection of gender and having a lifetime history of criminal legal system involvement likely exacerbate the impact on criminal-legal involved women, such as the high out-of-pocket costs reported by our participants. Beyond addressing costs themselves, there is a great need for structural changes to reduce intersectional disparities, such as initiatives aimed at eliminating the gender pay gap and discriminatory hiring practices against women with criminal records.
Transportation Barriers and Potential Solutions to MOUD Treatment Access
Among all groups interviewed, lacking transportation access emerged as the most prominent barrier to MOUD treatment access. Lived experiences discussed in the interviews reflected difficulties associated with not having a personal vehicle or a license, the unreliability of alternative arrangements, and feelings of embarrassment, burdening others, and shame around asking other people for rides to and from treatment facilities. Recent research stemming from changes made during COVID-19 offers several promising solutions for addressing the problem of transportation-related inaccessibility to MOUD treatment. For example, in the wake of COVID-19, many MOUD programs adapted to more flexible policies, such as delivering medications to patients’ homes, allowing telehealth prescriptions of buprenorphine, and allowing a greater number of take-home methadone doses. Early evidence supports these changes’ utility, pointing to greater treatment retention, greater feelings of self-efficacy, and lesser burdens for patients (Krawczyk et al., 2023). Moreover, interviews with individuals who use drugs as well as providers and government officials have found that being able to have greater flexibility around treatment delivery and take-home doses helps reduce transportation needs, lessen travel times to and from clinics, and expand the reach of MOUD treatment overall (Walters et al., 2022).
Beyond treatment delivery flexibility, further studies evidence the provision of free bus passes, rideshare vouchers, and prepaid coverage for taxi services by treatment facilities as supporting MOUD treatment access (Clingan et al., 2023; Eger et al., 2022). While they may not be able to address lengthy travel times, such options likely mitigate inaccessibility caused by limited transportation options and provide opportunities for individuals with OUD to better obtain MOUD treatment; eliminating the need for personal transportation and concerns associated with finding and funding a reliable option seems like an impactful step toward bolstering MOUD treatment accessibility. Altogether, insights from these studies support the argument that greater attention from policymakers, practitioners, and researchers should be directed toward developing evidence-based MOUD treatment interventions that offer various modalities, alleviate burdens associated with transportation, and support opportunities for flexible take-home dosages.
The interplay between gender, justice involvement, and travel hardships
While transportation inaccessibility likely impacts all individuals with OUD, our findings indicate that this barrier can be particularly intensified among criminal-legal involved women. Participant responses from affected women as well as SUD treatment and criminal legal professionals touched on this in discussing heightened experiences of barriers for women who are mothers. Although men also care for children, women are often disproportionately responsible for the care of children. Elsewhere, we have discussed how women's roles as mothers can pose barriers to accessing MOUD treatment, as they may face difficulties finding childcare during their appointments (Apsley et al., 2024). If they cannot find childcare, then they must not only find a way to transport themselves to MOUD treatment but also bring their children, which adds more complexity to the issue of treatment accessibility (Gao et al., 2023; Huhn & Dunn, 2020). Finding childcare is especially difficult for criminal-legal involved women, as their disparate rates of employment can further impede their ability to secure childcare (Apsley et al., 2023; Curcio & Pattavina, 2018), further complicating issues of transportation inaccessibility. This obstacle seems to enhance the utility of flexible policies in MOUD treatment programs and highlights the need for policies about gender equity for treatment access. Home delivery, telehealth prescriptions, and increased numbers of take-home doses of methadone likely reduce the burdens of finding both transportation and childcare (Krawczyk et al., 2023). Future research could examine the effectiveness of these changes for women and investigate options for developing programs related to child-friendly transportation or childcare during MOUD treatment to support overall accessibility.
An additional facet of the interplay between gender, criminal legal system involvement, and transportation-related barriers touched on by participants involved experiences of stigma. Elsewhere, we have discussed how gendered expectations and stigma interacted with other types of barriers to impede access to MOUD treatment among our participants (Jones et al., 2024; McCracken et al., 2024; Strong-Jones et al., 2024). Within the present study, this manifested through women experiencing acts of discrimination stemming from stigmatizing attitudes around individuals seeking MOUD treatment. Specifically, one affected woman detailed how the community would intentionally throw eggs at individuals traveling the only road, an unpaved service path, to the treatment facility, with her own father regarding the path as “the walk of shame.” Just as women with OUD already face stigma around obtaining MOUD treatment (Fiddian-Green et al., 2022), criminal-legal involved women already face stigma around their criminal legal system involvement (Rutter & Barr, 2021)—both with societal associations drawn between each identity and being a neglectful mother, failing in their patriarchal role as a caregiver, and sex work. When criminal legal system involvement intersects with gender, evidence from our study seems to indicate a compounded effect of stigma for women who are simply trying to access MOUD treatment. This not only aggravates the impact of travel hardships as a physical accessibility barrier among criminal-legal involved women with OUD but also emphasizes the need for varying modalities and a significant shift in societal attitudes toward this population and MOUD treatment overall.
Insufficient Availability Barriers and Potential Solutions to MOUD Treatment Access
Participants from each group discussed the role of limited options for placements in treatment programs as a significant accessibility barrier to MOUD treatment. Affected women, criminal legal professionals, and SUD treatment professionals spoke to the great “luck” required in finding an open placement in a treatment program. With sufficient availability, finding a placement for an individual with OUD would not require luck—it would be the norm. Because so many of the women we met first began MOUD through other types of facilities, such as inpatient treatment centers, being unable to find an opening in an inpatient facility would mean losing out on a potential referral for MOUD; a lack of spots at these programs would imply that women who are turned away may never be referred to begin MOUD treatment. A solution to this barrier could be to increase availability through developing more facilities for both residential and outpatient treatment programs. An analysis of state-level trends offers evidence in support of this, for increased availability of MOUD treatment at facilities offering outpatient and residential treatment was significantly associated with increased MOUD utilization (Solomon et al., 2022). Although a greater number of facilities would likely alleviate the barrier of insufficient availability of treatment, it is a difficult solution to enact; it is likely not as feasible as solutions addressing other facets of inaccessibility. Another alternate solution would be to increase access to MOUD through other settings—such as care navigation programs that direct people seeking recovery to providers who can prescribe buprenorphine. Finally, evaluations of programs should include a gender focus to ensure equity and bring to light more potential obstacles to address in future policy and practice.
The interplay between women with OUD, justice involvement, and insufficient availability
The issue of limited options for treatment program placement is not unique to criminal-legal involved women; however, it may be more pronounced in that criminal-legal involved women with OUD may see a greater scarcity of programs that meet their unique treatment needs. These needs extend beyond treating OUD itself to involve trauma-informed care (Saraiya et al., 2024), childcare and/or prenatal care (Apsley et al., 2023), and integrated care for women's mental health (Marsh et al., 2021). As women have unique needs, it is probable that MOUD treatment programs that address some or all of these components are in shorter supply than the already-insufficient number of MOUD treatment programs in general. To mitigate this barrier for criminal-legal involved women in particular, future research should strive to develop, implement, and evaluate MOUD treatment programs that take their unique needs into account.
Limitations
When interpreting the results of this study, it is important to recognize its limitations. One such area is generalizability. With its focus on women with OUD, criminal legal professionals, and SUD treatment professionals in P.A., we did not intend for this qualitative study to be representative of all groups on a broad scale. While this impedes generalizability, researchers globally can replicate this study design for their regions of interest and further grow the body of literature in this area. In this regard, there is great utility in this work in how it could shape the development of more effective, accessible MOUD treatment interventions that could benefit all women with OUD.
Another limitation to consider in this study is its design. Given that this is a qualitative interview study, findings rely on self-report, which may be influenced by social desirability bias. In this regard, participants in all groups may have felt inclined to discuss their lived experiences in a more positive, favorable manner to come across as socially desirable to the interviewer. Additionally, the modality of the telephone interview might have limited findings, for it could have obscured important nonverbal cues and body language. While the telephone modality may act as a weakness in this matter, it could also be a strength, for the anonymity that comes with not being face-to-face may mitigate social desirability bias and leave participants feeling more comfortable to openly share their experiences.
An additional limitation of the study design was that it aimed to analyze whether accessibility barriers to MOUD treatment were intensified among women in particular. While our findings may apply to men, we cannot draw comparisons between perspectives by gender, nor did we likely identify all barriers to access to MOUD treatment. Despite these constraints, this study's insights gleaned from examining women with OUD and the SUD treatment and criminal legal professionals who serve them are valuable perspectives that can help inform future research on potentially gender-specific physical accessibility barriers to MOUD treatment as well as identify points of convergence and divergence across individuals with differing gender identities.
Conclusions
In conclusion, triangulating insights from the lived experiences of women who have received MOUD treatment, SUD treatment professionals, and criminal legal professionals provided a comprehensive understanding of accessibility barriers facing women seeking MOUD treatment. Taken together, these perspectives shed light on issues standing in the way of treatment uptake and retention and offer paths forward to developing solutions to address these issues in practice and policy. Centering the voices of women with OUD, our study's results make the strongest case for addressing hardships related to travel. To best serve women who seek MOUD treatment, we suggest the consideration of solutions such as allocated transportation, gas mileage reimbursement, bus passes, and flexible take-home treatment options to mitigate transportation-related barriers to accessibility. This might be especially helpful for criminal-legal involved women who tend to be more likely to face financial instability, lack transportation, and experience more barriers to MOUD treatment accessibility overall as they work to reintegrate into their communities (Smith et al., 2020). Moreover, future research should triangulate the perspectives of these groups in other regions of interest to contribute to the wealth of knowledge on accessibility barriers to MOUD treatment and inform the development of relevant solutions and more effective treatment programs.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Drug Abuse (grant number: K01DA051715).
