Access to medications for opioid use disorder among primary care patients with homeless experience in the Department of Veterans Affairs.

Abstract

Primary care settings tailored for persons with experience of homelessness (PEH) could enhance opioid use disorder treatment delivery, but evidence is lacking. To examine medication treatment for opioid use disorder (MOUD) among PEH who received homeless-tailored primary care in the Department of Veterans Affairs (VA). Receipt of MOUD was assessed from electronic health records among VA primary care patients with experience of homelessness and OUD in 2016-2020. We estimated the proportion who received MOUD over time and applied mixed effect Poisson models with entropy balance weighting to estimate differences in MOUD by primary care type (homeless-tailored vs. mainstream). Secondary analyses examined the consistency of findings across 18VA service regions. The percentage of eligible PEH (n = 45,864) receiving any MOUD rose from 42.1 % to 51.0 % over time. Half (51.3 %) of those initiating MOUD received > 30 days MOUD over one year. In unadjusted models, the proportion receiving MOUD was slightly higher in homeless-tailored primary care, compared to mainstream primary care (48.8 % vs 46.4 %, Unadjusted Incidence Rate Ratio=1.09, 95 % CI=1.03-1.16). After covariate adjustment, there was no statistical difference between groups (Adjusted IRR=0.97, CI=0.92-1.02). This proved broadly consistent across VA service regions. Concomitant with a national VA initiative to tailor primary care services for PEH, half of diagnosed patients received MOUD. Yet evidence of durable treatment was low, and the homeless-tailored clinics did not outperform mainstream clinics. Efforts to tailor primary care for PEH may require specialized addiction staffing and implementation support to improve MOUD care in these settings.