Social Determinants of Health and 1-Year Buprenorphine Initiation Among Justice-Involved Veterans

Importance: Justice-involved veterans (JIVs), with incarceration history or other legal involvement, experience high opioid use disorder (OUD) rates but low uptake of medications for OUD (MOUD). Given its common use, assessing the associations of buprenorphine medication for OUD (hereafter buprenorphine) with social determinants of health (SDOH) is critical. Objective: To assess the association between SDOH and buprenorphine initiation, and to estimate the 1-year initiation rate across demographic subgroups. Design, Setting, and Participants: This nested case-control study obtained data from the Veterans Health Administration (VHA) national electronic health record system. JIVs with an OUD diagnosis receiving VHA care between fiscal years 2015 and 2020 were included. Cases were OUD episodes with buprenorphine initiation, which were matched 1:4 with control episodes without initiation. The unit of analysis was the OUD episode, a period of 1 year following initial OUD diagnosis. Data analyses were conducted in August 2025. Exposures: Exposure to defined SDOH domains from the index date (first OUD diagnosis) until buprenorphine initiation date, 365 days after index date, or study end date, whichever occurred first, compared with no exposure. Main Outcomes and Measures: The primary outcomes were the 1-year buprenorphine initiation rate and the association of SDOH with initiation. Conditional logistic regression adjusted for clinical and demographic covariates was used to estimate adjusted odds ratios (AORs) and 95% CIs for the association between buprenorphine initiation and 8 domains of SDOH extracted from structured data and unstructured clinical notes. Results: Among 13 321 new OUD episodes in 12 511 JIVs, 1372 were case episodes (involving 1279 male JIVs [93.2%]; mean [SD] age, 40.8 [12.8] years) matched with 5436 control episodes (involving 5334 male JIVs [98.1%]; mean [SD] age, 39.2 [12.1] years). The 1-year buprenorphine initiation rate was 11.16% (95% CI, 10.63-11.71). Among SDOH domains identified from combined structured and unstructured data, violence (AOR, 0.31; 95% CI, 0.25-0.38), nonspecific psychosocial problems (AOR, 0.35; 95% CI, 0.30-0.40), food insecurity (AOR, 0.36; 95% CI, 0.30-0.44), and transitions of care (AOR, 0.50; 95% CI, 0.35-0.71) were associated with lower odds of buprenorphine initiation. Additional factors included barriers to care (AOR, 0.54; 95% CI, 0.45-0.64), financial problems (using structured data: AOR, 0.33; 95% CI, 0.28-0.40), and social problems (using structured data: AOR, 0.58; 95% CI, 0.44-0.79). Conclusions and Relevance: This case-control study found that buprenorphine initiation remained low and that multiple SDOH domains acted as significant barriers to treatment uptake among JIVs. The findings emphasize the importance of systematic SDOH screening and interventions to address barriers to buprenorphine initiation.