Impact of social determinants on opioid use disorder treatment engagement after release from jail: a case note content analysis

Abstract Background Despite strong evidence that sustained engagement in OUD treatment reduces overdose risk, individuals leaving jail face substantial barriers to initiating and maintaining care. Motivational interventions such as motivational interviewing (MI) are commonly used during this reentry period to enhance engagement. While MI effectively targets internal readiness to change, it is less clear how such approaches operate in the presence of persistent structural barriers. This study explores how social determinants of health (SDOH) factors shaped participant engagement during a motivational intervention following release from jail. Methods We conducted a qualitative content analysis of 500 clinical case notes generated by personnel facilitating linkage to treatment for participants (n = 155) with OUD and recent criminal legal system involvement. Notes were generated during a clinical trial (NCT04365920, Registered 2019-12-19) of Recovery Management Checkups (RMC); RMC is an evidence-based intervention that uses ongoing “check-up” meetings grounded in MI to link individuals to substance use treatment and support their treatment retention and recovery, or re-link them to treatment as needed. Case notes were coded according to a framework adapted from the Centers for Disease Control and Prevention’s SDOH domains, and categorized as either facilitators or barriers to participants’ treatment engagement. Results Findings highlighted economic stability as the most frequently cited barrier to treatment engagement, particularly housing instability, unemployment, and lack of transportation. Other barriers included poor physical health, legal constraints, and negative social influences. Facilitators included support from family and community, healthcare access, mutual aid involvement, and religious engagement. Conclusions Results revealed how social and structural barriers impede treatment engagement within the context of a motivational-based linkage intervention. These findings underscore the need for integrated approaches that acknowledge both motivational readiness and the structural realities of participants' lives. Interventions may benefit from pairing motivational strategies with practical supports (e.g., transportation, housing navigation, harm-reduction planning). Given the challenges intervention staff face when attempting to help individuals in low-resource environments, implications for supporting personnel delivering motivational strategies are discussed.