Factors associated with primary care, behavioral health, and emergency department utilization among men with opioid use disorder and criminal-legal involvement: a cross-sectional study

Background: Men with both criminal-legal involvement (CLI) and opioid use disorder (OUD) experience high overdose risk and substantial barriers to evidence-based treatment. However, the intersection of both conditions remains understudied, and less is known about factors associated with healthcare utilization among individuals with OUD and CLI. This study examined individual- and neighborhood-level factors associated with service utilization among this population. Methods: We conducted a cross-sectional analysis of a de-identified, linked dataset (2015-2019) combining electronic health records from an urban safety-net healthcare system, local prison records, and neighborhood-level data. The sample included adult men with both CLI and documented OUD (n = 159). Outcomes were any primary care, behavioral health, and emergency department (ED) use. Guided by the Andersen Behavioral Model for Vulnerable Populations, we estimated Firth bias-reduced logistic regression models. Results: Over the study period, 64.8% had at least one primary care visit, 62.9% had at least one behavioral health visit, and 95.0% had at least one ED visit. Need-related factors showed the most consistent associations with service use. Anxiety disorders and non-opioid substance use disorders were associated with higher odds of both primary care and behavioral health use; Few factors were associated with ED utilization. Predisposing and enabling factors, including age, race/ethnicity, and insurance type, were not significantly associated with service use. Conclusions: In this safety-net population, healthcare utilization was common and was primarily associated with behavioral health need rather than predisposing or enabling factors. ED use was very common and not strongly associated with measured individual or neighborhood-level factors, suggesting that emergency care may function as a point of entry into the healthcare system for this population. These findings suggest that, in this high-risk population, clinical need may play a more important role in influencing service use than traditional structural factors.