Statewide implementation of MOUD in jails: aligning barriers and strategies in the quest for acceptability and feasibility

In 2019, the Maryland legislature passed a bill mandating that county jails provide medications for opioid use disorder (MOUD) to incarcerated persons. While vast scholarship points out common barriers to MOUD implementation in carceral settings, and some also depict facilitators of implementation, largely missing from these evaluative studies is a clear understanding of the process of identifying barriers and identifying ways to overcome these barriers (i.e., strategies). To address this scholarly gap, we conducted in-depth interviews with jail and community health leaders in Maryland counties in 2022 and follow-up interviews one year later, after the January 2023 compliance deadline. These leaders were participating in a Learning Collaborative as part of a larger comparative effectiveness trial comparing extended-release buprenorphine versus extended-release naltrexone. In interviews, participants focused their discussion on nine main implementation barriers and associated strategies, including: 1) staffing shortages, 2) financial barriers, 3) staff buy-in, 4) concerns of medication diversion, 5) space, 6) client buy-in, 7) intra- and extra- organizational relationships, 8) peer support, and 9) leadership. Our analysis suggests that while some barriers to MOUD implementation were mitigated through targeted strategies, others remained persistent or worsened. Notably, it appears that some important and salient challenges were ignored (or at least, not acted on) and sometimes leaders came up with strategies that were targeting non-existent (or not important and salient) challenges. Specifically, we find that while barriers including staff buy-in, client buy-in, space concerns, and fears of medication diversion lessened as strategies including staff education, client education, space accommodations, and diversion protocols increased, others, including staffing shortages, financial constraints, strained intra- and extra-organizational relationships, and leadership challenges, were particularly persistent and even intensified over time. Further, comparing barrier and strategy frequencies revealed critical mismatches, where the most frequently cited barriers (e.g., staffing and medication diversion) were met with disproportionately fewer strategies while lesser cited barriers (e.g., client buy-in) were frequently innovated on. This work identifies insights that may inform carceral-based MOUD efforts more broadly, especially as more states consider legislation mandating carceral-based MOUD.