Implementing a Mobile Clinic for Opioid Use Disorder Treatment in an Urban and Rural Context

Abstract

Different barriers inhibit access to medications for opioid use disorder (MOUD), such as transportation limitations or reduced geographic proximity to providers. Mobile clinics for opioid use disorder (OUD) treatment provide opportunities to expand access to MOUD. There is limited literature describing the lessons learned and barriers faced when implementing a mobile clinic for OUD treatment in an urban and rural context. This paper focuses on 2 mobile clinics: Prevention Point Medical Mobile Unit, which was implemented in an urban location in Pittsburgh, Pennsylvania, and Addiction Treatment: Linking Access & Services, which was implemented in a rural location in Robeson County, North Carolina. The focal points of this paper include (1) community engagement, (2) community environment, (3) cost, (4) low-barrier MOUD, (5) mobile unit, (6) partnerships with local pharmacies, and (7) weather. With direct insight from providers who led programs in 2 different geographic contexts, this paper offers valuable guidance and lessons learned for those considering initiating mobile clinics to increase access to OUD treatment.

Highlights

• Mobile clinics for opioid use disorder (OUD) treatment expand access to medications for opioid use disorder (MOUD).

• This paper discusses lessons learned from implementing 2 separate mobile clinics for OUD treatment in a rural and urban context.

• This paper discusses topics such as (1) community engagement, (2) community environment, (3) cost, (4) low-barrier MOUD, (5) mobile unit, (6) partnerships with local pharmacies, and (7) weather.

• Information presented in this paper may assist other providers with developing mobile clinics for OUD treatment.

Introduction

Increasing access to opioid use disorder (OUD) treatment, including gold standard medications for OUD (MOUD), is a public health priority. Unmistakably, OUD and opioid-related overdoses continue to remain a significant public health concern. With over 6 million individuals meeting the criteria for an OUD and over 81 000 fatal opioid-related overdoses in 2022,^1,2 it is critical to rapidly and effectively expand access to OUD treatment.

The social determinants of health that inhibit access to OUD treatment also impact the expansion of access to these services. Geographic access to in-person OUD treatment remains a prominent barrier. ³ Regarding in-person health care visits, geographic access may be described as the ability to engage with services not hindered by transportation or proximity burdens. ⁴ Barriers to geographic access may present themselves differently, including but not limited to no OUD treatment in close geographic proximity, an individual lacking reliable transportation, safety concerns related to traveling to and from treatment, no transportation services offered by treatment facilities, and individuals lacking familiarity of what treatment services are locally available.^5-10 These barriers could be faced in both urban and rural geographic contexts. To address the geographic barriers many individuals face, mobile clinics for OUD treatment often serve as salient community, county, and even state-level interventions.

Mobile clinics for OUD treatment have been identified as expanding treatment access, ¹¹ providing linkages to other needed services,^12-14 being associated with reduced arrests, ¹⁵ and providing services that reduce the harms associated with illicit opioid use, such as opioid-related overdoses.^16,17 These beneficial outcomes have been identified in both urban and rural contexts with the concept of meeting the person where they are. ¹⁸ As such, mobile clinics can often serve communities that face inequitable access to services,^19-24 such as Indigenous populations ²⁵ and individuals recently released from the carceral systems.^12,26,27 Each of these mobile clinics may operate in vastly disparate communities with varying political contexts and perspectives from lawmakers and local citizenry on OUD.^28-33 Further, in the United States, variability in legal policies related to MOUD is identified across different states.^34,35 Despite operating in disparate contexts, mobile clinics for OUD can “meet people where they are” and dispense lifesaving treatment. With all programs, guidance regarding implementation is a prominent consideration for mobile clinics for OUD treatment.

There is limited literature describing the lessons learned and barriers faced when implementing a mobile clinic for OUD treatment in an urban and rural context. This current paper aimed to add to the literature by describing the real-world implementation considerations of 2 separate mobile clinics for OUD treatment. This paper focuses on 2 separate mobile clinics, the Addiction Treatment: Linking Access & Services (ATLAS) program, ³⁶ which was implemented in a rural location in Robeson County, North Carolina, and Prevention Point Medical Mobile Unit, which was implemented in an urban location in Pittsburgh, Pennsylvania. ³⁷ This paper’s authors include members of the 2 teams of providers (physicians, nurse practitioners, and physician assistants) involved with implementing these programs that provide buprenorphine/naloxone. As the authors of this commentary-style paper, these 2 teams present their perspectives on essential factors related to implementing these programs. This paper describes factors related to (1) community engagement, (2) community environment, (3) cost, (4) low-barrier MOUD, (5) mobile unit, (6) partnerships with local pharmacies, and (7) weather. By highlighting each of these 7 concepts, aspects of this commentary can be directly accessed to provide guidance for other mobile clinics for OUD in the planning or implementation stages. It should be noted that methadone is a medication for OUD, which is not available on either of the 2 mobile units due to federal regulations around how it can be prescribed and where it can be dispensed.

Community Engagement

Lack of community support has been identified as a barrier faced by mobile clinics for OUD treatment. ³⁸ However, beneficial relationships with the community and collaborations with critical stakeholders in the area can facilitate the operation of these programs. ³⁸ During the planning stages of the ATLAS program, critical stakeholders were identified and participated in a town hall discussion with the ATLAS program team, including representatives from the county commissioner’s office, sheriff’s office, local judicial system, and local medical providers. These critical stakeholders identified the community’s needs and provided suggestions about the mobile treatment clinic, preferred parking locations for the mobile unit, and the best days/times to encounter individuals needing OUD treatment services. The ATLAS program team also met with members of the Lumbee tribe, a state-recognized Indigenous American group with a significant population in Robeson County. ³⁹ During each meeting, the critical stakeholders identified trust as a prominent aspect of initiating the ATLAS program. In Robeson County, NC, the ATLAS program team was seen as “outsiders,” therefore, maintaining consistency, following through on tasks, and incorporating community feedback throughout the planning and implementation stages were prominent aspects of building trust and rapport with the community. ⁴⁰

Prevention Point Medical Mobile Unit was created through an initiative from a Syringe Service Program (SSP), Prevention Point Pittsburgh (PPP). PPP was created over 25 years ago and has been servicing communities that lack critical resources for people who use drugs and have high overdose rates. By establishing a medical mobile unit within an existing SSP, this clinical program was able to collaborate effectively within an established community setting. This mobile unit was able to build trust with the community by approaching the provision of MOUD through a harm reduction lens, by ensuring clinical care met patient expectations and their ability to engage in care. Additionally, this mobile unit provides wound care at all sites. Due to historic mistrust within this community due to stigma in health care settings and poor treatment of this population, it was imperative to build trust through collaboration with the SSP and provide health care that aligned with the needs of this population. Additionally, the PPP Mobile Unit established connections to local community organizations and health care systems to ensure continuity of care across the continuum. Overall, all services should be provided in a non-stigmatizing manner to ensure continued engagement. ⁴¹

Community Environment

A prior qualitative study found that patients preferred the relative speed of receiving MOUD in mobile clinics over a brick-and-mortar office. ⁴² Alongside speed, providing an environment where individuals feel comfortable engaging in treatment services is imperative. Several community members in Robeson County, NC, described safety as a major concern, acknowledging violence in the community and a lack of safety for Indigenous persons. Since the majority of people receiving care from the ATLAS program are either uninsured that receive Medicaid, or are eligible for Medicaid, community members suggested the ATLAS program provide services in the parking lot of a centrally located government building that many would be familiar with. The community felt this location would also be perceived as a safe area to receive services without fear of violence. Having a representative from the Sheriff’s office present in an unmarked law enforcement vehicle was a condition to operate the MOUD mobile clinic safely in this rural county.

Prevention Point Medical Mobile Unit established mobile clinics near the existing SSP mobile sites. These were created in 4 areas highly impacted by both overdoses and limited access to health care resources. The mobile unit sites were established alongside the SSP, which allowed for regular collaboration between both programs.

Similar to the ATLAS program, the community served by Prevention Point Medical Mobile Unit is also impacted by physical violence (ie, gun violence) and harmful social determinants of health, prompting some to engage in survival sex or substance trading. In contrast to the ATLAS program, the Prevention Point Medical Mobile Unit found that parking near law enforcement was challenging since some individuals who were in need of services had prior negative experiences with law enforcement and some had active warrants, making it less likely that these persons would engage in treatment.

Cost

It is estimated that the costs of implementing a mobile unit may range from $150 000 to $250 000.^43,44 This estimate was accurate to the costs of purchasing the ATLAS program’s mobile unit, which was ~$225 000. Other necessary items such as canopies, tables, printers, WiFi, and chairs may be estimated at $2000. Other costs include 2 generators and set up costs. The overall supplies needed after purchasing the mobile unit may cost ~$25 000. Similarly, maintenance may also cost ~$25 000. Depending on the mobile unit’s design, it may be unsafe for staff to travel in the rear clinic area. Therefore, team members must provide their own transportation, which should also be factored into the cost, especially if the clinic travels a significant distance. Prevention Point Medical Mobile Unit startup costs were ~$200 000, which was paid for by grant funding. While the initial costs of the van and startup were supported by grant funding, the unit became its own entity that was self-sustainable through billing. Many individuals that encountered Prevention Point Medical Mobile Unit were uninsured, and the mobile unit team was able to assist them in obtaining insurance to increase their access to lifesaving MOUD and other needed medical services. Additionally, Prevention Point Medical Mobile Unit received grant funding to provide MOUD to uninsured persons.

Low-barrier MOUD

Both the ATLAS program and Prevention Point Medical Mobile Unit identified numerous factors presented by community members, community stakeholders, and recipients of care to truly make services low barrier. A common theme identified was the concept of freedom from judgment. It is imperative to present services in a manner that is non-stigmatizing and nonjudgmental. Health care discussions are focused on patient perspectives and desires rather than provider expectations. In these discussions, language is open, encouraging, and positive. All success, even small wins such as entering the mobile unit, is celebrated. It is critical to meet patients where they are in the care continuum and discuss desires around treatment and substance use around client expectations and abilities. It is also important for individuals to guide their own care, and all services should be patient-centered. Another addressable barrier to MOUD is a lack of reliable transportation. Therefore, both the ATLAS program and Prevention Point Medical Mobile Unit incorporated strategies to use ride hailing-apps or local transportation services to ensure that individuals could access care.

Mobile Unit

The design of the mobile unit is critical to providing comprehensive care for MOUD while also maintaining accessibility. Both mobile units incorporated a small restroom for patients, both for collecting samples for urine drug screens and for general use. Additionally, Prevention Point Medical Mobile Unit included a clinic style bed to ensure patient comfort. This mobile unit focused on a compact design to ensure all necessary items could be stored but that the mobile unit could also fit compactly into small parking spaces. Additionally, flyers and informational pamphlets were included on the mobile units for patients to browse and access critical resources for intimate partner violence services or food access. Wound care items, antibiotics, and vein lights were also identified as useful items to include on the mobile unit. Other useful components in these mobile clinics include blood draw laboratories, an office space to speak with patients, and a backup generator.

Partnerships With Local Pharmacies

The ATLAS program and Prevention Point Medical Mobile Unit identified the need to improve local access to buprenorphine/naloxone. To improve access, partnerships were created with local pharmacies. In Robeson County, NC, there was an overall lack of pharmacists filling prescriptions for buprenorphine products. The ATLAS program addressed this barrier by establishing an initial relationship with 1 pharmacy that agreed to fill their prescriptions. Over time, this local pharmacy began increasing the number of buprenorphine product prescriptions filled by other community providers. After establishing their local reputation as a reputable treatment provider for OUD services, the ATLAS program was able to build a relationship with an additional community-based, independent pharmacy. Imperative to these relationships being successful was frequent and open communication. Another initiative to establish rapport in the community was providing a local lecture series about the treatment of OUD targeted at physicians, pharmacists, and other care providers. The ATLAS program used these lecture series to engage local providers and identify potential local stigma about buprenorphine prescribing.

Prevention Point Medical Mobile Unit identified that many local pharmacies refused to dispense buprenorphine/naloxone despite the high rates of overdoses in the area. Discussions with recipients of services identified that many persons felt stigmatized and unwelcomed by many of the local clinicians and pharmacies. To address these systemic barriers to services, Prevention Point Medical Mobile Unit sought pharmacies that were welcoming and accepting of treating individuals with OUD. Agreements were developed with these pharmacies to “back bill” for services (ie, pay for received services in the future) since many individuals receiving care were uninsured. Multiple pharmacies located near the mobile sites declined to collaborate with this program due to concerns about distributing large amounts of buprenorphine/naloxone and concerns about the patient population. However, pharmacies willing to do both were identified and served as stalwart partners in ensuring individuals in need can receive MOUD.

Weather

Protocols should be developed to plan for inclement weather. The best way to prepare for the weather depends on the specific geographic context. Each season brings new challenges to providing services.

The ATLAS program encountered a scorching summer in which the generator malfunctioned. Air conditioning units inside of the mobile unit were relied upon to address the high summer temperatures. To increase the comfort of individuals outside of the mobile unit awaiting an appointment, fans, misting systems, and shaded areas using canopies were included as remedies. However, the wind drastically impacted these same canopies during the fall. With the wind as a newfound adversary to providing mobile OUD treatment, the ATLAS program was adapted by purchasing heavy-duty canopies that were strengthened by weights, auger stakes, and a ratchet system to provide formidable resistance against the wind. The ATLAS program encountered a prominent decrease in patients in the winter due to the cold weather. People seeking services often waited in their cars to avoid waiting outside for services at the mobile OUD clinic. Multiple heaters were added to address the low temperatures of the winter, which then created a blown fuse in the breaker box because of the numerous electrical currents. Zippers were also added to the canopy to quickly enclose the space due to the cold temperatures. The spring also presented specific barriers to the ATLAS program, such as copious amounts of rain, which required extra precaution for individuals entering and exiting the mobile unit to avoid slips and falls. Another concern for the ATLAS program in the spring was hail.

Prevention Point Medical Mobile Unit identified the need to be adaptable to adjust to the impact of various weather patterns. It is imperative to consider where individuals in need of care are coming from and how they will get there. Certain weather patterns will undoubtedly serve as a barrier to them accessing needed services. To address this, Prevention Point Medical Mobile Unit ensured adequate access to water and shade through the use of pop-up tents. Additionally, this program created protocols to determine “remote” clinic days to limit patient wait times during extreme weather conditions, in both excessive heat and excessive cold. During these “remote” clinic days, members of Prevention Point Medical Mobile Unit staff would be available using telephones and on site to direct patients to a prescription provided by a health care provider who would conduct telehealth visits. This limited patient exposure to undesirable weather conditions. Another identified strategy was partnering with local community organizations for recipients of care to wait inside of these facilities during snowstorms, for example. It is imperative to develop protocols and contingency plans to adapt to different seasons and weather patterns.

Conclusions

This commentary describes the first-hand experiences of providers who implemented 2 separate mobile clinics for OUD treatment, with 1 located in an urban (Pittsburgh, Pennsylvania) and another located in a rural (Robeson County, North Carolina) context. Despite being in different geographic contexts (urban and rural) and geographic regions of the United States (northeast and south), similar barriers and considerations were identified during the implementation of these 2 separate programs. There were also unique barriers identified by the differing programs that guided their individual trajectories. It is hoped that this commentary will serve as guidance for other providers considering implementing mobile clinics for OUD treatment. The authors acknowledge that not every barrier or consideration to the implementation of a mobile clinic for OUD treatment was addressed or could be within a concise research publication. Implementation costs and the frequency of purchases may also vary depending on each program’s needs. While this paper describes 2 programs implementing buprenorphine/naloxone, different experiences may present for those implementing other MOUD. Further, the political context in different areas may dictate what is legally feasible regarding implementing a mobile clinic for OUD treatment. ²⁸ As such, this is not a comprehensive list of every variable component of implementing a mobile clinic. However, we anticipate that the factors addressed in this paper may inform program development and stimulate thought about your programs’ specific needs, political context, and geographic context.