“Cognitive impairments are the worst”: Staff perspectives on challenges in buprenorphine care for people with cognitive and mental health disabilities who inject drugs.

BACKGROUND: Opioid use disorder (OUD) is highly prevalent among people with disabilities, who often experience cognitive and mental health impairments. These disabilities can complicate treatment and contribute to disparities in access and outcomes. OBJECTIVE: To explore staff perspectives on cognitive and mental health impairments among people who inject drugs (PWID) receiving buprenorphine treatment, and how these challenges affect care delivery. METHODS: From March 2025 to January 2026, 29 staff members from two buprenorphine clinics in the San Juan metropolitan area of Puerto Rico participated in semi-structured interviews. Data were analyzed using inductive and deductive coding to identify themes related to cognitive and mental health disabilities, treatment barriers, and management strategies. RESULTS: Staff encountered a wide range of cognitive and mental health challenges. Stigmatized severe mental health conditions, such as schizophrenia or bipolar disorder, tended to be hidden by patients, affecting treatment outcomes. Staff viewed severe intellectual disabilities as a barrier to treatment due to the perception that patients with such disabilities could not adhere to the requirements of the cognitive therapy employed by the clinics. Often patients exhibited both cognitive and mental health impairments simultaneously, adding complexity to buprenorphine treatment and erecting new barriers. CONCLUSION: This study identifies cognitive and mental health impairments among PWID in buprenorphine treatment and highlights the challenges they pose for staff. The findings underscore the need for integrated, disability-informed approaches, including systematic screening, continuous assessment, culturally sensitive training, and community engagement and peer support, as well as further research on prevalence, barriers, and treatment outcomes.