The role of neighborhood stressors in methadone treatment engagement: an explorative qualitative study

Background Engagement in methadone treatment for opioid use disorder (OUD) remains a major challenge. Many patients drop out of treatment prematurely, thus contributing to opioid-related disparities in the United States. Communities like Baltimore City, Maryland are particularly burdened by the opioid crisis, and many residents experience various stressors that may be barriers to treatment engagement. Previous reports have identified neighborhood stressors, such as residential instability, financial difficulties, and other individual and community factors as significant predictors of methadone treatment engagement that disrupt recovery progress. This study sought to understand how patients with OUD in a low-income urban neighborhood in Baltimore City perceive their neighborhoods and how stressful neighborhood factors shape their engagement with methadone treatment. Methods Semi-structured, in-depth interviews were conducted with 18 adults from the HEAL Together trial that took place in a Baltimore City methadone clinic. The interview guide examined how neighborhood stressors, such as built environment features, finances, housing stability, and transportation, influence methadone treatment outcomes and recovery experiences. Transcripts were analyzed using inductive and deductive thematic analysis. A codebook was developed, and main- and sub-themes were derived from the coded data. Results We found that individual- and community-level neighborhood stressors were identified as barriers to consistent methadone treatment engagement and attendance. Economic stressors, specifically financial difficulties, and pervasive drug exposure, emerged as prominent triggers that disrupted engagement. Despite these barriers, many participants reported developing personal strategies to avoid high-risk situations and expressed strong motivation to remain engaged in treatment. Conclusions Neighborhood stressors, especially financial instability and drug exposure, pose substantial challenges to methadone treatment engagement. Yet, participants demonstrated coping strategies and motivation to sustain care. These findings reveal the role of the neighborhood as a source of risk and opportunities for resilience. Addressing the economic and community barriers while reinforcing patient-driven coping and support mechanisms may enhance methadone treatment engagement and inform community-level interventions to reduce opioid-related disparities in urban communities.