Medications for opioid use disorder, recovery supports, and overdose risk -- a database linkage study of a rural cohort of people who inject drugs and use opioids

BACKGROUND: Medications for opioid use disorder (MOUD) are the gold standard treatment for opioid use disorder, but rural-dwelling people who inject drugs (PWID) may have lower access. PWID may also receive outpatient or residential treatments, attend mutual help groups, or reside in recovery housing. We aimed to investigate which supports were associated with time to first fatal or nonfatal opioid-involved overdose in a cohort of PWID who used opioids in the past 30 days. METHODS: PWID who used opioids (N = 751) in the past 30 days were recruited in Wisconsin using respondent-driven sampling and completed a cross-sectional survey in 2018-2019. Fatal and nonfatal opioid-involved overdose incidence was estimated through 2022 via linkage with vital records, emergency department, and hospitalization data. Cox proportional hazards models summarized associations of reporting MOUD, outpatient counseling, residential treatment, mutual help group participation, and living in recovery housing in the 30 days before enrollment with time to first fatal/nonfatal opioid overdose adjusted for sociodemographic characteristics, health insurance, drug use frequency, substance use severity, criminal legal system involvement, and overdose history. Self-reported barriers to MOUD were summarized among those who had never used each MOUD. RESULTS: Approximately 18.1% (N = 136) used MOUD, 22.0% (N = 165) had outpatient counseling, 7.2% (N = 54) had residential treatment, 19.7% (N = 148) participated in mutual help, and 7.2% (N = 54) lived in recovery housing in the 30 days before enrollment. During follow-up, 10.7% of participants experienced ≥ 1 opioid-involved overdose, including 114 nonfatal overdoses (incidence: 3,291.6 per 100,000 person-years) and 26 fatal overdoses (incidence: 784.5 per 100,000 person-years). Past 30-day MOUD was associated with a 78% reduction in risk of future opioid-involved fatal/nonfatal overdose (95% CI: 0.08, 0.57). Past 30-day counseling, residential treatment, mutual help, and recovery housing were not associated with fatal/nonfatal overdose. The top barrier to MOUD reported was being unable to afford MOUD (reported among 33.2% who never used buprenorphine, 27.7% who never used methadone, 22.7% who never used naltrexone). CONCLUSIONS: Recent MOUD was highly protective against experiencing fatal or nonfatal overdose in a cohort of PWID who used opioids in the past 30 days, reinforcing the need for widespread MOUD access in rural communities.