This study is testing whether offering buprenorphine treatment directly at syringe service programs (SSPs) helps more people start and stay in treatment for opioid use disorder (OUD) than referring them to community buprenorphine treatment providers. Buprenorphine is a medication that helps reduce opioid cravings and withdrawal symptoms. The study compares two ways of connecting people to treatment: Referral to a community treatment provider (usual care before the new program begins). Onsite, low-threshold buprenorphine treatment at the SSP, which allows participants to start medication quickly and without having to establish care at another provider. Participants will be adults who have opioid use disorder and are SSP clients. Each SSP will begin offering the new onsite buprenorphine program at different times during the study. Researchers will collect information before and after the new program begins to see how it affects treatment engagement and health outcomes. The study will also examine how easy or difficult it is for SSPs to start and run the new program, how acceptable it is to staff and participants, and whether it is cost-effective. The overall goal is to find better ways to expand access to life-saving opioid treatment in community-based settings.
This is a Type 1 hybrid effectiveness-implementation study designed to evaluate the impact and feasibility of implementing low-threshold buprenorphine (BUP) treatment at syringe service programs (SSPs) in order to improve access to and retention in medications for opioid use disorder (MOUD) treatment among people with moderate to severe opioid use disorder (OUD). The study seeks to understand whether the low-threshold approach improves participant-level outcomes and how SSPs can successfully implement and sustain this model. Study Design The study uses a cluster randomized stepped wedge design, in which eight SSPs will be randomly and sequentially assigned to begin implementing the low-threshold BUP program until all sites have transitioned from the referral condition to the intervention condition. This design allows each site to serve as its own control and ensures equitable access to the intervention over time. The stepped wedge design also facilitates examination of temporal effects, while accounting for differences in local environments and SSP readiness for implementation. Participants will be recruited across the eight SSPs in different geographic regions of the United States. SSPs will be selected to represent a range of community types (urban, suburban, and rural) and to reflect varying policy environments related to MOUD access. Study Rationale and Background Despite robust evidence that buprenorphine reduces overdose deaths and improves recovery outcomes, access to this medication remains limited, especially among people who use drugs and have difficulty navigating the healthcare system. Low-threshold buprenorphine models aim to reduce barriers by emphasizing same-day access, flexibility, and a treatment orientation that meets participants "where they are." SSPs provide a trusted, nonjudgmental environment and are uniquely positioned to engage individuals who are at highest risk for overdose and least likely to access formal treatment. Integrating buprenorphine prescribing directly within SSPs could substantially expand access to life-saving treatment in community settings. Study Objectives Primary Objective: To evaluate the effectiveness of low-threshold BUP treatment at SSPs compared to treatment as usual (TAU) for increasing 3-month retention in buprenorphine treatment. Secondary Objectives: Assess buprenorphine adherence, additional OUD treatment outcomes, and health-related quality of life. Examine the cost-effectiveness of implementing low-threshold BUP at SSPs from both payer and societal perspectives. Characterize implementation outcomes-adoption, acceptability, appropriateness, feasibility, reach, fidelity, and sustainability-across diverse SSP settings. Exploratory Objectives: Explore participant-level moderators (e.g., polysubstance use, co-occurring mental health conditions, housing status, rurality) that may predict outcomes or differential intervention effects. Identify contextual determinants (organizational capacity, policy environment, leadership engagement) associated with successful SSP implementation. Study Procedures Participants will complete study assessments at baseline, 1 month, 3 months, and 6 months post-enrollment. Measures will include substance use patterns, treatment engagement, overdose events, hospitalizations, and self-reported recovery activities. Laboratory-confirmed urine drug screens will be used to verify buprenorphine adherence. Pre-implementation (Treatment-as-Usual) Prior to implementing the low-threshold BUP model, SSPs will provide standard care, which includes referral to community MOUD providers for BUP treatment. Post-implementation (Low-Threshold BUP Program) Once implementation begins, SSPs will offer onsite BUP treatment directly through trained prescribers and peer outreach workers. Clients identified as eligible and interested will receive a medical evaluation from a study clinician (SC), including assessment for contraindications, education on BUP use, and initiation via home induction or observed dosing as appropriate. Follow-up visits will occur approximately every 4 weeks for 6 months and include focused psychosocial counseling, urine drug screening (when requested by the study clinician), and continued prescription management. Both in-person and telehealth models may be used to enhance accessibility. Participants may use any FDA-approved formulation of buprenorphine, including injectable long-acting formulations, based on shared decision-making between study clinician and participant. Implementation Facilitation Strategy To support successful and sustainable adoption of the low-threshold BUP model, the study's Lead Node (LN) will develop and deliver an Implementation Facilitation Package. This package will include: Structured training for SSP staff and clinicians on low-threshold buprenorphine principles and program logistics. Coaching on identifying a site champion, hiring or engaging a prescriber, and establishing clear protocols for medication management. Ongoing facilitation meetings between the LN and SSP implementation teams (champion, prescriber, peer outreach worker) to troubleshoot challenges, monitor fidelity, and adapt workflows. Tools for tracking and sustaining reach, fidelity, and acceptability over time. Hypotheses and Analytical Approach The central hypothesis is that embedding low-threshold buprenorphine treatment within SSPs will improve engagement and retention in MOUD compared to standard referral pathways. Analyses will use mixed-effects regression models accounting for site-level clustering and time effects. Effectiveness analyses will focus on 3-month retention as the primary outcome, with sensitivity analyses at 6 months. Cost-effectiveness analyses will use quality-adjusted life years (QALYs) as the main effectiveness measure. Implementation analyses will use the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to identify determinants, measure outcomes, and map facilitation processes. Qualitative interviews with staff and participants will complement quantitative metrics, offering a comprehensive understanding of how and why the intervention succeeds or encounters barriers. Expected Impact This study addresses a critical public health need by testing a scalable, community-driven model of OUD treatment. If the low-threshold SSP-based buprenorphine program is found to be effective and cost-efficient, the Implementation Facilitation Package developed through this study will serve as a replicable framework for dissemination to SSPs or other community-based settings nationwide. The findings have the potential to directly inform national strategies for expanding access to evidence-based treatment, reducing overdose deaths, and promoting patient-centered care.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
512
During the pre-implementation phase, SSP staff will refer participants with opioid use disorder to external community providers for buprenorphine treatment. Services offered include information, referral assistance, and linkage to care, but buprenorphine will not be initiated or managed at the SSP site.
During the post-implementation phase, SSPs will implement a low-threshold model of care for buprenorphine treatment. This model includes: Low barrier to entry Flexible scheduling and follow-up procedures Risk reduction counseling Collaboration with a peer outreach worker Training and technical assistance for SSP staff and clinicians to deliver care in non-traditional, low-barrier settings This intervention focuses on implementing and evaluating a service delivery model to expand access to medication for opioid use disorder within SSPs.
Community Health Project Los Angeles (CHPLA)
Los Angeles, California, United States
HIPS
Washington D.C., District of Columbia, United States
CARPBR/Be Safe Syringe Program
Baton Rouge, Louisiana, United States
Harm Reduction Sisters
Duluth, Minnesota, United States
Alianza of New Mexico
Roswell, New Mexico, United States
HIV Alliance
Grants Pass, Oregon, United States
Challenges, Inc/Prisma Health
Greenville, South Carolina, United States
Vivent Health
Milwaukee, Wisconsin, United States
3-month Buprenorphine treatment retention (3-month retention)
Buprenorphine (BUP) treatment retention will be defined as having an active buprenorphine prescription between baseline and 1-month and between the 1-month (days 1-30) and 3-month (days 31-90) time points. Participants will be asked to provide evidence of BUP prescriptions at study visits (i.e., confirmed prescriptions). If a participant receives a second BUP prescription before the 1-month follow-up and the number of days dispensed covers dates after day 30 (i.e., carries over into the 31-90 days interval), this participant will have met the primary outcome. The primary outcome will require at least one day of an active BUP prescription based on confirmed prescriptions within the 2 time-points. BUP treatment retention will be summarized as a binary ("Yes/No") variable. The number/percentage of participants who are retained at each timepoint will be summarized by arm. BUP treatment retention is the primary measure of effectiveness.
Time frame: Between baseline and 1-month following intervention, and between baseline and 3-months following intervention
Buprenorphine Adherence
Adherence to buprenorphine is a composite measure and will be defined as participants meeting the primary outcome AND having a urine drug screen (UDS) that is positive for BUP at the 3-month timepoint. The number/percentage of participants who demonstrate BUP adherence will be summarized by arm.
Time frame: Baseline to 3-months following intervention
6-month Buprenorphine Treatment Retention (6-month retention)
Buprenorphine (BUP) treatment retention at 6-months is a composite measure and will be defined as participants meeting the primary outcome AND having an active BUP prescription at the 1-month, 3-month, and 6-month timepoints.
Time frame: From baseline to 6-months following intervention
Treatment and Recovery Activities
Treatment and Recovery activities will be measured using the Treatment Effectiveness Assessment (TEA). The TEA is a patient-centered instrument for evaluating progress in recovery from addiction. The TEA consists of 4 items used to measure recovery progress in substance use, health, lifestyle, and community domains. Participants rate progress on a scale from 1 ("not better") to 10 ("very much better"), yielding a total score from 4-40, wherein higher scores indicate greater improvement. Results will be summarized by study arm using descriptive statistics.
Time frame: 6-months following intervention
Non-prescribed Opioid Use
Non-prescribed opioid use will be determined by the number of self-reported days of use of heroin, fentanyl, methadone, or opioid analgesics in the prior 30 days at each study visit (1-month, 3-months, and 6-months). Results will be summarized by study arm.
Time frame: 1-month, 3-months, and 6-months following intervention
Overdose (non-fatal and fatal)
Non-fatal overdoses will be determined based on participant self-reporting during the 6 months of study participation. Fatal overdoses will be based on data collected from available administrative records or other reliable sources. This a continuous measure and the number/percentage of both fatal and non-fatal overdoses will be summarized by study arm.
Time frame: 6-months following intervention
Mean Intervention Costs
Mean cost (in US dollars) of buprenorphine treatment will be reported for participants in each study arm. The resource utilization and resulting cost of implementing and administering the intervention will be estimated using micro-costing analysis and participant self-report. Mean costs (in US dollars) will be summarized by study arm.
Time frame: 6 months
Health-related Quality of Life - PROPr
Health-related Quality of Life will be assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Preference (PROPr) questionnaire. PROPr is a comprehensive, multi-attribute health utility measure that consolidates 7 PROMIS domains-Cognitive Function, Depression, Fatigue, Pain Interference, Physical Function, Sleep Disturbance, and Social Roles-into a single score, the health utility index value. A single-attribute scoring function for each PROMIS domain is calculated, with 1 = "the utility of full health" and 0 = "the utility of that domain's disutility state. The 7 single-attribute functions are combined to produce a multi-attribute summary scoring function, where 0 = "the utility of dead" and 1 = "the utility of full health," with scores less than 0 corresponding to states judged worse than dead. Results will be summarized by study arm.
Time frame: 1-month, 3-months, and 6-months following intervention
Change in Health-related Quality of Life - QALYs
Change in Health-related Quality of Life will be used to calculate quality-adjusted life-years (QALYs). QALYs is a measure that incorporates both duration and health-related quality-of-life into a single assessment and is used to assess cost-effectiveness. The health utility index value from the PROPr is converted into QALYs. Mean years gained from baseline to 6 months intervention will be summarized by study arm.
Time frame: From Baseline to 6-months following intervention
Cost effectiveness - incremental cost-effectiveness ratio (ICER)
The outcome of the cost-effectiveness analysis will be the incremental cost-effectiveness ratio (ICER), calculated as the adjusted-difference in costs (i.e., mean intervention costs per arm) divided by the adjusted-difference in effectiveness (i.e., mean change in Health-related Quality of Life per arm). The outcome is reported as a ratio of the two numbers.
Time frame: 6-months following intervention
Satisfaction with BUP treatment
Satisfaction with BUP treatment will be measured by an adapted version of the Primary Care Buprenorphine Satisfaction Scale. The adapted version will use 5 (out of 19) items, covering satisfaction with the following three domains: overall and specific service components; staff expertise, concern and responsiveness; and helpfulness of overall and specific treatment components. Items are rated on a 5-point scale with 1 indicated low satisfaction and 5 indicating high satisfaction. The mean score from the 5 items will be reported.
Time frame: 6-months following intervention
Initiation of BUP treatment
Initiation of BUP treatment will be defined as having any self-report of taking prescribed BUP over 6 months of follow-up. Initiation of BUP treatment will be assessed as a binary ("Yes/No") variable. The number/percentage of participants who initiate BUP treatment over the 6 months of follow up will be summarized by arm.
Time frame: Up to 6-months following intervention
Retention in any MOUD treatment
Retention in any MOUD treatment will be measured based on participant self-reporting of having been engaged in an approved MOUD treatment service at 6 months. Retention in any MOUD treatment will be assessed as a binary ("Yes/No") variable. The number/percentage of participants who demonstrate retention in any MOUD treatment at the 6 months timepoint will be summarized by arm.
Time frame: 6-months following intervention
OUD severity
OUD severity will be measured using the Diagnostic and Statistical Manual for Opioid Use Disorder, 5th Edition (DSM-5 OUD) checklist. The DSM-5 OUD checklist consists of 11 criteria, with diagnosis and severity based on the number of symptoms met within a specified period, in this case 6 months. Scoring is calculated by counting the number of "yes" responses for the 11 criteria: mild (2-3 symptoms), moderate (4-5 symptoms), and severe (6 or more symptoms). The number participants with mild, moderate, and severe symptoms will be summarized by study arm.
Time frame: 6-months following intervention
Number of days of other substance use
The number of days of other substance use will be measured based on participant self-reporting, using a modified version of the Addiction Severity Index. Assessments will ask separately about past-30 day use of heroin, fentanyl, methadone, buprenorphine, other opioids, benzodiazepines, other sedatives, cocaine, amphetamines, methamphetamine, cannabis, alcohol, and more than one substance. A composite measure that represents the number of days (0-30) using benzodiazepines, other sedatives, cocaine, amphetamines, methamphetamine, or alcohol will be reported as "days of other substance use".
Time frame: 1-month, 3-months, and 6-months following intervention
Depression
Depression will be assessed using the individual Depression domain subscale from the PROMIS-PROPr instrument. The PROMIS-PROPr Depression domain subscale consists of 4 items asking participants to rate their levels of depression over the prior 7-day period. Scores are rated on a scale ranging from 1 "Never" to 5 "Always" for an overall possible raw score ranging from 4-20, such that higher scores are indicative of higher depression severity. Scores will be summarized by study arm using descriptive statistics.
Time frame: 6-months following intervention
Anxiety
Anxiety will be assessed using the individual Anxiety domain subscale from the PROMIS-PROPr instrument. The PROMIS-PROPr Anxiety domain subscale consists of 4 items asking participants to rate their levels of anxiety over the prior 7-day period. Scores are rated on a scale ranging from 1 "Never" to 5 "Always" for an overall possible raw score ranging from 4-20, such that higher scores are indicative of higher anxiety severity. Scores will be summarized by study arm using descriptive statistics.
Time frame: 6-months following the intervention
Pain Intensity
Pain Intensity will be assessed using the individual Pain Intensity item from the PROMIS-PROPr. The PROMIS-PROPr Pain Intensity item asks participants to rate their average intensity of pain over the prior 7-day period. Scores are rated on a scale ranging from 1 "No Pain" to 10 "Worst Pain Imaginable" for an overall possible raw score ranging from 1-10, such that higher scores are indicative of higher pain intensity. Scores will be summarized by study arm using descriptive statistics.
Time frame: 6-months following intervention
Safety Outcomes
A composite measure of experiencing one or more Targeted Safety Event (dichotomous, yes/no), which includes opioid overdoses (non-fatal and fatal), any hospitalization, or death, will be reported as an outcome measure.
Time frame: 6-months following intervention
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