Barriers to Equitable Moud Access in Rural Wisconsin: Provider and Systems Perspectives

Background and Purpose: Rural areas have been heavily impacted by rising overdose rates. Medications for opioid use disorder (MOUD), including methadone and buprenorphine, are highly effective but underutilized in rural areas, particularly for people in active use. Low-barrier models—such as same-day initiation, harm reduction approaches not requiring abstinence from illicit opioid use, and collaboration with syringe service programs—have shown promise in increasing MOUD initiation and retention rates, both of which are associated with improved outcomes and reduced mortality. Thus, low-barrier models may increase equitable access to MOUD. In this project, we examine equity-related barriers to MOUD access and engagement among people who use drugs (PWUD) in rural Wisconsin as perceived by prescribers (MOUD providers) and those who interact with them (e.g., social workers, care coordinators, AODA counselors, treatment court directors). In analyzing these barriers, we discuss implications for expanding low-barrier MOUD care within such contexts.

Methods: As part of the Wisconsin hub of the Rural Opioid Initiative, 48 providers across medical, social service and legal systems who work with PWUD across 6 rural counties were interviewed between 2018-2019. All interviews were audio-recorded, transcribed, and analyzed using Dedoose qualitative analysis software. Guided by thematic analysis, we identified preliminary analytic categories from the Health Equity Implementation Framework (HEIF) and inductive constructs emerging from the data (e.g., beliefs about MOUD; perceptions of drug users; barriers to prescribing MOUD). Throughout the coding process, we held weekly discussion meetings and wrote memos, which were used to refine code definitions and reflect on code relationships.

Results: Our findings support that rural-dwelling PWUD face severe gaps in MOUD access, driven by three equity-related barriers, which are interrelated: (1) treatment orientation/ philosophical differences (e.g., abstinence-contingent vs. harm reduction model; lack of harm reduction training or specialized training in MOUD; lack of engagement with syringe service programs; mistrust), (2) structural determinants to healthcare use (e.g., lack of stable housing, lack of criminal-legal system buy-in), and (3) service encounter misalignment (e.g., workforce shortages; restrictions on methadone receipt; reimbursement concerns and administrative burden; perceived need for clinical control over accessibility; strict requirements for adjunctive services and attendance).

Conclusion and Implications: The progression to low-barrier MOUD adoption is hindered by systems misaligned with the needs of PWUD—particularly for those who are non-abstinent and at highest risk for overdose. This study adds to limited research on rural systems serving PWUD, revealing how institutional bias and systemic barriers hinder treatment uptake and likely perpetuate more restrictive care. Given the strong evidence for low barrier approaches to MOUD service provision, context-specific policy and practice recommendations informed by local practitioners and area harm reduction providers are provided. Further research could draw upon this work, combined with further interviews with MOUD prescribers, to develop implementation strategies to support the uptake of low-barrier approaches.