Overdose deaths have disproportionately affected racial and ethnic minoritized groups in recent years. A study examining overdose death rates in the U.S. by age, sex, race, and ethnicity during the COVID-19 pandemic demonstrated that in 2021, non-Latine Black (hereafter referred to as Black) men accounted for the highest rate of overall overdose deaths and overdoses, involving fentanyl at rates of 61.2 deaths per 100,000 population and 43.3 per 100,000, respectively (1). Comparable trends took place in Massachusetts the same year. Overdoses among Black individuals increased 70% between 2019 and 2020, and again by 42% between 2021 and 2022. At 143.8 per 1,000,000 in 2022, overdose rates for American Indian/Alaska Native individuals (hereafter referred to as Indigenous) are 433% of the rate for the general population (2). Similarly, opioid-related overdoses increased among Latine individuals (hereafter referred to as Latine) from 35.4 per 100,000 in 2020 to 39.1 and 45.5 per 100,000 in 2021 and 2022, respectively (2). Meanwhile, a decrease in opioid-related overdose death rates was observed among White individuals (36.5 per 100,000 in 2021 versus 33.3 per 100,000 in 2022) (2). Of note, the authors acknowledge that bodies of literature employ widely varied descriptors of racial and ethnic groups. Hereafter, formatting of descriptors will align with preferred terminology from the American Medical Association’s Inclusive Language for Reporting Demographic and Clinical Characteristics (3). When referring collectively to individuals with Black, Latine, and/or Indigenous racial and ethnic identities, the terms marginalized, historically marginalized or oppressed, or underrepresented racial or ethnic groups may be used (3).

Through a social justice and Right to Health lens, it is evident that structural racism, racialized discriminatory drug policy, and subsequent systemic disadvantages result in disparities in accessibility, availability, acceptability, and quality (AAAQ) of addiction treatment and its outcomes for minoritized racial and ethnic groups (4, 5). Buprenorphine is an evidence-based medication for opioid use disorder (MOUD) that is widely considered to be a first line form of treatment (6). Inequities in AAAQ to this treatment modality for Black, Indigenous and Latine groups are well-documented. In recent years, availability of buprenorphine has increased overall in the United States, however the greatest increases in numbers of buprenorphine providers have occurred in zip codes with highest percentages of White residents (7). A study at the neighborhood level has shown that predominantly Black and Latine communities have less physical availability of buprenorphine (8).

Patients from minoritized racial backgrounds experience delays in accessing addiction treatment (9). When patients from minoritized backgrounds are enrolled in treatment, treatment programs are unsuccessful at retaining them (10–12). Similarly, patients from minoritized backgrounds are at a greater risk for discontinuation of treatment once enrolled than their White counterparts (13). Delays in accessing medical care, and early termination from treatment are attributed to racial discrimination in healthcare settings (14, 15). These factors cumulatively contribute to unequal access to addiction treatment and differential treatment outcomes for racial and ethnic minority communities.

Brockton, Massachusetts is an urban community 20 miles south of Boston. According to the 2020 U.S. Census, 41% of Brockton’s population identifies as Black, 12% are Latine, 0.47% are Indigenous peoples, 32% of residents are foreign-born, and 47% of the population speaks a language other than English in their home (24). Mirroring trends taking place on the state and national levels, Brockton’s historically marginalized populations have been disproportionately impacted by overdose deaths in recent years. Community-level data made available via the National Institutes of Health HEALing Communities study found a 40% increase in overdose deaths among non-Latine Black individuals in Brockton between 2017 and 2021, while overdose deaths for non-Latine White individuals decreased by 8% (25).

The HEALing Communities Study (HCS) is a multi-site study in 67 communities in four states (Kentucky, Massachusetts, New York and Ohio) which uses the Communities that HEAL (CTH) intervention to reduce opioid overdose deaths (26). As part of the Communities That HEAL intervention, (27) developed within the HCS trial, a community coalition was formed in Brockton, comprised of individuals and organizations in Brockton working on the overdose crisis. Health center leadership and coalition members recognized that traditional brick-and-mortar treatment locations were not accessible or acceptable to the entire population, and that a mobile program could increase access to addiction treatment.

In 2020, the HCS coalition in Brockton funded a mobile medical services program operated by Brockton Neighborhood Health Center (BNHC), a Federally Qualified Health Center (FQHC) in Brockton, MA. In September 2021, with support from the HCS coalition, and alongside a partnership with The Kraft Center for Community Health at Massachusetts General Hospital, Brockton Neighborhood Health Center (BNHC) launched its mobile services initiative – Community Care-in-Reach – to bring low-threshold substance use treatment, safer use supplies, and preventive medical care to a patient population at high risk for overdose at sites where overdoses frequently occur.

Equity for marginalized patients, particularly those from oppressed racial and ethnic groups and people experiencing homelessness was a driving force behind program design. BNHC’s mobile services program deconstructed obstacles that contribute to disparities in health outcomes among patients from historically marginalized and oppressed racial and ethnic backgrounds. These challenges included poor accessibility and limited availability of buprenorphine treatment, failure of service providers to engagement patients in treatment, (10) and early discharge from programming for failure to adhere to strict clinic attendance, urine testing, and other requirements (13).

This Community Case Study assesses the equity impact of the Brockton mobile program strategy to increase buprenorphine access. Programs with similar models have demonstrated ability to promote buprenorphine access (28, 29). We hypothesized that a mobile services model that entails accessible MOUD and non-judgmental harm reduction interventions, delivered by a diverse team trained in concepts related to health equity, could effectively promote access for individuals from marginalized racial and ethnic groups to buprenorphine as a first-line treatment and improve engagement in health services for historically oppressed groups, including those experiencing homelessness.

To evaluate buprenorphine access, a quantitative assessment of electronic health record (EHR) data from BNHC’s Nextgen and later Epic EHRs was conducted. Encounters resulting in a sublingual buprenorphine prescription were extracted from September 1, 2021 through August 31, 2023 for both the Community Care-in-Reach mobile program and BNHC’s brick-and-mortar office-based addiction treatment program. Prescriptions for extended-release injectable buprenorphine prescribed from the stationary clinic were excluded in this analysis (n = 100), which is unavailable in the mobile setting given DEA restrictions on storage and transport of the medication. The resulting report contained all prescription fills in the 2-year timeframe for each patient (e.g., a patient receiving seven refills would appear seven times), which was then deduplicated to obtain a list of unique patients who had received buprenorphine by site. Patients receiving buprenorphine from both locations were represented on both mobile and brick-and-mortar reports. Demographic information for the distinct lists of participants were used to determine aggregate tallies of buprenorphine-receiving patients by race and ethnicity for each clinical site. This allowed for a comparison of percentage of patients receiving buprenorphine by demographic characteristics between the mobile services and brick-and-mortar programs.

Following 24 months of operation, the mobile services unit has expanded accessibility of MOUD within the Brockton community. From the conception of the program in August 2021 through September 2023, 1,283 medical appointments were conducted for 297 unique individuals. Of these patients, 41% were female, 57% male, 74% were Brockton residents, 7% reported speaking a language other than English, and 29% were experiencing homelessness, of whom half reported staying in a shelter. Two-thirds (66%) identified as White, 25% as Black, 10% as having Latine ethnicity, and 1.0% of Indigenous background. More than half of these visits (59%, n = 790) were for the purpose of prescribing buprenorphine (Table 1).

In the two-year operating period, providers on the mobile unit prescribed buprenorphine to 107 unique patients and wrote a total of 695 buprenorphine prescriptions. The average dose per prescription was 17.8 mg per day. Thirty-seven percent of MOUD patients were female and 63% male; approximately 70% were Brockton residents. Those receiving buprenorphine from the mobile unit were as racially diverse (24% Black, 14% Latine, 1.9% Indigenous) as the overall mobile unit patient population and had a similarly high prevalence of homelessness (35%). In contrast, those receiving buprenorphine at the brick-and-mortar clinic were more likely to be White (74%, with 19% Black, 13% Latine, 1.0% Indigenous) than mobile unit buprenorphine patients.

One-third of initial visits to the mobile unit were for wound care. Seventy-four percent of buprenorphine patients presented requesting MOUD access; however, 26% initially presented seeking other services and later returned for buprenorphine treatment (Table 2).

The mobile services program has also proven to be an effective tool in reaching individuals experiencing homelessness and individuals reentering the community from incarceration, two groups that are known to be at an elevated risk for overdose (33, 34). Eighty-six (29.0%) of the 297 individual patients the mobile unit served in this period were identified as homeless in the electronic medical record, and 46.1% of homeless patients received buprenorphine prescriptions from the mobile services team. Forty-one patients had been incarcerated in the past 5 years, 65.9% of whom were treated with buprenorphine from the mobile team. It is likely that these data under-represent the prevalence of incarceration and homelessness in the patient population due to limitations of the Electronic Health Record (EHR) in capturing these metrics.

A mobile treatment model for people with OUD that brick-and-mortar treatment fail to engage is feasible. Indeed, similar mobile care models have been implemented successfully to increase access to preventive health and addictions care in diverse settings in the US (28, 35–37). Such models, through geographic and philosophic flexibility, can work to promote health equity and, in part, begin to redress discriminatory practices in the medical system that lead to disparities in MOUD and substance use-related AAAQ measures. At a time when overdose deaths are disproportionately increasing among those identifying as Black, Latine, and Indigenous peoples, it is key that strategies to address the overdose crisis are centered in social justice and a Right to Health framework. The Brockton Community Care-in-Reach® program reached many patients who identified their race or ethnicity from an underrepresented group or reported homelessness, who might otherwise not have MOUD or other forms of medical care accessible to them.

In our experience, harm reduction programs and addiction treatment providers in both mobile and clinic settings should cultivate an atmosphere of acceptance to promote equitable care for patients from marginalized communities. This can be accomplished through thoughtful program design that intentionally eliminates barriers that are reticent of discriminatory policies and practices in the medical system to help promote available, accessible, acceptable, and quality services (23). Nonjudgmental treatment works to foster mutual trust between patients who have experienced current and historical oppression and healthcare providers. Developing culturally appropriate services should be an organizational priority for addiction treatment providers to facilitate patients from historically marginalized racial and ethnic groups to access care. Substance use services should be offered in languages used in the catchment area and delivered in a culturally relevant manner by a multidisciplinary team whose experiences reflect those of the patient population. Staff should participate in regular training relating to antiracism and health equity and be encouraged to use their lived experience to raise up strategies that promote AAAQ. Regularly seeking and incorporating participant feedback into program design is essential.

Establishing a mobile unit involves overcoming many obstacles. Onerous licensing requirements developed with brick-and-mortar sites in mind require reform to encourage mobile programs such as the one highlighted here. Local politics and relationships with other community organizations also determine successful program implementation. To establish a mobile unit, an organization must have strong relationships with existing institutions in the community, which in this case the HCS coalition helped foster.

Clinical takeaways include the importance of wound care and other services because many patients who ultimately received buprenorphine accessed other services first. Providing comprehensive harm reduction supplies including safer injection, sniffing, and smoking kits, is critical to building trust and promoting engagement with services. Additionally, some patients attended appointments at both mobile and brick-and-mortar sites. Mobile services added access for patients already engaged at other BNHC sites who might need occasional geographic flexibility. Finally, buprenorphine served a harm reduction purpose. Even patients who might intermittently missed prescription visits would report that having at least some buprenorphine in their system seemed to prevent overdose. Lastly, while patient feedback helped shape clinical offerings, future opportunities include ongoing engagement of patient and community to shape mobile unit operations.

Finances and sustainability are persistent issues for mobile units (28). Seeking out all relevant grant opportunities is vital. Secondly, maximizing billable encounters – and offering a wide variety of billable clinical services, such as wound care – is crucial. Finally, supportive state-level policies are key to sustainability of such interventions. While Medicaid reimbursement policies are a strength in Massachusetts, they may still under-support mobile MOUD and harm reduction programs that offer low-threshold models of care. Finally, telehealth policies that support remote visits are also important since many mobile unit patients require engagement via telehealth at some point in their care. With many patients lacking smartphone access or data plans, reimbursement for audio-only telehealth visits must remain a point of advocacy as COVID-19 policies are repealed across the country. Medicaid expansion, sufficient coverage of OUD-related treatment and services, and telehealth service coverage are vital policies that must be expanded to further support mobile access to lifesaving MOUD at a time of ever-increasing overdose deaths.

In our experience, a mobile unit offering MOUD is feasible and can help promote availability, accessibility, acceptability, and quality of MOUD services to populations that have been disproportionately impacted by oppression, discrimination, and under-resourcing of medical services.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

AP: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review & editing, Methodology. KC: Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review & editing. TB: Methodology, Writing – review & editing. AC: Conceptualization, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing. KL: Investigation, Methodology, Supervision, Writing – review & editing.