Differences in MOUD receipt by legal referral type in outpatient treatment

INTRODUCTION: Opioid use and opioid use disorder (OUD) are prevalent among persons with legal system involvement. Medications for opioid use disorder (MOUD) are recommended for treatment, yet access is limited for legal-involved populations. In outpatient treatment settings, persons with legal-system involvement are less likely to receive MOUD. However, the influence of the type of legal system involvement on MOUD access is understudied. The purpose of this study was to examine if MOUD receipt differs by the type of legal system referral among adults referred to outpatient treatment by the legal system. METHODS: Data came from the 2021-2022 Treatment Episode Dataset-Admissions (TEDS-A). The sample included 32,213 legal-involved adult admissions to outpatient treatment for primary opioid use. The independent variable was the type of legal system referral; court/diversionary program, probation or parole, prison, or other. The outcome was whether MOUD was included in the treatment plan. Covariates included the following sociodemographic, substance use, and treatment-related variables: sex, age, race/ethnicity, education, employment, living arrangement, prior substance use treatment, co-occurring mental disorder, type of opioid use, attendance of a substance use self-help group, outpatient treatment type, injection drug use, past-month arrest, and past-month opioid use frequency. Multivariable logistic regression was used to examine associations of referral type with MOUD, adjusting for sociodemographic, substance use, and treatment-related covariates. RESULTS: Compared to court/diversionary referral, probation or parole referral (AOR = 0.80, 95% CI = 0.76-0.85), prison referral (AOR = 0.85, 95% CI = 0.76-0.94) and other referral (AOR = 0.42, 95% CI = 0.39-0.46) were each associated with lower odds of MOUD when adjusting for covariates. Use of other opioid analgesics and synthetic opioids was associated with lower odds of MOUD than heroin use (AOR = 0.48, 95% CI = 0.46-0.51). CONCLUSIONS: MOUD access in the community varies by the type of legal system referral. To inform MOUD community linkage policies and practices, research is needed to identify gaps in referral processes for specific legal system institutions. Examining how opioid use behavior characteristics impact MOUD community linkage is an appropriate next step for future research.