Opioids continue to drive drug-related morbidity and mortality (Zhang et al., 2024) particularly among persons with experience of homelessness (PEH) (Bradford and Lozano-Rojas, 2024, Cano and Oh, 2023). Opioids are involved in one in four deaths among PEH in some places (Fine et al., 2022). Medication treatments for opioid use disorder (MOUD), including buprenorphine, methadone and naltrexone can reduce opioid use or overdose risk (National Academies of Sciences, Engineering, Medicine, 2019a) but treatment uptake among PEH is poor (Ali et al., 2021). Documented barriers include logistical challenges, burdensome program requirements, perceptions of stigma or discrimination, and readiness to seek treatment (Chatterjee et al., 2018, Hsu et al., 2024, Swartz et al., 2022).

Primary care settings could enhance OUD treatment access (Blanco and Volkow, 2019). Patients with OUD often seek primary care (Gertner et al., 2022). Most U.S. primary care clinicians can legally prescribe buprenorphine and naltrexone, but few do (Valenstein-Mah et al., 2018). Clinics tailored to serve PEH, including the U.S. Health Care for the Homeless programs or U.S. Veterans Affairs (VA) Homeless Patient-Aligned Care Teams (H-PACTs), could help. Homeless-tailored primary care settings provide low-barrier care along with case management and integrated behavioral health and social services (McLaughlin et al., 2021, Tsai et al., 2023). Prior studies suggest office-based models of MOUD in homeless-tailored settings decrease drug use and mortality, and increase employment and housing stability (Alford et al., 2007, Fine et al., 2021). However, the extent to which MOUD is available to PEH managed in homeless-tailored primary care settings is unknown.

We compared MOUD receipt among PEH who received primary care in homeless-tailored vs. mainstream clinics in the VA. Since 2012, more than 70 VA settings have adopted H-PACTs. Their goal is to deliver timely, comprehensive, and integrated primary care. Because the tailored H-PACTs are structured to mitigate health care barriers often experienced by PEH, we hypothesized that PEH in H-PACTs would be more likely than PEH in mainstream primary care to receive any MOUD.