The first five years of implementing Missouri's medication first approach to opioid use disorder treatment: Plateaus, regressions, and underbellies of progress

Introduction: Missouri's Medication First ("MedFirst") approach promotes same-day and long-term low-threshold access to medications for opioid use disorder (MOUD). Since 2017, Missouri's SAMHSA-funded State Targeted and State Opioid Response (STR/SOR) grants have supported MedFirst services (both medical and psychosocial) for uninsured individuals with opioid use disorder at state-contracted treatment programs. Though MedFirst demonstrated early success, results - with attention to possible racial disparities - must be revisited after five years of implementation. Methods: Using state behavioral health claims, we examined four outcomes: (1) MOUD utilization, (2) time-tomedication, (3) psychosocial service volume, and (4) substance use disorder (SUD) treatment retention. Models compared four groups: (a) individuals in MedFirst during the first and fifth year of implementation (2018 vs. 2022), (b) individuals in MedFirst compared to non-MedFirst, (c) individuals prior to MedFirst (2017) compared to individuals during MedFirst's fifth year (2022), and (d) White compared to Black individuals within and outside MedFirst. Results: Overall, MedFirst outcomes were superior to non-MedFirst outcomes. Among individuals in MedFirst, however, outcomes were generally poorer in 2022 than in 2018, and Black individuals had shorter treatment episodes and were less likely to receive MOUD than White individuals. Overall, Missourians had only slightly better outcomes in 2022 than prior to STR/SOR initiation. Conclusions: Since Missouri's initial implementation of STR/SOR-funded MedFirst, select overall treatment outcomes have improved. Within MedFirst programs, however, outcomes worsened over time, and racial disparities were evident. Though fentanyl's dominance of the drug supply alongside the COVID-19 pandemic contributed to these results, fidelity drift, particularly due to financial implications of MedFirst, likely also negatively impacted sustainability.