Engaging the Great Circle: a qualitative study of the Confederated Tribes of Grand Ronde’s mobile medication unit

Abstract

Background

The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services.

Methods

Semi-structured qualitative interviews with patients (n = 11), MMU staff (n = 5), and the state opioid treatment authority (n = 1) gathered details on the initiative’s development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach.

Results

Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients’ themes noted the MMU’s professional and ‘caring’ environment, accessible rural locations and general suggestions including culturally responsive ancillary services.

Conclusion

The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.

Keywords:

• Methadone
• rural
• opioid treatment program
• AI/AN
• mobile MOUD

Introduction

Substance use and substance use disorders disproportionately affect American Indian (Native American) and Alaska Native (AI/AN) communities. Substance-related poisonings and deaths among AI/AN are elevated compared to other U.S. racial and ethnic groups [1]. A greater proportion of individuals who identify as AI/AN reported past year illicit drug use (25.9%) compared to those who self-identify as African American (20.8), White (19.6%), Native Hawaiian or Pacific Islander (16.9%), or Asian (9.8%); rates of drug use exceeded 40% among AI/AN individuals aged 18 to 34 years [2]. Drug use disorders are also elevated among persons self-identified as AI/AN (4.8%) when compared to those who are Black (3.4%), Native Hawaiian or Pacific Islander (3.0%), White (2.9%) and Asian (1.3%) [3]. Disparities in overdose mortality increasingly burden Tribal communities: the national rate of AI/AN opioid-related overdose fatalities increased from 5.2 per 100,000 in 1999 to 33.9 in 2019 [4].

Use of opioid agonist therapy with methadone or buprenorphine, the most effective clinical interventions for OUD, is uncommon in AI/AN communities because agonist therapy can conflict with traditional healing practices and methadone integration into holistic healing strategies is uncommon [5]. Many AI/AN views of wellness, moreover, do not incorporate continuing use of medications. Implementation of methadone is especially difficult because federal regulation requires daily observed dosing for new patients, and strict control of medication storage and dispensing, despite small caseloads in rural settings [5]. These and other factors contribute to a paucity of research on the use of agonist therapy in AI/AN communities [5, 6].

History of mobile medication units (MMUs) for opioid use disorder

A small number of MMUs were implemented in the late 1980s to facilitate access to methadone because of the spread of HIV infection among people who inject drugs and opposition to siting new opioid treatment programs (OTPs) in urban communities; MMUs lowered barriers to care in urban neighbourhoods and rural settings [7, 8]. Limited research on the few MMUs operating during this period documented enhanced access to OUD care within underserved communities [9, 10]. The Drug Enforcement Administration, subsequently, issued a moratorium on approval of MMUs in 2007 [11]. In response to the ongoing opioid overdose emergency, the DEA proposed new regulations in 2020 [12] and released the final rule for ‘Narcotic Treatment Programs with Mobile Components’ on 28 June 2021 [13]. The Great Circle Recovery OTP’s MMU received DEA approval in 2022.

The great circle recovery opioid treatment program

The Confederated Tribes of Grand Ronde, a federally recognized Tribe located in western Oregon, includes more than 30 Tribes and bands from western Oregon, southwestern Washington and northern California that were relocated to the Grand Ronde Reservation between 1855 − 1875. Because Tribal leadership understands that supportive recovery includes healing of the greater community, Great Circle Recovery services are offered to Native and non-Native community members. The Great Circle symbolizes the whole person approach to wellness offered at the OTP and mimics the service offerings at the Grand Ronde Health and Wellness Centre, where focus is on the collective needs of the patients. The Great Circle OTP operates within the Tribe’s cultural framework to improve health care for American Indians and Alaska Natives and extends the framework to include treatment for opioid use disorder. Health care begins with community education, embraces medications that enhance patient outcomes, integrates cultural, social, and medical needs and supports care with psychosocial services [5].

After conversations with the Tribal Council and with the Council’s approval, the Confederated Tribes of Grand Ronde’s Health and Wellness Center opened the Great Circle Recovery OTP in Salem, Oregon (spring 2021) to serve individuals with OUD and added an MMU (summer 2022). The MMU dispenses methadone or buprenorphine during stops at the Grand Ronde Wellness Centre (on Tribal lands) and a church parking lot in McMinnville, Oregon, both of which have broad rural catchment areas. The MMU operates as a ‘medication unit’ (SAMHSA regulations) and a ‘Mobile Narcotic Treatment Program’ (DEA regulations) and is the only known Tribally operated MMU in the nation (personal communication, Patti Julianna, Director, Division of Pharmacologic Therapies, SAMHSA, 21 March 2023). The Oregon State Opioid Treatment Authority also approved the MMU and ‘provided technical assistance to guide program operations within the context of the [federal] regulations’ (personal communication, John McIlveen, Oregon SOTA, 15 March 2023).

The Great Circle MMU (Figure 1) travels a daily route, Monday through Friday, beginning with a stop on Tribal lands. The unit parks at the Grand Ronde Health and Wellness Centre from about 9:00 AM to 11:30 AM–approximately 38 min from the brick-and-mortar site in Salem (33.6 miles). The mobile unit departs Grand Ronde at 11:30 PM and travels to First Baptist Church located at 125 SE Cowls St, in McMinnville stopping from 12:00 to 2:15 PM. This is approximately 35 min from the brick-and-mortar site (26.0 miles) and 30 min from Grand Ronde (25.0 miles). It returns to the Salem OTP about 3:00 PM. The van is staffed with a nurse, a counsellor, and a safety technician who also serves as the driver. Patients are strongly encouraged to attend weekly counselling at the fixed site in Salem or on the MMU.

Figure 1. Great Circle mobile van.

Creation of a Tribally operated, culturally oriented OTP serving Tribal members and non-members (Figure 2) is noteworthy. Because it is the only Tribally operated MMU, and to document the operations and impact of the MMU, the Great Circle Recovery OTP’s leadership invited investigators to review OTP documents and conduct qualitative interviews with patients and staff. The qualitative implementation study addressed two aims: (1) describe the development of the MMU initiative through document review and an interview with the state opioid treatment authority and (2) examine experiences, barriers and facilitators to MMU services from the perspectives of patients and staff.

Figure 2. Great Circle mobile van brochure.

Materials and methods

The study team conducted semi-structured qualitative interviews with patients (n = 11) and staff (n = 5) affiliated with the Great Circle Recovery MMU (February and March 2023). Patients received a $40 gift card after completing the interview. Interviews with providers probed implementation experiences including barriers and facilitators (employees did not receive a gift card). Patient interviews focused on their experiences with the MMU and the MMU staff, changes in quality of life, and suggestions they might have for enhancing treatment. An interview was also conducted with the Oregon State Opioid Treatment Authority to gather details on the initiative’s development. To understand the context for the OTP, the team completed an informal document review prior to conducting interviews.

Data collection and processing

Great Circle Recovery staff developed a purposive sample of prospective patients and staff. Staff member CG approached prospective participants, explained the study’s purpose and ascertained interest in participation as a study respondent. Following Informed Consent, in-depth, one-to-one interviews were conducted either in person or by phone (KH and CG). Twelve patients were invited to participate and 11 completed an interview, a sample size adequate to fulfill thematic saturation. All invited staff members participated. The interviews ranged from 15 to 35 min. Interviews were audiotaped and professionally transcribed verbatim, removing identifying information. The study was approved by the Oregon Health and Science University Institutional Review Board. The Grand Ronde Tribal Council also approved the study and manuscript.

Data analysis

Data were analysed using Thematic Analysis [14] with a five-step mixed deductive and inductive approach. The first author (KH) led the qualitative analysis; she has extensive experience leading qualitative investigations [15–17] as well as publishing qualitative methods manuscripts [18–20]. Step 1: ‘Familiarizing yourself with your data’: KH, KP and DM read all transcripts making note of initial ideas for a coding framework. Step 2: ‘Generating initial codes’: KH and KP crafted the coding framework, with input from DM. The preliminary coding scheme was applied to the data set, collating data relevant to each code. Step 3: ‘Searching for themes’: KH, KP and DM collated codes into potential themes by gathering relevant data into each potential theme. Step 4: ‘Reviewing themes’: KH reviewed themes and generated a thematic schema. Step 5: ‘Defining and naming themes’: KH and KP performed continued analysis to further operationalize each theme and generate definitions. A consensus-based inter-coder agreement process was conducted to ensure coding reliability. Using ATLAS.ti Web (Version 3.19.1.-2022-06-20) [21], KH and KP coded the data with this framework. Step 6: ‘The Standards for Reporting Qualitative Research’ structured presentation of results.

Results

Staff results

The staff sample included two counsellors, a nurse, and two administrators. Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members, and the catalysts for the MMU’s creation), two steps towards MMU development (i.e. Tribal approvals and support, and the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers and facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Results are summarized in Table 1.

Table 1. Staff results.

Theme	Subtheme	Example Quote
The driving force	Desire to create a “great circle” of wellness accessible to all community members.	“We operate as a culturally sensitive and a culturally diverse organization. The Tribe realizes they are a part of a larger community—a Great Circle. We are part of a larger community, and we help everyone” (Staff 05).
	Catalysts for the unit’s creation included increases in overdose deaths and rural transportation barriers among Tribal members.	“People are dying, they are killing themselves. We are saving lives. … What really becomes the ah ha moment is when they have a family member, or we have a Tribal member that everybody knows … overdose. All of a sudden, the light bulb goes off and people are like, we got to do something about this. … We are doing something. This is how you can help. Once that happens and [members] realize they can be a part of that healing process by helping people get connected to services.” (Staff 04).
Establishing networks	Initial Tribal approvals and support for the mobile unit.	“I have never had that kind of support anywhere I have worked. It is because the membership is us. It’s our families. It’s our people. It becomes our connection to our membership. The [Tribal council’s understanding of] the importance of being able to provide these services is amazing … My Tribal council supported our ability to bring on these services and the mobile unit. I can’t say enough about how much that means, having a Tribal council that supports all of the good work that we are doing. They have been critical to making this happen.” (Staff 04)
	Building and maintaining community relationships	“Few states had experience with the operation and management of MMUs. It is all new and every situation is unique. We [The Great Circle Recovery OTP director and I] thought about how to develop the OTP and where to locate the OTP for the most impact.” (SOTA)
Implementation and impact	MMU operations, implementation barriers, and facilitators.	“If they have an appointment, we can see that on the screen and we remind them that day or ask, ‘did you go to it?’ If not, let’s re-schedule and get you back on your schedule. If they are not going to counseling appointments, the counselors will put a stop check to have a session before they receive a dose. We do that right there with a cell phone.” (Staff 02).
	Reduced stigma associated with opioid agonist therapy.	“A lot of the younger [Tribal members] are afraid of being seen getting treatment … because there’s a big stigma around addiction and with their culture … they don’t believe in the medication. … With the mobile unit we’ve helped people overcome that feeling. They feel they are getting the help that they need in a way that is good for them. … They are not afraid of getting treatment anymore.” (Staff 02)

Theme 1: the driving forces

1a. Desire to create an inclusive approach to wellness accessible to all community members

Development of the Great Circle Recovery OTP began with a vision for a community of individuals supporting recovery. A critical feature was embracing the Tribe’s cultural beliefs and practices. The program supervisor explained that Tribal membership plays a pivotal role in this conceptualization:

“I can’t explain the feeling of being a member of the Tribe other than being part of something bigger than yourself. … We all have this connection that brings us together. We might not all be cousins; we might not have family relationships, but we have this Tribal relationship. For some, [when they seek treatment] they feel like they are failing. … That step isn’t failure, that step is success because you are coming forward for help. We are here for you. One of the biggest things for me has been this idea of creating an environment in health and wellness. Very much about people having access no matter where you are or what you’ve done. You deserve the services we can provide, and you deserve to be a part of this community. That’s been a big chore. …With Great Circle we’ve been able to create that, beyond the Tribal membership really. You are a part of something bigger than just your own recovery and we have more to offer you.” (Staff 04)

Similarly, a counsellor voiced, ‘We operate as a culturally sensitive and a culturally diverse organization. The Tribe realizes they are a part of a larger community–a Great Circle. We are part of a larger community, and we help everyone’ (Staff 05). This perspective on inclusiveness creates an ambiance of recovery and community.

Additionally, the MMU offers a low-barrier approach. The MMU supervisor explained, ‘First and foremost, we have to get people not overdosing and feeling sick’ (Staff 01). Lowered barriers to OTP services begin with an understanding that patients new to care do not immediately stop illicit opioid use. A nurse echoed this sentiment:

“Harm reduction is the initial goal. Full recovery is the optimal thing but our [first step] is to slow down their use. If we can get them to come in four days a week instead of seven, we’ve made progress. [They may not] engage in counseling but [they] come in for their methadone and we can work on counseling. We can work on education. We can work on building rapport and move them along the stages of change.” (Staff 03)

A staff member in a leadership role elaborated on the role of the mobile medication unit:

“We see our clients all the time within the walls of the clinic. Being able to see them on the mobile unit … to access services is amazing. They are here. They made it. This isn’t a barrier. Transportation isn’t a barrier. That’s what we are all about is making this a low barrier option for [patients]. Make it as easy as possible for them to connect and find wellness. The staff are amazing. I feel empowered by them. It’s an honor to be in my role and have the staff working with me.” (Staff 04)

1b. Catalysts for the unit’s creation included increases in overdose deaths and rural transportation barriers among tribal members

Increasing fentanyl use within the Grand Ronde community escalated the need for an MMU. The unit manager explained, ‘this is a new animal [illicitly manufactured fentanyl] we are dealing with. … We have to open up different measures in order to help the community’ (Staff 05). He continued, ‘health and wellness is a very, very large part of the Tribe and [the MMU] was a part of battling an opioid and fentanyl crisis that’s affecting that community. … I believe [Tribal Elders and leaders] are all for it if we are operating it with respect and using culturally sensitive, even spiritual, dynamics.’ His supervisor added, ‘I had to do a business plan. … [Grand Ronde leadership] understood because they were seeing the effects of heroin use and fentanyl use. Now it’s all fentanyl mixed with other polypharmacy’ (Staff 04).

The health director echoed the background and need for the MMU: ‘We were seeing the surge of fentanyl, and we were seeing the problems of heroin. We’ve had Tribal members die from overdose. Knowing that [the MMU] could be a potential resource that’s right here, right now, was huge.’ She elaborated,

“People are dying, they are killing themselves. We are saving lives. … What really becomes the ah ha moment is when they have a family member, or we have a Tribal member that everybody knows … overdose. All of a sudden, the light bulb goes off and people are like, we got to do something about this. … We are doing something. This is how you can help. Once that happens and [members] realize they can be a part of that healing process by helping people get connected to services.” (Staff 04)

The health director championed the need for an OTP as a necessary response to the increased risks of overdose because of the increased presence of fentanyl in the community drug supply and the need that effective and safe treatment required access to methadone and the creation of an OTP.

The OTP also wanted to extend their reach beyond the brick-and-mortar Salem site to more rural areas, but ‘the biggest barrier for our clients and Tribal members that live outside of the Salem area was transportation.’ They explored multiple options such as a bussing system: ‘We tried putting together some fixed route transportation ideas. Could we do a bus system? but when the Oregon SOTA [State Opioid Treatment Authority] announced they would be open to mobile methadone, we realized it was the answer to reaching vulnerable patients in remote areas such as the Grand Ronde reservation.’

Oregon’s State Opioid Treatment Authority (SOTA) described his role in the process and his expectations for how the unit will impact the communities it services. He had salient observations (quotation paraphrased for clarity and conciseness).

“The Grand Ronde mobile medication unit serves underserved populations in Tribal communities and in rural Oregon. … The Salem OTP serves many who are not native … They fill a niche serving rural communities in the Willamette Valley and the Oregon coast. Previously, these rural communities did not have access to OTP services. We need treatment in rural communities. The van serves that need. It is a good outcome. I have encouraged other OTPs to reach out to underserved areas of the state.

We can do this to scale and care for more people who are underserved. Great Circle also provides culturally specific care with programming and support for Tribal members, other American Indians, and non-natives. It is a care option. We need many options.

Having options is better than having only one choice…. It is satisfying to see it come to fruition with a brick-and-mortar OTP and an MMU.”

Federal regulation requires the ‘State Opioid Treatment Authority’ in each state to approve OTP services in their state. SOTAs manage the development, licensing, and operation of OTPs within their jurisdiction. Even though American Indian Tribes are considered Sovereign Nations, the SOTA must approve an OTP even if it is based on a reservation; SAMHSA will not certify an OTP without SOTA approval. Grand Ronde invested in developing a collaboration with the SOTA and assisted the SOTA’s goal to expand access to opioid agonist medication within Oregon.

Theme 2: Establishing networks

2a. Initial tribal approvals and support for the mobile unit

The clinic director stressed her gratitude for the support of the Tribal Council and the Tribe.

“I have never had that kind of support anywhere I have worked. It is because the membership is us. It’s our families. It’s our people. It becomes our connection to our membership. The [Tribal council’s understanding of] the importance of being able to provide these services is amazing … My Tribal council supported our ability to bring on these services and the mobile unit. I can’t say enough about how much that means, having a Tribal council that supports all of the good work that we are doing. They have been critical to making this happen.” (Staff 04)

She volunteered that support from the DEA and SAMHSA was critical, as well. She expressed that the DEA were ‘amazing’ and ‘super helpful’. Given that this was a unique population, there were questions about the inclusiveness of the van and general OTP operations such as whether they would they be open only to tribal members and ‘how does this relate to being a sovereign nation?’ (Staff 04). The OTP could not develop without explicit approval from the Tribal Council. She described implementation challenges with staffing and physician coverage for inductions:

“The biggest barrier to mobile services, right now, is that you cannot [complete] an intake without a physician present. In order to make sure we can get Tribal members access, once a week I have a physician that goes out to Grand Ronde to do intakes. If you don’t have somebody ready to do an induction the moment someone shows up, you lose that patient because this population [does not] schedule appointments with primary care and return at 2 pm. You have to have physicians on standby and that can get expensive.” (Staff 04)

Another participant noted that inclement weather and staff coordination are consistent challenges for mobile services and pose an additional toll to the workforce given the need for ‘a lot of planning’ (Staff 01).

2b. Building and maintaining community relationships

An advantage of MMUs is the ability to travel to remote locations and provide services closer to where patients live. The OTP, however, needed community support (or minimal community opposition to its presence) to park and provide needed care when operating off-reservation. Staff worked hard to gain acceptance by the surrounding community:

“We did a full court press trying to just break that down [community concerns]. It’s something we deal with all the time but before we went live with [the van] we did a real push on it so people would be ready and understand what we were doing. … Education around what medications are, what the medications do, and how it helps people … There’s always people that are not ready to accept these types of services, especially in a community that’s small.” (Staff 04)

The State Opioid Treatment Authority mentioned that the operation and management of MMUs is unique, and each environment posed its own challenges. He noted that ‘We [The Great Circle Recovery OTP director and I] thought about how to develop the OTP and where to locate the OTP for the most impact.’

When asked about building community relationships, a nurse noted, ‘Our director had to meet with the rotary club of one town … they talked to local police, they talked to the local fire department; this was in multiple places. And we just kind of had to get the okay of where to park, let the city know we were going to be there, and basically get the word out to the community that we were available as a resource’ (Staff 02). There was minimal community resistance. According to the MMU manager, ‘The only push back that I dealt with is with methadone and child welfare and things like that because … other systems don’t necessarily understand how methadone works’ (Staff 01). Another staff member added,

“We spoke with community members about where to park. Communities received us well. They let us know they are happy that we are there. … Everyone usually knows somebody that is affected by the opioid crisis. They know that there is somewhere they can direct them to. [That] outweighs the negative reaction to anybody about us being there. We have rules and regulations about where we can park. … We follow those to a T.” (Staff 05)

The mobile services also prompted new prospective patients to seek treatment. One staff member reported that existing clients would spread the word to friends and family members and encourage them to ‘walk on’. Additionally, he mentioned that the MMU ‘is an advertisement’ driving through communities. (Staff 05)

Theme 3: Implementation and impact

3a. MMU operations, implementation barriers, and facilitators

Providing care from the MMU required creative and flexible adjustments to the mobile environment in terms of workflow and use of space. A nurse described her initial concerns and reactions, ‘I thought it was crazy [the MMU] and I also thought it was a super scary situation because anything could happen. It’s a mobile unit that’s going out and … we didn’t know what to expect. Expecting the unexpected is hard.’ She explained that her concerns were quickly alleviated as patients and staff bonded and crafted a secure structure, ‘We created a little family with the nurses, a safety tech and a counsellor. … All the patients, especially in the Grand Ronde area, know each other and they are their own little family. They come in. They ask each other how they are. They watch out for us. They are our little protectors.’ (Staff 02)

Dispensing MMU nurses help patients maintain contact with their counsellors. The nurse explained:

“If they have an appointment, we can see that on the screen and we remind them that day or ask, ‘did you go to it?’ If not, let’s re-schedule and get you back on your schedule. If they are not going to counseling appointments, the counselors will put a stop check to have a session before they receive a dose. We do that right there with a cell phone.” (Staff 02).

A counsellor reported using the MMU for sessions and check-ins: ‘If people are missing counselling sessions or not attending groups, I can hang out and talk with them. If they are not doing groups, I meet them individually’ (Staff 03). A peer recovery support specialist is also available, who ‘assists if they can’t make it to the dosing unit; she picks them up and brings them in so they get their medication. She will help them if their car broke down. She gets them in to get their medication’ (Staff 03). The MMU staff became more flexible in how they provided care.

3b. Reduced stigma associated with opioid agonist therapy

Respondents reported that the MMU’s mobility and presence in the community has reduced the stigma associated with agonist therapy. A counsellor observed that the MMU ‘Is breaking down walls. It is an amazing tool for the AI/AN community. … [OUD] is not a shameful thing. …. People [in rural communities] can really get help’ (Staff 05). A nurse explained that time was required for people to become comfortable with the mobile service and ‘understand their wellness was more important than the concerns, shame, or paranoia [of receiving care]. … The mobile unit doesn’t scream, “I am in an opioid treatment program.” The van says, “Grand Ronde Health and Wellness: Great Circle Recovery”’ (Staff 04). Another staff member elaborated:

“A lot of the younger [Tribal members] are afraid of being seen getting treatment … because there’s a big stigma around addiction and with their culture … they don’t believe in the medication. … With the mobile unit we’ve helped people overcome that feeling. They feel they are getting the help that they need in a way that is good for them. … They are not afraid of getting treatment anymore.” (Staff 02)

Tribal leadership saw the need and lent their support. A counsellor reflected, ‘With our unit and the changes that we have made in the last two years, the Elders … see that we are helping people overcome the barriers, overcome the stigma and getting the treatment that they need’ (Staff 02). The mobile unit became an extension of the Grand Ronde brand and reflected the Tribe’s efforts to enhance its healthcare services.

Because the MMU serves rural patients in their rural communities, patients have a certain ease with utilizing its services. They are not required to drive to ‘the city’ and be seen at a large OTP as ‘Sometimes people … are nervous about coming into a clinic where there could be a lot of people … and uncomfortable-ness, and maybe some shame’ (Staff 05). Another staff member elaborated:

“[On the van,] we’ve created a good rapport with the clients. … They are a lot more open. They feel … closer to us because they don’t have to come into the clinic and worry they are 200th in line. They get to have conversation with us and we learn a lot more about them on mobile. Which is nice because we want to provide wrap around care. We want them to be that whole person, whether they are Tribal or not. With mobile [services], we get better relationships with people because there’s so much more 1 on 1 time with them.” (Staff 02)

Patient results

Of the 11 patient participants, 73% identified as AI/AN, and 27% identified as White. 60% were married, 40% were single or divorced. 27% were below age 34 (minimum age 31), 18% were between the ages of 35–44, and 56% were above age 44 (maximum age 69), and the mean age was 48.5. Themes which emerged from the patient interviews included, (1) the MMU’s operational and ‘caring’ environment, (2) accessible location saves on time and transportation costs, and (3) general suggestions including culturally responsive ancillary services. See Table 2 for summary of patient results.

Table 2. Patient results.

Theme	Example Quote
MMU’s professional and “caring” environment.	“I met the people on the mobile van. They were so sweet and so nice. I was excited and nervous and scared, but they made it so easy. It made me feel very comfortable. The next day they picked me up and made [methadone induction] easy and pleasant. Very caring. Which means a lot to me.” (Patient 1)
Accessible location saves on time and transportation costs.	“Well, obviously the location. Just the way it’s set up is really nice, too. You know, it’s just easy-peasy. The location-- they use, there’s parking, there’s not a problem with that. The staff is super nice. So, it just feels very welcoming to like, it’s fast. I am always at the Salem place way longer than I am at the mobile, you know, waiting. It’s very efficient I feel like, too.” (Patient 6)
Critiques and suggestions including culturally responsive ancillary services	“I think that if we had like you know, wheelchair accessible or easier way to get into it-- it would be a lot better…’Cause that’s kind of what sometimes stops me is having to climb up the steps to get in there.” (Patient 5)

Theme 1: MMU’s professional and ‘caring’ environment

MMUs differ from traditional brick-and-mortar OTPs. Patients typically wait near the van’s parking area prior to its arrival and stand in a line in the open while waiting for their daily dose of medication. It is all in public and there could be concerns about confidentiality and safety. Asked about confidentiality concerns, a patient explained, ‘[Staff] are pretty good about it [confidentiality]. They don’t say anything in front of anybody. It’s not like they try to talk about it in front of anybody’ (Patient 07). A second patient explained that they did not have concerns about physical safety, ‘I’m not really worried about it. [Tribal] security should be well aware that we are here, patrolling at least while [the van is] here’ (Patient 5).

All participants noted the welcoming environment provided by staff. A patient described her decision to use the van to begin methadone treatment and confided that initially she and her husband were not interested in using the MMU. However, both used fentanyl and ‘…finally said “we are going– jump in with both feet al.l balls straight ahead” (Patient 5). She and her husband feel that the staff are friendly and the methadone is working well for them.

Staff’s support and friendliness was a key feature to patient satisfaction with the mobile services. A patient entering treatment explained,

“I met the people on the mobile van. They were so sweet and so nice. I was excited and nervous and scared, but they made it so easy. It made me feel very comfortable. The next day they picked me up and made [methadone induction] easy and pleasant. Very caring. Which means a lot to me.” (Patient 1)

Another added, ‘They take things slow. They don’t just try to rush you in and out.’ A third patient opined, ‘The people that work in [the van] are awesome. I like how welcoming and outgoing and kind they are’ (Patient 3). Another added,

“Everybody is so nice and patient. … If there’s people before me, I am not waiting very long. It’s hard to say anything bad about [staff on the van] because they are awesome. I would say it’s the easiest best way to get into recovery. … They know your first name. They don’t ignore you, it’s just not like a ­regular clinic. It’s more like family…It’s awesome.” (Patient 9)

One patient summarized his experience as ‘There’s no judgement, they don’t look down on you, it’s like … they are just one of us’ (Patient 8). In general, the professional and caring environment of the MMU described by participants is in keeping with the tribal concept of ‘wellbriety’ where patients are met ‘where they are at’. This conception is critical to creating a healthy, non-stigmatizing environment. Stigma related to the use of methadone or the MMU did not feature in the interviews; rather, as seen above, the participants reported a sense of welcome and inclusiveness from the staff.

The program is also responsive in accommodating specific patient needs. A patient on dialysis described their situation, ‘I am on dialysis so I had to get permission [for take-home] doses because I can’t take it [in the morning] when I have dialysis. I … take it in the nighttime after dialysis because it sedates me too much. … Monday, Wednesday and Friday I have take-homes; the other times I dose here in the van’ (Patient 5).

Theme 2: Accessible location saves on time and transportation costs

All participants mentioned ways in which the MMU facilitates their access to treatment, specifically how easy and convenient it is to use the van and how that impacts their treatment experience. A participant noted: ‘So far, it’s really worked, and I have been able to make it here every day, so it’s been really beneficial for me’ (Patient 4). Participants spoke to the location of the van and the hours of operation as primary reasons the van is so accessible, as one participant expressed:

“Well, obviously the location. Just the way it’s set up is really nice, too. You know, it’s just easy-peasy. The location– they use, there’s parking, there’s not a problem with that. The staff is super nice. So, it just feels very welcoming to like, it’s fast. I am always at the Salem place way longer than I am at the mobile, you know, waiting. It’s very efficient I feel like, too.” (Patient 6)

When asked if they would recommend the MMU to friends or family, all participants said they would or have done so already. Participants noted reasons why they would recommend services, stating for example: ‘It’s easy. Accessible. Like they could come from their job, do it, then go back to their job. If they worked here. … It’s easy to get there and do it’ (Patient 5).

Three patient participants described how well the MMU hours of operation fit into their daily routine, noting that ‘the time of day is perfect’ (Patient 7) and that the operating hours give them time to ‘get other things done’ (Patient 7) during the day, including work.

All participants mentioned that ‘not having to drive to Salem’ (Patient 4) saves them time and money spent on gas. On average, their drive time was reduced from about 40 min to 5 min. A participant explained:

“It’s really convenient. A lot of gas. It saves a lot of time and gas. To the mobile unit– I from my office it only takes me two minutes. I just go on my fifteen-minute break and go over there. It’s awesome.” (Patient 9)

A participant stressed how the MMU is imperative for participants who don’t have consistent access to transportation, describing the MMU as ‘an amazing resource’ (Patient 8). One participant summarized her experience about the MMU’s accessibility:

“What I like about using the van is that it does make it more convenient for travel. It’s also– financially it’s better for us, and it’s really cool. We know so many people out there [and have] so many friends up here, it’s a neat little thing, it’s like a little golden star over there, you know.” (Patient 11)

An unmentioned benefit of the MMU services is the reduction in Medicaid expenditures for medical transportation. State Medicaid programs reimburse patient transportation costs or provide bus, van, or taxi services for individuals to attend medical appointments. Because many OTP patients commute to OTPs daily, the Medicaid costs for medical transportation can be substantial. Mobile services not only reduce commute time and expense for patients, MMUs also reduce Medicaid costs for medical transportation.

Theme 3: Critiques and suggestions including culturally responsive ancillary services

When asked if they had general suggestions for improving the MMU, more than half responded that they did not have any suggestions. Several participants, however, felt that the van could be improved. Some suggested that the van could be made more accessible for the disabled or elderly, specifically those in wheelchairs:

“I think that if we had like you know, wheelchair accessible or easier way to get into it– it would be a lot better…’Cause that’s kind of what sometimes stops me is having to climb up the steps to get in there.” (Patient 5)

Others reported that though they did not need a wheelchair, the stairs were somewhat narrow and steep for their comfort level. One respondent suggested an awning for protection during inclement weather: ‘Maybe just setting up or having like an awning for the days that it is raining … other than that, you know, we can wait in our cars, or we can do whatever, you know. There’s really not much that, you know, else that needs done. It’s just really nice’ (Patient 8).

Two respondents noted minor administrative barriers when coordinating care between the MMU and the main OTP site. The first felt some frustration about not being able to reach staff immediately if there was a ‘flag’ that needed to be addressed before they could dose on the MMU. However, they noted, ‘Usually they can, they will–work together and figure it out like what they can and can’t do.’ (Patient 7). Similarly, another patient described:

“Like today when we got here, we couldn’t dose until we signed some papers– I mean, I feel like we should have signed all the papers right when we started [at the OTP site], you know, so that’s the only thing I could think of was just– and I don’t know there might be reasoning for that, I don’t know. They didn’t say but yeah, that’s the only thing I can think of. Everything else I am very satisfied with.” (Patient 3)

All patient participants remarked that the care they received was culturally appropriate and ‘fulfilling.’ They viewed the MMU as ‘part of the Tribe’ and an opportunity to leverage western medical innovations along with more heritage and/or spiritual approaches they might utilize within their own traditions. When asked for specific suggestions for tailoring of current activities or additional, ancillary opportunities, participants offered a number of ideas. One participant suggested that the counselling groups include cultural topics, specifically ‘how our culture fits in with sobriety; I think we should be able to talk about that’ (Patient 5). Two other participants suggested additional provision for Elders. One suggestion included Elders having the option of receiving weekend take homes on Friday to reduce the burden of traveling to the Salem site for Saturday dosing/Sunday take homes. Another explained:

“We are big on helping our Elders and stuff so maybe even being able to just like if they are home or something and don’t have rides, maybe come to them. So, with the pharmacy, sometimes they have like people that will take the Elders medicine and stuff like that and that helps them. We like to make sure they are taken care of.” (Patient 9)

Another participant endorsed that it would be helpful to those in recovery to have the opportunity to include their family members in traditional healing activities and support recovery:

“I think having more options to go to different you know… made it optional to have like a sweat lodge or drumming class or something like that. A lot of people would like that. Kind of like make it like a family thing. I am more about family, and you know, being with them and showing them like walking them through my recovery so they see where I am at, and you know? You can even add to that, like a drum making class. Or something like know how to make natural stuff…like so when we were younger in culture camp, we would learn how to make certain things - like natural… oil and ointment stuff. We made it and like they have fun doing it and they get to use it and it actually helps.” (Patient 7)

When asked about wrap-around services that could be added either at the MMU or the Salem OTP that would be important for AI/AN community members, a participant responded with important contextual information:

“Culture. Culture is prevention. And if they had more cultural activities at the clinic, ‘cause I know there’s some natives that can do drum making classes, making drums is part of culture. Beading classes, music—drumming groups, all that stuff—outreach, outreach. I mean they already got it perfect there. I was always ashamed to be an Indian and fighting all my life ‘cause I was a different color—I wasn’t pale, I was dark. And just me and my sisters always fighting all our lives. Anyways, the whole point is that I didn’t have any spirituality in me. I was in foster homes, and I was forced Catholic, forced Christian, Mormon. All this stuff, so when I finally got out of foster homes and I was back in my home and we are already broken, there’s no spirituality or anything like that. I always didn’t feel—like I was missing something and then I ended up going to prison and I got into a native club, and I was like, why—what’s this about and they started doing talking circles. Drum groups, they started doing sweats and stuff like that. It opened my heart. It opened my heart and it felt like this is where I needed to be all my life. It was what I was missing, it was that hole in my heart. I probably would have been dead by now. That’s how I stayed clean for 27 years. A lot of natives that don’t know the culture and once they get that little taste it’s going to open their heart… and [get] the tools that they need to stay clean and sober.” (Patient 9)

Discussion

The opioid epidemic has had serious and detrimental consequences for AI/AN communities, creating the need for evidence-based, culturally appropriate treatments for substance use disorders. A scoping review indicates that culturally sensitive interventions used in substance use disorder treatment for AI/ANs are beneficial to help improve function in overall wellness [22]. The Confederated Tribes of the Grand Ronde Community are among the first Tribes to sponsor and operate a culturally oriented OTP. The Great Circle’s MMU serves people with OUD who are culturally and rurally isolated with limited care options. Results of our study indicate that patients are pleased with the care they receive as well as the elimination of the transportation barrier to daily dosing at the Salem OTP. The subtext of the caring environment theme contrasts with the reputation of fixed-site OTP programs known for strict rules, robotic dosing, and little evidence of personalized care. The flexibility of the mobile setting and environment broke the mold and exceeded patient expectations. Results show that the treatment provided meets the current general guidance for serving AI/AN communities [5, 23]. Staff results describe the driving forces behind the creation of the MMU and how the community relationships are built and maintained.

The Drug Enforcement Administration ceased approval of mobile medication units in 2007 citing concerns with regulatory challenges and diversion [11, 24–26]. In response to the increasing toll of opioid overdoses, the need for more access to opioid treatment programs, and public advocacy, the DEA reconsidered mobile medication units and issued new regulatory requirements and guidance in 2021 [11, 13, 25, 26]. Long-term effects of the regulatory change, however, are unknown because of the absence of systematic research on how the MMUs operated in the 1990s and the challenges of implementing and operating mobile services.

Mobile medication units promise expanded access to care. The American Association for the Treatment of Opioid Dependence, for example, anticipates support from the U.S. Department of Agriculture to finance the purchase and use of vans to serve rural communities and support from states and counties to provide methadone and buprenorphine for individuals in jails and prisons [27]. The initial costs of purchasing a vehicle and customization to meet Drug Enforcement Administration requirements (e.g. a secured safe, vehicle tracking technology13] and to address clinical needs (e.g. wireless access′s to the clinic’s electronic record system) are substantial, and combined with the operational costs (e.g. staff, gasoline and vehicle maintenance), however, are prohibitive in many settings [28]. The Great Circle OTP repurposed an out-of-service mobile medical van. Still, the vehicle transformation costs exceeded $100,000. To facilitate broader use of mobile medication units, OTPs require financial reimbursement mechanisms that fully support the construction and operation of the services.

Our analysis of the interviews with Great Circle patients and staff and the mobile unit’s operational details adds to the scant literature assessing mobile methadone treatment [7]. Consistent with the assessments of methadone vans in New Jersey and Baltimore, access to opioid agonist therapy with methadone increased in rural and urban communities [9, 10]. The mobile methadone medication units that operated in the 1990s provided essential clinical care but, unfortunately, little of that experience was documented in the peer-reviewed research literature. Qualitative and quantitative analyses of the 2020s vans and services are critical to better understand how mobile medication units operate and the long-term impacts of the services.

American Indian communities have been reluctant to incorporate medications for the treatment of opioid use disorder into tribal health services [5]. The Great Circle MMU operates within the tribal concept of wellbriety where ‘culture is prevention’ and recovery is a progression from sobriety to being well in spirit and in health [29]. The Great Circle MMU patients described the caring and confidential atmosphere they experienced on the van and in the clinic. They appreciated that the MMU reduced transportation problems and facilitated their use of care. The MMU clients were generally pleased with the services and encouraged more opportunities to include family members in care processes and for services to incorporate more culturally oriented activities (e.g. drumming). MMU staff spoke with pride about their initial emphasis on harm reduction, their ability to coordinate care and encourage clients to be active in counselling sessions. Counsellors and nurses acknowledged the Tribes’ support for the OTP and van and perceived less community and Tribal stigma associated with the need to address drug use disorders.

Limitations

The qualitative analysis of the Great Circle Recovery OTP’s MMU examines the implementation of mobile methadone distribution in one OTP that is uniquely culturally oriented toward serving Native patients. As such, the results describe patient and staff perceptions of the van and its operation and may not generalize to other MMUs. Additionally, the study relied on a convenience sample and the views of the participants currently in treatment and willing to participate in an interview may not be representative of all individuals served by the MMU. A strength of the study, conversely, is that it offers insight into the implementation of culturally oriented methadone treatment among AI/ANs. The elevated rates of opioid use and opioid overdoses among persons who identify as AI/AN suggest a need for more access to opioid treatment programs in Indian Country.

Policy implications

The Grand Ronde Great Circle Recovery opioid treatment program is enriching patients and surrounding communities, reducing stigma associated with opioid treatment and the use of methadone to support recovery, and addressing the burden of opioid use and opioid overdose mortality in Indian Country. AI/AN Tribes throughout the nation (n = 547) can learn from the Confederated Tribes of the Grand Ronde by introducing opioid treatment and the use of mobile medication units for their respective communities.

Our study demonstrates how State Opioid Treatment Authority (SOTA) flexibility can improve access to methadone care for a vulnerable population. This flexibility was mainly due to pressure on the state of Oregon to provide opioid use treatment to rural communities. Additionally, the DEA and SAMHSA have been much more flexible in the past few years, also largely due to the accelerating opioid overdose numbers. The sustainability of the increased flexibility on the part of governmental agencies – Tribal, State and Federal – experienced over the past three years remains to be seen. It is largely driven by politicians’ need to be seen as ‘doing something to address morbidity and mortality of opioid use disorder and is susceptible to shifts in political attention.

Recommendations for future research

The lessons from the analysis of the Great Circle MMU include the value of integrating cultural learnings and traditions with medical care, recognizing that healthy environments are a component of personal health. Services for non-tribal members are a facet of healing the environment. Opportunities for research include (1) examining the experiences of patients who left treatment but had dosed for more than 30 days through the mobile unit; (2) assessing if and how suggestions from the patients were implemented, proved satisfactory to the patients, and found to be sustainable from the perspective of the SOTA and the OTP; (3) quantitative investigations to measure access and retention of MMU patients vs. TAU (traditional brick-and-mortar treatment) (4) community response (neighbours, businesses, police) to the MMU.

Conclusions and lessons learned

The development of the Great Circle Opioid Treatment Program and its mobile medication unit and the use of opioid agonist medication (i.e buprenorphine and methadone) was a difficult decision for the Confederated Tribes of Grand Ronde as it is for many Tribes [5]. The Grand Ronde Tribes, however, succeeded in developing methadone services because members served as champions and invested in educating the Tribe, the Tribal Council, and the surrounding communities on the extend of the social and health impacts of opioid use disorder among its members. Advocates worked carefully and persistently with tribal leadership, honoured Tribal traditions with the Great Circle perspective, embraced tribal members and non-members as patients and stakeholders, and developed culturally relevant programming consistent with an understanding that restoring culture is part of healing the person and the community. American Indian and Alaska Native Tribes can emulate the Confederated Tribes of Grand Ronde, take a seven-generation perspective and support the use of opioid agonist medications for their members and their communities.

Author contributions

KH, CG, JW, DM and PTK were involved in the conception and design. KH and CG carried out data collection. KH, KP, CG, JW, KR, DM and PTK participated in data analysis and interpretation of the data; KH drafted an initial draft of the manuscript; KH, KP, CG, JW, KR, DM, JL and PTK revised it critically for intellectual content and the final approval of the version to be published. All authors agree to be accountable for all aspects of the work.

Acknowledgments

The authors wish to thank all participants as well as the Confederated Tribes of Grand Ronde for their participation in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Appendix 1

 

Staff interview Guide

Grand Ronde Great Circle Qualitative Interview Guide – STAFF

Thank you so much for talking with me today. We are interested in understanding your experience with the Great Circle Mobile Van. Everything you tell me will be kept confidential. We record interviews to help with remembering the information you share. Stop me at any time if you have any questions, if anything is unclear, or if you would prefer to skip a question.

Your participation may help to make things better for those using the mobile van services, so we appreciate the time that you are taking to talk to us.

What questions do you have before we begin?

OK, I’ll turn the recorder on now and we’ll get started.

Turn on recorder: State today’s date, the current time, and the Participant ID.

Example: “Today is August 2nd, it is 11:30am, and I’m talking to Participant 112.”

First, could you please tell me about yourself – your position at Great Circle, how long you have been there, any credentialing that you have and so forth.

Next, let’s get a brief history of the van and how it got started. What brought about the decision to have a mobile methadone van service

Where is it operating and how does it serve the community?

What are the van’s specific services?

Can you tell me about your target population for the van service?

Could you tell me a bit about the barriers and facilitators to implementation or approaches to solving problems?

Probe: what has gone well, what hasn’t gone well?

Can you tell me a bit about your relationships with the community? How are things going?

Lastly, let’s discuss some of the ways that you see the van operating in the future. Are there changes that you could see occurring, or improvements that you think could be made?

Thanks so much for your time!

Appendix 2

 

Patient interview Guide

Project: Great Circle Recovery Mobile Van Qualitative Study

Qualitative Interview Guide

Thank you so much for talking with me today. We are interested in understanding your experience with the Great Circle Mobile Van. Everything you tell me will be kept confidential and we won’t share your name with anyone besides study staff. We record interviews to help with remembering the information you share. Stop me at any time if you have any questions, if anything is unclear, or if you would prefer to skip a question.

Your participation may help to make things better for those using the mobile van services, so we appreciate the time that you are taking to talk to us.

What questions do you have before we begin?

OK, I’ll turn the recorder on now and we’ll get started.

Turn on recorder: State today’s date, the current time, and the Participant ID.

Example: “Today is August 2nd, it is 11:30am, and I’m talking to Participant 112.”

1. Could you please tell me you’re a) age, b) relationship status, c) employment status d) race/ethnicity

2. Please tell me a little bit about your history and treatment with Great Circle. probes: How long have you been in treatment, how long have you been using the Mobile Van Services?

3. On your first day of treatment, the day you received medication we call this your admission date. Where did you perform your visit? (Salem or Grand Ronde)

4. When you first heard about the van’s services, what did you think? (How did you hear about it?)

5. About how long does it take for you to get to the van? (time, distance, cost) vs. the clinic?

   1. Most travel to Salem on Saturday for dosing-if so, ask what services they receive while onsite there? (i.e. dosing, counseling)

   2. Has the patient received telehealth services?

   3. Have they received services from the counselor at Grand Ronde that is dedicated to the mobile unit?

6. What are some of the "facilitators", or things that make using the Van easy? probes: proximity, times of day, other services like drug screens etc.

7. What are some of the "barriers", or things that make using the Van difficult? probes: family or work responsibilities, worries about been seen by others in the community

8. If a friend was interested in using the Mobile Van Services, would you recommend it? Why or why not?

9. What are some suggestions you might have to make the Van easier to use?

10. We’d like to know a bit about how you feel the Van is meeting the needs of the community, specifically if there are ways to better serve the cultural needs of the indigenous community. Is there anything you could share about that?

    1. Earlier you identified as Native American ask some question as how the van is meeting the needs as a native American? Could it meet your needs any better? Is there something more we could do culturally appropriately?

11. Anything else you would like to share?