xxx (xxxx) xxx Please cite this article as: Claradina Soto et al., , https://doi.org/10.1016/j.josat.2023.209115 Available online 1 July 2023 2949-8759/© 2023 Published by Elsevier Inc. Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation Claradina Soto * , Kimberly Miller , Lou Moerner , VyVy Nguyen , Guadalupe G. Ramos a University of Southern California, 1845 N Soto St., Los Angeles, CA 90032, USA A R T I C L E INFO Keywords: MOUD MAT American Indian Alaska natives Substance use disorder (SUD) Opioid use disorder (OUD) Addiction ABSTRACT Introduction: American Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can beneft from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care. Methods: The study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant in- terviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke’s (2006) refexive thematic analysis in qualitative research. Results: Eleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN pro- viders adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively infuenced MOUD maintenance. Conclusions: Clinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the mul- tiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes. 1. Introduction American Indian and Alaska Native (AIAN) populations experience disproportionately higher rates of substance use disorders (SUD) compared to other racial and ethnic groups (Rieckmann, Moore, Croy, Aarons, & Novins, 2017; Whitesell et al., 2007). AIAN communities suffer a disparate burden of opioid overdose deaths, with rates 2.7 times higher than non-Hispanic whites and heroin overdose rates 4.7 times higher than non-Hispanic whites (Joshi & Warren-Mears, 2019; Scholl et al., 2019). The rate of opioid-related deaths among AIAN populations increased by 39 % between 2019 and 2020 (Centers for Disease Control and Prevention, 2022a). Specifcally, opioid-related deaths increased from 17.7/100,000 persons in 2019 to 27.4/100,000 persons in 2020 (Centers for Disease Control and Prevention, 2022b). Misuse is high as are deaths, and these rates are commonly underestimated among AIAN communities (Becker, Babey, Dorsey, & Ponce, 2021; Espey et al., 2014; Joshi & Warren-Mears, 2018; Manson, 2020). Differences in data coding and weighting adversely impact accurate classifcation and measure- ment of AIAN data (Becker et al., 2021). For example, classifying AIAN individuals solely based on a single race and not allowing the inclusion or combination of other races or ethnicities underrepresents the total number of AIAN individuals identifed (Becker et al., 2021; Falkenstern & Rochat, 2021). This misclassifcation is a considerable public health concern given that racial misclassifcation is tied to the underestimation * Corresponding author. E-mail address: toya@usc.edu (C. Soto). Contents lists available at ScienceDirect Journal of Substance Use and Addiction Treatment journal homepage: www.journals.elsevier.com/journal-of-substance-use-and-addiction-treatment https://doi.org/10.1016/j.josat.2023.209115 Received 12 October 2022; Received in revised form 22 April 2023; Accepted 13 June 2023