Accessibility of methadone treatment via public transit for syringe services program participants in Miami-Dade County, Florida

Accessibility of methadone treatment via public transit for syringe services program participants in Miami-Dade County, Florida | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Accessibility of methadone treatment via public transit for syringe services program participants in Miami-Dade County, Florida Marina Plesons, Eileen Malecki, Katrina Ciraldo, Emilie Ashbes, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4791074/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Methadone is an opioid receptor agonist medication used in the treatment of opioid use disorder (OUD). Geographic distance to opioid treatment programs (OTPs) is a major barrier to treatment, given requirements for direct observation of dosing and periodic drug screens, and ‘methadone treatment deserts’ are defined as a public transit threshold of 30 minutes. The purpose of this study was to examine public transit access to methadone treatment for participants of a syringe services program (SSP) in Miami-Dade County, Florida. Public transit times were calculated using the R library r5r, which facilitates multi-modal transportation network routing. General Transit Feed Specification data was combined with street network data from OpenStreetMap for Miami-Dade County. Transit times were estimated from the population-weighted centroid of each zip code (n=79) with participants of Miami’s only SSP (n=1597) to the nearest OTP (n=4) using 10 departure windows aligned with OTP service hours. The mean one-way transit time from zip codes with SSP participants in Miami-Dade County to the nearest OTP was 80 minutes. 75 of the 79 (95%) zip codes with SSP participants in Miami-Dade County have a mean transit time to the closest OTP greater than 30 minutes. Transit times differ substantially between zip codes with different numbers of SSP participants, but not between departure windows. Nearly all zip codes with SSP participants in Miami-Dade County can be classified as ‘methadone treatment deserts’. Geographic isolation of methadone treatment from public transit routes represents a significant barrier to equitable OUD treatment. Methadone public transit access people who inject drugs Figures Figure 1 Figure 2 Introduction In 2021, more than 106,000 people in the United States died due to drug overdose, representing a 14% rise in overdose deaths compared to 2020; 1 of these deaths, approximately 75% involved opioids. 1 Treatment with a medication for opioid use disorder (MOUD) has been shown to reduce rates of opioid overdose, all-cause mortality, and suicide by more than 50%. 2,3 Discontinuation of a MOUD, meanwhile, is associated with relapse and overdose; thus the recommended duration of treatment is indefinite and individualized. 4 However, while the number of facilities providing MOUD and patients receiving MOUD have increased over time, 5 major gaps remain in the opioid use disorder (OUD) cascade of care. 6 It is estimated that only 20% of people with OUD in the United States receive specialty care in a given year, less than 35% of those individuals receive evidence-based treatment with a MOUD, and most of those individuals discontinue treatment within months. 6 Furthermore, significant disparities exist in access to and use of MOUD across the rural-urban continua and by race and ethnicity. 7 , 8 Methadone, a full µ-opioid receptor agonist, is one of two opioid receptor agonist medications used in the treatment of OUD. Despite being a life-saving medication, especially for the increasing number of patients who do not tolerate buprenorphine in the era of fentanyl and other high-potency synthetic opioids, 9 it is tightly regulated by SAMHSA, the DEA, and the FDA as a Schedule II controlled medication. Historically, these regulations required that it be dispensed daily under direct observation at federally and state-designated OTPs until patients met certain criteria, including accrual of time in treatment and demonstrated abstinence from all illicit substances by urine drug testing. After three months of daily observed treatment, OTPs allowed patients with a daily dose ≤ 100 mg two take-home doses per week for the first two treatment years, three take-home doses per week for the third treatment year, and six take-home doses per week for subsequent years, conditioned on appointment attendance and negative urine drug screens. 10 In addition, patients had to comply with periodic random drug tests and be seen yearly by a physician in the clinic. In March 2020, to reduce risk of COVID infection for patients and staff at OTPs, SAMHSA made temporary allowances for relaxed take-home protocols, permitting states to allow OTPs to provide 27 take-homes to patients who were stable and 13 take-homes to patients who were less stable. Based on evidence that these relaxed take-home protocols did not result in increased negative outcomes, 11 , 12 SAMHSA made these flexibilities permanent in February 2024, marking the first substantial update to the OTP treatment standards in over 20 years. Patients may now be eligible for unsupervised, take-home doses of methadone upon entry into treatment. While this federal change increases access to methadone, states still have the authority to determine their own OTP regulations (see Table 1 for a comparison of previous and current regulations in Florida), and decisions regarding take-home protocols, where permitted, are based on the clinical judgment of healthcare providers. Table 1 Current and previous take-home allowances for methadone treatment in Florida 13 Pre COVID-19 pandemic Take-home privileges shall be limited to the following: i. No take-homes shall be permitted during the first 30 days following placement unless approved by the state authority. ii. Following 30 consecutive days in treatment, the client may be eligible for 1 take-home per week from day 31 through day 90, provided that the client has had negative drug screens for the preceding 30 days. iii. Following 90 consecutive days in treatment, the client may be eligible for 2 take-homes per week from day 91 through day 180, provided that the client has had negative drug screens for the preceding 60 days. iv. Following 180 consecutive days in treatment, the client may be eligible for 3 take-homes per week with no more than a 2-day supply at any one time from day 181 through 1 year, provided that the client has had negative drug screens for the preceding 90 days. v. Following 1 year in treatment, the client may be eligible for 4 take-homes per week with no more than a 2-day supply at any one time through the second year of treatment, provided that the client has had negative drug screens for the preceding 90 days. vi. Following 2 years in treatment, the client may be eligible for 5 take-homes per week with no more than a 3-day supply at any one time, provided that the client has had negative drug screens for the preceding 90 days. Current (as of May 19, 2022) Take-home privileges shall be limited to the following: i. During the first 90 days of treatment, the take-home supply is limited to a single dose each week. The individual shall ingest all other doses under appropriate medical supervision. ii. In the second 90 days of treatment, the take-home supply is limited to two doses per week. iii. In the third 90 days of treatment, the take-home supply is limited to three doses per week. iv. In the remaining months of the first year, an individual may be given a maximum of six-day supply of take-home medication. v. After one year of continuous treatment, an individual may be given a maximum two-week supply of take-home medication. vi. After two years of continuous treatment, an individual may be given a maximum of one-month supply of take-home medication but must make monthly visits. Table 1 . Current and previous take-home allowances for methadone treatment in Florida 13 This regulatory environment stands in stark contrast to that of buprenorphine, a partial µ-opioid receptor agonist also used in the treatment of OUD. In April 2020, SAMHSA removed the requirement for an in-person assessment for the prescription of buprenorphine, thereby enabling new telehealth-based models of care for OUD. Based on evidence that this policy change increased patient engagement and satisfaction with care, it extended this flexibility in the post-pandemic era. 14 Likewise, in December 2022, US Congress removed the requirement for practitioners to apply for a special waiver prior to prescribing buprenorphine for OUD. Since then, there has been progress in expanding low-threshold buprenorphine treatment in critical settings like SSPs. 15 However, evidence demonstrates that White patients are four times more likely to be prescribed buprenorphine as Black patients, 16 and that buprenorphine patients are more likely than methadone patients to be employed, have higher levels of education, and use prescription opioids instead of heroin. 17 Thus, this progress risks exacerbating existing racial and socioeconomic inequities in treatment for OUD unless paired with similar efforts to create low-threshold methadone treatment. 18 Availability and accessibility, two of the five dimensions of access to healthcare, of OTPs are critical considerations in increasing initiation and retention in methadone treatment. 19 Research has shown that a significant number of patients travel considerable distances to access methadone treatment at OTPs. 20 Geographic distance to OTPs, and the associated time and financial costs of attending treatment, are thus major barriers that people who inject drugs (PWID), including those enrolled in syringe services programs (SSPs), face in accessing methadone. 21 , 22 As a result, studies have also shown that geographic distance is negatively associated with methadone treatment retention. 23 – 25 However, nearly all studies examining the accessibility of OTPs have utilized geographic distance or driving time, rather than public transportation transit time. 20 , 22 , 23 , 26 – 30 This is an important distinction since lower-income individuals, especially those in urban areas, are more likely to rely on public transportation, 31 and access to efficient, well-functioning transportation systems is a notable social determinant of health equity. 32 In 2021, approximately 7,800 deaths due to drug overdose occurred in Florida 33 . However, as of October 2023, there were just 78 clinics licensed to dispense methadone for the treatment of OUD in Florida and 4 in Miami-Dade County. To date, there are no studies investigating the geographic accessibility of methadone treatment in either the state or the county. To begin to fill this gap, this study sought to examine public transit access to methadone treatment for participants of an SSP in Miami-Dade County, Florida. Methods Based on the methods utilized by Yücel et al, 26 this study leveraged open-source geographic databases and local public transit scheduling data to estimate multi-modal public transit access to methadone treatment for SSP participants in Miami-Dade County. We then compared estimated transit times to the 30-minute transit threshold established in the literature as an indication of a ‘methadone treatment desert’ 34 to describe methadone treatment accessibility. Data Sources Four data sources were required for this analysis. First, OTPs operating in Miami-Dade County as of October 2023 were identified from SAMHSA’s Opioid Treatment Program Directory and contacted to confirm provision of outpatient methadone treatment. The addresses of these OTPs were obtained from the Florida Department of Children and Families and converted into latitude and longitude coordinates, as were the addresses of the SSP’s fixed site and mobile locations. Second, the zip codes of PWID enrolled as participants of the SSP (n = 2267 as of October 30, 2023, n = 1597 of whom reported a zip code in Miami-Dade County on enrollment) were extracted from the SSP’s administrative data. Of the 89 zip codes in Miami-Dade County, 79 had at least one SSP participant; zip codes with ≤ 5 individuals were suppressed to maintain participant anonymity. The population-weighted centroids of these zip codes were identified from the Department of Housing and Urban Development. Third, street network data for Miami-Dade County was obtained from OpenStreetMap, a spatial data source that provides a free, maintainable, and editable map of the world. Finally, General Transit Feed Specification data was obtained from the Miami-Dade Department of Transportation and Public Works. General Transit Feed Specification data is published by transit agencies and contains the locations of transit stops and the schedules and routes of the various transit modes in a transit network for use by a wide variety of software applications. Routing Analysis Following the methods proposed by Yücel et al, 26 this routing analysis utilized the R library r5r, which facilitates multi-modal transportation network routing. 35 The General Transit Feed Specification and OpenStreetMap data were combined to create the transit network. The population-weighted centroids of each zip code with PWID enrolled in the SSP were designated as points of departure, and the locations of the four OTPs in Miami-Dade County were designated as points of interest. Finally, ten departure windows were specified in line with the OTPs’ service hours (8am and 10am Monday-Friday). The r5r library then identified the nearest point of interest for each point of departure and calculated the average one-way transit time for each departure window. Table 2 Mean transit times by departure window Day Time Transit time (minutes) Mean Std Dev Min Max Monday 8am 79.14 30.77 7 153 10am 80.62 31.72 7 153 Tuesday 8am 79.14 30.77 7 153 10am 80.62 31.72 7 153 Wednesday 8am 79.14 30.77 7 153 10am 80.62 31.72 7 153 Thursday 8am 79.14 30.77 7 153 10am 79.17 30.89 7 153 Friday 8am 80.60 31.60 7 153 10am 79.17 30.89 7 153 Threshold Analysis and Visualization Based on the definition established by Hyder et al, 34 we utilized 30 minutes as the threshold above which a zip code was classified as being a ‘methadone treatment desert.’ Geographic Information System (GIS) maps were then constructed to support visualization of the distribution of SSP participants in Miami-Dade County and average transit times by zip code. Results An SSP participant in Miami-Dade County had a mean 80-minute one-way transit time to their nearest OTP. Assuming daily round trips 6 days per week (which excludes Sundays when the four OTPs are closed and patients receive a take-home dose), individuals would have to travel approximately 16 hours per week to remain engaged in methadone treatment. Transit times did not differ substantially between departure windows, ranging from 79 to 81 minutes (Table 2 ). However, they differed substantially between zip codes with various numbers of SSP participants, ranging from a minimum of 66 minutes from zip codes with 15–31 SSP participants to a maximum of 98 minutes from zip codes with ≤ 5 SSP participants (Table 3 ). For the zip code with the highest number of SSP participants (≥ 75), the mean transit time was 70 minutes. Table 3 Mean transit times by number of SSP participants (n = 1597) by zip code (n = 77) Number of SSP participants per zip code N Transit time (minutes) Mean Std Dev Min Max ≤ 5 20 98.07 32.25 48 153 6–14 25 79.52 31.20 22 127 15–31 21 65.94 27.24 7 112 32–74 10 73.60 18.29 48 98 ≥ 75 1 69.80 - 70 70 Table 2 . Mean transit times by departure window Table 3 . Mean transit times by number of SSP participants (n = 1597) by zip code (n = 77) The distribution of SSP participants in Miami-Dade County and mean transit times by zip code are mapped in Figs. 1 and 2, respectively. Of the 79 zip codes with SSP participants in Miami-Dade County, 75 of them (95%) had a mean transit time to the closest OTP greater than 30 minutes, thus categorizing them as ‘methadone treatment deserts’. Of the 4 zip codes with mean transit times less than or equal to 30 minutes, one had 6–14 participants and three had 15–31 SSP participants. Figure 1. Distribution of SSP participants in Miami-Dade County Figure 2. Average transit times to the closest OTP by zip code in Miami-Dade County Discussion We identified extremely long one-way public transit times during OTP service hours for PWID enrolled in the county’s only SSP, with an average transit time of 80 minutes. Using the established definition of a ‘methadone treatment desert’ as a public transit time of more than 30 minutes, 34 nearly all (95%) of the zip codes with SSP participants were classified as living in a ‘methadone treatment desert’. Unlike Yücel et al’s findings, and those of analyses of public transit access to other health services in a handful of cities around the world, 26 transit times did not differ substantially between departure windows. However, they did differ between zip codes with various numbers of SSP participants. While transit times were greatest for zip codes with ≤ 5 SSP participants, they were all still more than double the 30-minute threshold for all categories. To our knowledge, only one other study has examined public transit times to methadone treatment in the United States; this study was conducted in Franklin County, Ohio and identified a substantially shorter median transit time of 42 minutes. 34 Internationally, one other study, on which the methods of this analysis is based, quantified public transit times to methadone treatment in Toronto, Canada; this study, likewise, found significantly greater access to methadone treatment with an average transit time of only 24 minutes. 26 However, the findings of this study align with more general findings regarding driving times to methadone treatment, which have demonstrated that many patients travel considerable distances to access methadone treatment at OTPs. 8 , 20 , 22 , 23 , 27 While regulatory changes in recent years have enabled important progress in expanding low-threshold buprenorphine treatment through novel models of care (e.g., telehealth) in new settings (e.g., SSPs), 15 , 21 we risk exacerbating existing racial and socioeconomic inequities in treatment for OUD unless similar progress is made for methadone treatment. 18 In the Miami-Dade County context, this analysis points to a need for improvements in public transit generally, establishment of additional OTPs, creation of mobile medication units, and use of exception requests that can be submitted to SAMHSA on an individual basis to permit additional take-home doses. Notably, the zip code with the highest number of SSP participants contains the county’s public safety net hospital and is adjacent to the zip code with the county’s Veterans Affairs Medical Center, both of which would be logical candidates for additional OTPs. At the state and federal level, there is a need for additional policy revisions to reduce broader barriers to initiation of methadone treatment and improve retention – geographic and otherwise. This study has a few notable limitations. First, because of our focus on the accessibility of methadone treatment for SSP participants by public transit in Miami-Dade County, Florida, we did not consider accessibility of methadone treatment for people with OUD, more generally. Second, the zip code locations in the SSP’s database are those reported by SSP participants at the time of their enrollment in the program. It is possible that their locations may have changed in the time since then; this is especially true for people experiencing homelessness given the frequency with which they change locations, both by choice and due to police intervention. Finally, we estimated transit times from the population-weighted centroids of zip codes with SSP participants. As noted by Yücel et al, 26 individuals who do not live at this centroid likely experience slightly different transit times than those calculated in the analysis. Despite these limitations, our analysis suggests the need for urgent action to 1) advance federal and state regulations for low-threshold methadone treatment, 2) capitalize fully on present opportunities, e.g., by establishing additional OTPs and mobile medication units and by increasing utilization of exceptions for take-home doses, and 3) improve public transit in Miami-Dade County. Conclusion The public transit times between the locations of SSP participants in Miami-Dade County and the county’s four OTPs represent a significant barrier to methadone treatment initiation and retention. While the recent relaxation of take-home protocol regulations represents a significant positive development, access to methadone remains inadequate to meet the demand of people with OUD. Geographic isolation of methadone treatment from public transit routes represents a significant and unmitigated barrier to equitable OUD treatment. Abbreviations COVID-19 Coronavirus disease 2019 DEA Drug Enforcement Administration FDA Food and Drug Administration GIS Geographic Information System MOUD Medication for opioid use disorder PWID People who inject drugs OTP Opioid treatment program OUD Opioid use disorder SAMHSA Substance Abuse and Mental Health Services Administration SSP Syringe services program Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of the University of Miami (IRB #20231164). Consent for publication Not applicable. Availability of data and materials Data and materials are available upon request to the corresponding author. Competing interests The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: TSB and HET receive research funding from Gilead Sciences. Funding This analysis was supported by the National Institute on Drug Abuse (NIDA 1DP2DA053720). NIDA did not have any role in the study design or writing of this manuscript. Authors' contributions MP, EM, and KC conceptualized the study. MP, EM, KC, and TSB designed the study. MP conducted the routine analysis, and EM prepared the GIS visualizations. MP and EM prepared a draft of the manuscript. KC, EA, ES, TSB, and HET reviewed the manuscript and provided substantial feedback. All authors read and approved the final manuscript. Acknowledgements We would like to express heartfelt thanks to the staff and participants of the IDEA Miami SSP for their contributions to this study, and for being an inspiration for all our work at IDEA. References Centers for Disease Control and Prevention. Drug overdose deaths. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=In%202021 %2C%20106%2C699%20drug%20overdose,driver%20of%20drug%20overdose%20deaths. Santo T, Jr., Clark B, Hickman M, et al. 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Transport Reviews . 2017/03/04 2017;37(2):170-191. doi:10.1080/01441647.2016.1257660 Centers for Disease Control and Prevention. Drug overdose mortality by state. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm Hyder A, Lee J, Dundon A, et al. Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county. PLoS One . 2021;16(5):e0250324. doi:10.1371/journal.pone.0250324 Pereira RHM, Saraiva M, Herszenhut D, Vieira Braga CK, Wigginton Conway M. R5r: Rapid Realistic Routing on Multimodal Transport Networks with R5 in R. Transport Findings . 2021;doi:https://doi.org/10.32866/001c.21262 Footnotes One of the four OTPs that confirmed provision of outpatient methadone treatment operates a medication unit at a separate location. However, given the medication unit’s limited patient capacity and requirement that patients complete intake and monthly visits for urine testing at the OTP’s main office, the medication unit was excluded from this analysis. The centroids of two zip codes with n ≤ 5 and n = 6 SSP participants were not accessible by public transportation. They were thus included in the maps as having > 30 minute average public transit times but were excluded from Tables 1 and 2 . Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4791074","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331391939,"identity":"6069d6e0-8856-4704-a8e1-9f3f885b78da","order_by":0,"name":"Marina Plesons","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIie3PIQvCQBTA8TcOZjm7huknEE4GS+JnuSG4tDoWl2YRs34IYWn5yQsrY9bZLH4CQQzCvAVBULjZDPdP7+D9eByAyfSn0SNuRsDUJAGspIOwkJfM/Ykw7KfMf23qyWQbIg5TO9iv2CU7w8zJUEO8spIoKh7mZHu1hKWrJ8VaoIwGikBLyNcT4gLRFoFHvZsiTQeirhySVEpl2yvYgai/EJQ4zYlHtRQLd6cldUhXiHHsHYv8dI/nzkZHAPj7Q2jXP4jJZDKZvvQE2UZNYBUh+jYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-3224-618X","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Marina","middleName":"","lastName":"Plesons","suffix":""},{"id":331391940,"identity":"c17c0871-1346-4595-bd16-c1183797737c","order_by":1,"name":"Eileen Malecki","email":"","orcid":"","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Eileen","middleName":"","lastName":"Malecki","suffix":""},{"id":331391941,"identity":"9675da7b-ae3d-4f90-9f0e-baac19865bfd","order_by":2,"name":"Katrina Ciraldo","email":"","orcid":"","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Katrina","middleName":"","lastName":"Ciraldo","suffix":""},{"id":331391942,"identity":"115b1b9d-f649-4cce-9d42-048d52d834f3","order_by":3,"name":"Emilie Ashbes","email":"","orcid":"","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Emilie","middleName":"","lastName":"Ashbes","suffix":""},{"id":331391943,"identity":"6aaa02ba-4c89-42ab-93f4-f24b0d6d0929","order_by":4,"name":"Edward Suarez","email":"","orcid":"","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Edward","middleName":"","lastName":"Suarez","suffix":""},{"id":331391944,"identity":"0124cf6d-c765-43b7-bade-d630fb902509","order_by":5,"name":"Hansel E. Tookes","email":"","orcid":"","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hansel","middleName":"E.","lastName":"Tookes","suffix":""},{"id":331391945,"identity":"ad8dc8e7-6d40-4049-b63c-30b94758c87d","order_by":6,"name":"Tyler S. Bartholomew","email":"","orcid":"","institution":"University of Miami Miller School of Medicine: University of Miami School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tyler","middleName":"S.","lastName":"Bartholomew","suffix":""}],"badges":[],"createdAt":"2024-07-23 20:21:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4791074/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4791074/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63368838,"identity":"19d0b83c-08e7-4b36-919d-13a0e2673797","added_by":"auto","created_at":"2024-08-27 11:39:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75970,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of SSP participants in Miami-Dade County\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4791074/v1/b301cd3250452b2872b999ad.jpg"},{"id":63368837,"identity":"3281aa7a-35ae-4ea1-bd00-ec5ef752ae43","added_by":"auto","created_at":"2024-08-27 11:39:33","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71197,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAverage transit times to the closest OTP by zip code in Miami-Dade County\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4791074/v1/8f25b99e91e4b982ab5430eb.jpg"},{"id":69940989,"identity":"5a09b0d7-78f2-4170-a87d-ffe1c1cc6b23","added_by":"auto","created_at":"2024-11-26 21:13:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":945786,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4791074/v1/97d1f133-0084-446e-827d-5851c2f017de.pdf"}],"financialInterests":"","formattedTitle":"Accessibility of methadone treatment via public transit for syringe services program participants in Miami-Dade County, Florida","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2021, more than 106,000 people in the United States died due to drug overdose, representing a 14% rise in overdose deaths compared to 2020;\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e of these deaths, approximately 75% involved opioids.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Treatment with a medication for opioid use disorder (MOUD) has been shown to reduce rates of opioid overdose, all-cause mortality, and suicide by more than 50%.\u003csup\u003e2,3\u003c/sup\u003e Discontinuation of a MOUD, meanwhile, is associated with relapse and overdose; thus the recommended duration of treatment is indefinite and individualized.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, while the number of facilities providing MOUD and patients receiving MOUD have increased over time,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e major gaps remain in the opioid use disorder (OUD) cascade of care.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e It is estimated that only 20% of people with OUD in the United States receive specialty care in a given year, less than 35% of those individuals receive evidence-based treatment with a MOUD, and most of those individuals discontinue treatment within months.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Furthermore, significant disparities exist in access to and use of MOUD across the rural-urban continua and by race and ethnicity.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMethadone, a full \u0026micro;-opioid receptor agonist, is one of two opioid receptor agonist medications used in the treatment of OUD. Despite being a life-saving medication, especially for the increasing number of patients who do not tolerate buprenorphine in the era of fentanyl and other high-potency synthetic opioids,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e it is tightly regulated by SAMHSA, the DEA, and the FDA as a Schedule II controlled medication. Historically, these regulations required that it be dispensed daily under direct observation at federally and state-designated OTPs until patients met certain criteria, including accrual of time in treatment and demonstrated abstinence from all illicit substances by urine drug testing. After three months of daily observed treatment, OTPs allowed patients with a daily dose\u0026thinsp;\u0026le;\u0026thinsp;100 mg two take-home doses per week for the first two treatment years, three take-home doses per week for the third treatment year, and six take-home doses per week for subsequent years, conditioned on appointment attendance and negative urine drug screens.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In addition, patients had to comply with periodic random drug tests and be seen yearly by a physician in the clinic.\u003c/p\u003e \u003cp\u003eIn March 2020, to reduce risk of COVID infection for patients and staff at OTPs, SAMHSA made temporary allowances for relaxed take-home protocols, permitting states to allow OTPs to provide 27 take-homes to patients who were stable and 13 take-homes to patients who were less stable. Based on evidence that these relaxed take-home protocols did not result in increased negative outcomes,\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e SAMHSA made these flexibilities permanent in February 2024, marking the first substantial update to the OTP treatment standards in over 20 years. Patients may now be eligible for unsupervised, take-home doses of methadone upon entry into treatment. While this federal change increases access to methadone, states still have the authority to determine their own OTP regulations (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for a comparison of previous and current regulations in Florida), and decisions regarding take-home protocols, where permitted, are based on the clinical judgment of healthcare providers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCurrent and previous take-home allowances for methadone treatment in Florida\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre COVID-19 pandemic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTake-home privileges shall be limited to the following:\u003c/p\u003e \u003cp\u003ei. No take-homes shall be permitted during the first 30 days following placement unless approved by the state authority.\u003c/p\u003e \u003cp\u003eii. Following 30 consecutive days in treatment, the client may be eligible for 1 take-home per week from day 31 through day 90, provided that the client has had negative drug screens for the preceding 30 days.\u003c/p\u003e \u003cp\u003eiii. Following 90 consecutive days in treatment, the client may be eligible for 2 take-homes per week from day 91 through day 180, provided that the client has had negative drug screens for the preceding 60 days.\u003c/p\u003e \u003cp\u003eiv. Following 180 consecutive days in treatment, the client may be eligible for 3 take-homes per week with no more than a 2-day supply at any one time from day 181 through 1 year, provided that the client has had negative drug screens for the preceding 90 days.\u003c/p\u003e \u003cp\u003ev. Following 1 year in treatment, the client may be eligible for 4 take-homes per week with no more than a 2-day supply at any one time through the second year of treatment, provided that the client has had negative drug screens for the preceding 90 days.\u003c/p\u003e \u003cp\u003evi. Following 2 years in treatment, the client may be eligible for 5 take-homes per week with no more than a 3-day supply at any one time, provided that the client has had negative drug screens for the preceding 90 days.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent (as of May 19, 2022)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTake-home privileges shall be limited to the following:\u003c/p\u003e \u003cp\u003ei. During the first 90 days of treatment, the take-home supply is limited to a single dose each week. The individual shall ingest all other doses under appropriate medical supervision.\u003c/p\u003e \u003cp\u003eii. In the second 90 days of treatment, the take-home supply is limited to two doses per week.\u003c/p\u003e \u003cp\u003eiii. In the third 90 days of treatment, the take-home supply is limited to three doses per week.\u003c/p\u003e \u003cp\u003eiv. In the remaining months of the first year, an individual may be given a maximum of six-day supply of take-home medication.\u003c/p\u003e \u003cp\u003ev. After one year of continuous treatment, an individual may be given a maximum two-week supply of take-home medication.\u003c/p\u003e \u003cp\u003evi. After two years of continuous treatment, an individual may be given a maximum of one-month supply of take-home medication but must make monthly visits.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. \u003cb\u003eCurrent and previous take-home allowances for methadone treatment in Florida\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis regulatory environment stands in stark contrast to that of buprenorphine, a partial \u0026micro;-opioid receptor agonist also used in the treatment of OUD. In April 2020, SAMHSA removed the requirement for an in-person assessment for the prescription of buprenorphine, thereby enabling new telehealth-based models of care for OUD. Based on evidence that this policy change increased patient engagement and satisfaction with care, it extended this flexibility in the post-pandemic era.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Likewise, in December 2022, US Congress removed the requirement for practitioners to apply for a special waiver prior to prescribing buprenorphine for OUD. Since then, there has been progress in expanding low-threshold buprenorphine treatment in critical settings like SSPs.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e However, evidence demonstrates that White patients are four times more likely to be prescribed buprenorphine as Black patients,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and that buprenorphine patients are more likely than methadone patients to be employed, have higher levels of education, and use prescription opioids instead of heroin.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Thus, this progress risks exacerbating existing racial and socioeconomic inequities in treatment for OUD unless paired with similar efforts to create low-threshold methadone treatment.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAvailability and accessibility, two of the five dimensions of access to healthcare, of OTPs are critical considerations in increasing initiation and retention in methadone treatment.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Research has shown that a significant number of patients travel considerable distances to access methadone treatment at OTPs.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Geographic distance to OTPs, and the associated time and financial costs of attending treatment, are thus major barriers that people who inject drugs (PWID), including those enrolled in syringe services programs (SSPs), face in accessing methadone.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e As a result, studies have also shown that geographic distance is negatively associated with methadone treatment retention.\u003csup\u003e\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e However, nearly all studies examining the accessibility of OTPs have utilized geographic distance or driving time, rather than public transportation transit time.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e This is an important distinction since lower-income individuals, especially those in urban areas, are more likely to rely on public transportation,\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e and access to efficient, well-functioning transportation systems is a notable social determinant of health equity.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn 2021, approximately 7,800 deaths due to drug overdose occurred in Florida\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. However, as of October 2023, there were just 78 clinics licensed to dispense methadone for the treatment of OUD in Florida and 4 in Miami-Dade County. To date, there are no studies investigating the geographic accessibility of methadone treatment in either the state or the county. To begin to fill this gap, this study sought to examine public transit access to methadone treatment for participants of an SSP in Miami-Dade County, Florida.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eBased on the methods utilized by Y\u0026uuml;cel et al,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e this study leveraged open-source geographic databases and local public transit scheduling data to estimate multi-modal public transit access to methadone treatment for SSP participants in Miami-Dade County. We then compared estimated transit times to the 30-minute transit threshold established in the literature as an indication of a \u0026lsquo;methadone treatment desert\u0026rsquo;\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e to describe methadone treatment accessibility.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Sources\u003c/h2\u003e \u003cp\u003eFour data sources were required for this analysis. First, OTPs operating in Miami-Dade County as of October 2023 were identified from SAMHSA\u0026rsquo;s Opioid Treatment Program Directory and contacted to confirm provision of outpatient methadone treatment. The addresses of these OTPs\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e were obtained from the Florida Department of Children and Families and converted into latitude and longitude coordinates, as were the addresses of the SSP\u0026rsquo;s fixed site and mobile locations. Second, the zip codes of PWID enrolled as participants of the SSP (n\u0026thinsp;=\u0026thinsp;2267 as of October 30, 2023, n\u0026thinsp;=\u0026thinsp;1597 of whom reported a zip code in Miami-Dade County on enrollment) were extracted from the SSP\u0026rsquo;s administrative data. Of the 89 zip codes in Miami-Dade County, 79 had at least one SSP participant; zip codes with \u0026le;\u0026thinsp;5 individuals were suppressed to maintain participant anonymity. The population-weighted centroids of these zip codes were identified from the Department of Housing and Urban Development. Third, street network data for Miami-Dade County was obtained from OpenStreetMap, a spatial data source that provides a free, maintainable, and editable map of the world. Finally, General Transit Feed Specification data was obtained from the Miami-Dade Department of Transportation and Public Works. General Transit Feed Specification data is published by transit agencies and contains the locations of transit stops and the schedules and routes of the various transit modes in a transit network for use by a wide variety of software applications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRouting Analysis\u003c/h2\u003e \u003cp\u003eFollowing the methods proposed by Y\u0026uuml;cel et al,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e this routing analysis utilized the R library r5r, which facilitates multi-modal transportation network routing.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e The General Transit Feed Specification and OpenStreetMap data were combined to create the transit network. The population-weighted centroids of each zip code with PWID enrolled in the SSP were designated as points of departure, and the locations of the four OTPs in Miami-Dade County were designated as points of interest. Finally, ten departure windows were specified in line with the OTPs\u0026rsquo; service hours (8am and 10am Monday-Friday). The r5r library then identified the nearest point of interest for each point of departure and calculated the average one-way transit time for each departure window.\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean transit times by departure window\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eTransit time (minutes)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStd Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMonday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTuesday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWednesday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eThursday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFriday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10am\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eThreshold Analysis and Visualization\u003c/h2\u003e \u003cp\u003eBased on the definition established by Hyder et al,\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e we utilized 30 minutes as the threshold above which a zip code was classified as being a \u0026lsquo;methadone treatment desert.\u0026rsquo; Geographic Information System (GIS) maps were then constructed to support visualization of the distribution of SSP participants in Miami-Dade County and average transit times by zip code.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAn SSP participant in Miami-Dade County had a mean 80-minute one-way transit time to their nearest OTP. Assuming daily round trips 6 days per week (which excludes Sundays when the four OTPs are closed and patients receive a take-home dose), individuals would have to travel approximately 16 hours per week to remain engaged in methadone treatment. Transit times did not differ substantially between departure windows, ranging from 79 to 81 minutes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, they differed substantially between zip codes with various numbers of SSP participants, ranging from a minimum of 66 minutes from zip codes with 15\u0026ndash;31 SSP participants to a maximum of 98 minutes from zip codes with \u0026le;\u0026thinsp;5 SSP participants (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). For the zip code with the highest number of SSP participants (\u0026ge;\u0026thinsp;75), the mean transit time was 70 minutes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean transit times by number of SSP participants (n\u0026thinsp;=\u0026thinsp;1597) by zip code (n\u0026thinsp;=\u0026thinsp;77)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of SSP participants per zip code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eTransit time (minutes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStd Dev\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. \u003cb\u003eMean transit times by departure window\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. \u003cb\u003eMean transit times by number of SSP participants (n\u0026thinsp;=\u0026thinsp;1597) by zip code (n\u0026thinsp;=\u0026thinsp;77)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe distribution of SSP participants in Miami-Dade County and mean transit times by zip code are mapped in Figs.\u0026nbsp;1 and 2, respectively. Of the 79 zip codes with SSP participants in Miami-Dade County, 75 of them (95%) had a mean transit time to the closest OTP greater than 30 minutes, thus categorizing them as \u0026lsquo;methadone treatment deserts\u0026rsquo;. Of the 4 zip codes with mean transit times less than or equal to 30 minutes, one had 6\u0026ndash;14 participants and three had 15\u0026ndash;31 SSP participants.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1. Distribution of SSP participants in Miami-Dade County\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2. Average transit times to the closest OTP by zip code in Miami-Dade County\u003c/b\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe identified extremely long one-way public transit times during OTP service hours for PWID enrolled in the county\u0026rsquo;s only SSP, with an average transit time of 80 minutes. Using the established definition of a \u0026lsquo;methadone treatment desert\u0026rsquo; as a public transit time of more than 30 minutes,\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e nearly all (95%) of the zip codes with SSP participants were classified as living in a \u0026lsquo;methadone treatment desert\u0026rsquo;. Unlike Y\u0026uuml;cel et al\u0026rsquo;s findings, and those of analyses of public transit access to other health services in a handful of cities around the world,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e transit times did not differ substantially between departure windows. However, they did differ between zip codes with various numbers of SSP participants. While transit times were greatest for zip codes with \u0026le;\u0026thinsp;5 SSP participants, they were all still more than double the 30-minute threshold for all categories.\u003c/p\u003e \u003cp\u003eTo our knowledge, only one other study has examined public transit times to methadone treatment in the United States; this study was conducted in Franklin County, Ohio and identified a substantially shorter median transit time of 42 minutes.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Internationally, one other study, on which the methods of this analysis is based, quantified public transit times to methadone treatment in Toronto, Canada; this study, likewise, found significantly greater access to methadone treatment with an average transit time of only 24 minutes.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e However, the findings of this study align with more general findings regarding driving times to methadone treatment, which have demonstrated that many patients travel considerable distances to access methadone treatment at OTPs.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile regulatory changes in recent years have enabled important progress in expanding low-threshold buprenorphine treatment through novel models of care (e.g., telehealth) in new settings (e.g., SSPs),\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e we risk exacerbating existing racial and socioeconomic inequities in treatment for OUD unless similar progress is made for methadone treatment.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In the Miami-Dade County context, this analysis points to a need for improvements in public transit generally, establishment of additional OTPs, creation of mobile medication units, and use of exception requests that can be submitted to SAMHSA on an individual basis to permit additional take-home doses. Notably, the zip code with the highest number of SSP participants contains the county\u0026rsquo;s public safety net hospital and is adjacent to the zip code with the county\u0026rsquo;s Veterans Affairs Medical Center, both of which would be logical candidates for additional OTPs. At the state and federal level, there is a need for additional policy revisions to reduce broader barriers to initiation of methadone treatment and improve retention \u0026ndash; geographic and otherwise.\u003c/p\u003e \u003cp\u003eThis study has a few notable limitations. First, because of our focus on the accessibility of methadone treatment for SSP participants by public transit in Miami-Dade County, Florida, we did not consider accessibility of methadone treatment for people with OUD, more generally. Second, the zip code locations in the SSP\u0026rsquo;s database are those reported by SSP participants at the time of their enrollment in the program. It is possible that their locations may have changed in the time since then; this is especially true for people experiencing homelessness given the frequency with which they change locations, both by choice and due to police intervention. Finally, we estimated transit times from the population-weighted centroids of zip codes with SSP participants. As noted by Y\u0026uuml;cel et al,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e individuals who do not live at this centroid likely experience slightly different transit times than those calculated in the analysis. Despite these limitations, our analysis suggests the need for urgent action to 1) advance federal and state regulations for low-threshold methadone treatment, 2) capitalize fully on present opportunities, e.g., by establishing additional OTPs and mobile medication units and by increasing utilization of exceptions for take-home doses, and 3) improve public transit in Miami-Dade County.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe public transit times between the locations of SSP participants in Miami-Dade County and the county\u0026rsquo;s four OTPs represent a significant barrier to methadone treatment initiation and retention. While the recent relaxation of take-home protocol regulations represents a significant positive development, access to methadone remains inadequate to meet the demand of people with OUD. Geographic isolation of methadone treatment from public transit routes represents a significant and unmitigated barrier to equitable OUD treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOVID-19\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eDEA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Drug Enforcement Administration\u003c/p\u003e\n\u003cp\u003eFDA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Food and Drug Administration\u003c/p\u003e\n\u003cp\u003eGIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Geographic Information System\u003c/p\u003e\n\u003cp\u003eMOUD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Medication for opioid use disorder\u003c/p\u003e\n\u003cp\u003ePWID\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;People who inject drugs\u003c/p\u003e\n\u003cp\u003eOTP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Opioid treatment program\u003c/p\u003e\n\u003cp\u003eOUD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Opioid use disorder\u003c/p\u003e\n\u003cp\u003eSAMHSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Substance Abuse and Mental Health Services Administration\u003c/p\u003e\n\u003cp\u003eSSP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Syringe services program\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the University of Miami (IRB #20231164).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eData and materials are available upon request to the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare the following financial interests/personal relationships which may be considered as potential competing interests: TSB and HET receive research funding from Gilead Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis analysis was supported by the National Institute on Drug Abuse (NIDA 1DP2DA053720). NIDA did not have any role in the study design or writing of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors' contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eMP, EM, and KC conceptualized the study. MP, EM, KC, and TSB designed the study. MP conducted the routine analysis, and EM prepared the GIS visualizations. MP and EM prepared a draft of the manuscript. KC, EA, ES, TSB, and HET reviewed the manuscript and provided substantial feedback. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express heartfelt thanks to the staff and participants of the IDEA Miami SSP for their contributions to this study, and for being an inspiration for all our work at IDEA.\u003cstrong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCenters for Disease Control and Prevention. Drug overdose deaths. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=In%202021\u003cbr\u003e%2C%20106%2C699%20drug%20overdose,driver%20of%20drug%20overdose%20deaths.\u003c/li\u003e\n \u003cli\u003eSanto T, Jr., Clark B, Hickman M, et al. 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University of California Press; 2023.\u003c/li\u003e\n \u003cli\u003ePenchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. \u003cem\u003eMed Care\u003c/em\u003e. Feb 1981;19(2):127-40. doi:10.1097/00005650-198102000-00001\u003c/li\u003e\n \u003cli\u003eRosenblum A, Cleland CM, Fong C, Kayman DJ, Tempalski B, Parrino M. Distance traveled and cross-state commuting to opioid treatment programs in the United States. \u003cem\u003eJ Environ Public Health\u003c/em\u003e. 2011;2011:948789. doi:10.1155/2011/948789\u003c/li\u003e\n \u003cli\u003eJakubowski A, Fowler S, Fox AD. Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature. \u003cem\u003eAddiction Science \u0026amp; Clinical Practice\u003c/em\u003e. 2023/06/10 2023;18(1):40. doi:10.1186/s13722-023-00394-x\u003c/li\u003e\n \u003cli\u003eKleinman RA. 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Availability of timely methadone treatment in the United States and Canada during COVID-19: A census tract-level analysis. \u003cem\u003eDrug Alcohol Depend\u003c/em\u003e. Apr 1 2023;245:109801. doi:10.1016/j.drugalcdep.2023.109801\u003c/li\u003e\n \u003cli\u003eAmiri S, Hirchak K, Lutz R, et al. Three-year retention in methadone opioid agonist treatment: A survival analysis of clients by dose, area deprivation, and availability of alcohol and cannabis outlets. \u003cem\u003eDrug Alcohol Depend\u003c/em\u003e. Dec 1 2018;193:63-68. doi:10.1016/j.drugalcdep.2018.08.024\u003c/li\u003e\n \u003cli\u003eJoudrey PJ, Edelman EJ, Wang EA. Drive Times to Opioid Treatment Programs in Urban and Rural Counties in 5 US States. \u003cem\u003eJama\u003c/em\u003e. Oct 1 2019;322(13):1310-1312. doi:10.1001/jama.2019.12562\u003c/li\u003e\n \u003cli\u003ePucher J, Renne JL. Socioeconomics of Urban Travel: Evidence from the 2001 NHTS. \u003cem\u003eTransportation Quarterly\u003c/em\u003e. 2003;52\u003c/li\u003e\n \u003cli\u003ePereira RHM, Schwanen T, Banister D. Distributive justice and equity in transportation. \u003cem\u003eTransport Reviews\u003c/em\u003e. 2017/03/04 2017;37(2):170-191. doi:10.1080/01441647.2016.1257660\u003c/li\u003e\n \u003cli\u003eCenters for Disease Control and Prevention. Drug overdose mortality by state. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm\u003c/li\u003e\n \u003cli\u003eHyder A, Lee J, Dundon A, et al. Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county. \u003cem\u003ePLoS One\u003c/em\u003e. 2021;16(5):e0250324. doi:10.1371/journal.pone.0250324\u003c/li\u003e\n \u003cli\u003ePereira RHM, Saraiva M, Herszenhut D, Vieira Braga CK, Wigginton Conway M. R5r: Rapid Realistic Routing on Multimodal Transport Networks with R5 in R. \u003cem\u003eTransport Findings\u003c/em\u003e. 2021;doi:https://doi.org/10.32866/001c.21262\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e One of the four OTPs that confirmed provision of outpatient methadone treatment operates a medication unit at a separate location. However, given the medication unit\u0026rsquo;s limited patient capacity and requirement that patients complete intake and monthly visits for urine testing at the OTP\u0026rsquo;s main office, the medication unit was excluded from this analysis.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e The centroids of two zip codes with n\u0026thinsp;\u0026le;\u0026thinsp;5 and n\u0026thinsp;=\u0026thinsp;6 SSP participants were not accessible by public transportation. They were thus included in the maps as having\u0026thinsp;\u0026gt;\u0026thinsp;30 minute average public transit times but were excluded from Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Methadone, public transit, access, people who inject drugs","lastPublishedDoi":"10.21203/rs.3.rs-4791074/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4791074/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Methadone is an opioid receptor agonist medication used in the treatment of opioid use disorder (OUD). Geographic distance to opioid treatment programs (OTPs) is a major barrier to treatment, given requirements for direct observation of dosing and periodic drug screens, and ‘methadone treatment deserts’ are defined as a public transit threshold of 30 minutes. The purpose of this study was to examine public transit access to methadone treatment for participants of a syringe services program (SSP) in Miami-Dade County, Florida. Public transit times were calculated using the R library r5r, which facilitates multi-modal transportation network routing. General Transit Feed Specification data was combined with street network data from OpenStreetMap for Miami-Dade County. Transit times were estimated from the population-weighted centroid of each zip code (n=79) with participants of Miami’s only SSP (n=1597) to the nearest OTP (n=4) using 10 departure windows aligned with OTP service hours. The mean one-way transit time from zip codes with SSP participants in Miami-Dade County to the nearest OTP was 80 minutes. 75 of the 79 (95%) zip codes with SSP participants in Miami-Dade County have a mean transit time to the closest OTP greater than 30 minutes. Transit times differ substantially between zip codes with different numbers of SSP participants, but not between departure windows. Nearly all zip codes with SSP participants in Miami-Dade County can be classified as ‘methadone treatment deserts’. Geographic isolation of methadone treatment from public transit routes represents a significant barrier to equitable OUD treatment.","manuscriptTitle":"Accessibility of methadone treatment via public transit for syringe services program participants in Miami-Dade County, Florida","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 11:39:27","doi":"10.21203/rs.3.rs-4791074/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dd320e1a-e9bb-4579-816c-642dfa85cdad","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-26T21:05:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 11:39:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4791074","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4791074","identity":"rs-4791074","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}