All respondents were white females, the majority of whom had a Master’s degree (73.33%, n = 11). SSCs had been employed in their current position for an average of 5.5 years, with lengths of tenure ranging from 2 months to 22 years. One-third (33.3%, n = 5) of the SSCs had previously been employed in corrections as a parole/probation or a correctional officer, and a little over one-fourth (26.7%, n = 4) had previously worked as a clinician in a substance use disorder treatment center.

Individual level barriers

High risk use Several SSCs (n = 5) discussed OUD clients as being significantly more challenging than clients of the past or clients without OUD. Injection drug use and the increased risk for overdose made this current generation of clients particularly high-risk in the eyes of the SSCs. The clinicians also referred to the high rate of relapse associated with OUD. Conceptualization of their clients as being at high risk of negative outcomes was additionally tied to the young age and limited life experience of clients, as expressed by one SSC supervisor:

And a lot of times they’re high risk substance abuser because they tend to use, IV [intravenous] drug users a lot of time. And over the course of my career it seems like 10 years ago, 15 years ago you would not have an IV user until they were in their late 20 s, early 30 s. Like we didn’t see it. And now they’re coming into the system at 18 and 19 as an IV drug user. SSC Supervisor #3

Stigma and lack of motivation Over half (n = 8) of the SSCs referred to specific client characteristics as preventing OUD treatment engagement and subsequent recovery. For these SSCs, clients were stated to be dishonest and/or lack the motivation necessary to succeed in recovery. Some SSCs stated their clients were unwilling to participate, or frequently would use other barriers as excuses to not participate in services such as SSC aftercare programs or MAT. Sometimes lack of honesty was thought to stem from embarrassment and stigma, especially among individuals whose OUD developed from a legitimate medical need:

I think a lot of times they’re embarrassed and don’t want to be honest. There are a lot of clients that started out that they were prescribed medications, and I think they’re very shocked to find themselves in this situation and that’s an embarrassment and they don’t want to be honest about that. SSC # 15

Interpersonal level barriers

Homophilious social networks Most SSCs noted that drug use was considered normative among the friends and families of clients (n = 12) indicating homophilious social networks. Homophily refers to the homogeneity of characteristics among individual’s personal networks [41]. Further, networks tended to remain the same pre- and post-reentry. This stability of networks, combined with normative drug use, was discussed at length by SSCs. The homophilious networks threatened clients’ likelihood of recovery, and were observable within the DOC and community at large, as explained here:

It seems that everyone, everyone they know or associate with has been or is currently facing the challenge of their addiction, the challenges of their addictions as well. They don’t have sober friends or a sober support system. And a lot of it is generational use. Even their family are not a good support system because it’s been so embedded. SSC Supervisor #4

Networks have limited knowledge of treatment In addition to social networks being homophilious, SSCs stated that client networks had misperceptions about MAT (n = 7), particularly when family members had negative perceptions of pharmacotherapy, as illustrated by the following SSC statement:

The families are like, ‘it’s just another drug that you’re on, I don’t know why you’re on it, you don’t need to be on anything else, you’ve been clean for years or months’- however long they stayed in the jail or the institution, ‘you don’t need to be on that.’ SSC #14

The normativity of drug use in the clients’ networks (i.e., homophilious networks), created a lack of knowledge on how to best promote recovery for clients’ OUD. Specifically, it was perceived that the networks and clients themselves, do not prioritize certain places or behaviors that could best promote recovery among clients. As explained by one SSC supervisor:

So it’s like, well if they’re not using heroin or if they’re not using opioids then alcohol’s not going to hurt them because that’s not what got them in trouble, or that’s not what they OD’d [overdosed] on. And so then what’s the, social norms sometimes get skewed by their family. And the farther removed you are from having a bigger, I guess network of people to associate with, your abnormal looks normal. SSC Supervisor #3

Thus, the lack of knowledge and perceptions of people with whom clients have social relationships after their release from prison present challenges not only to accessing treatment, but also to succeeding even when treatment was made available.

Institutional and organizational level barriers

High SSC caseload A majority (n = 9) of SSCs stated that large caseloads made their job difficult and was a significant barrier in providing services to their clients. High caseloads, coupled with responsibility for large geographic areas spread across multiple counties, resulted in limited time with each client with months between appointments. Consider the struggles as stated by one SSC:

However just time to get to your mobile sites is a barrier. It takes a lot of time, you’ve got to get up early. Even two to three hours earlier. Go there. And of course your schedule is full for even next month, two months, even three months. So you might have someone test positive for heroin or even, let’s say, oxycodone- but you don’t see them for two months from now. SSC #14

For this particular SSC, the use of e-mail allowed her to close some of the time gaps in her previously two-month long waiting list. The SSC utilized e-mail for initial assessments to determine if clients needed service recommendations for clients with active drug use or if clients were simply complying with DOC regulations and/or judge mandates to receive an assessment. Other SSCs mentioned being accessible by phone or relying on the probation and parole officers to assess and screen those with the most immediate needs for referral. One SSC explained her relationship with the parole and probation officers in the following statement:

So I do my best to try to make sure that they [the officers] know kind of triage, so they know who needs to get on the phone right away, who can wait a week and go on my schedule when I make it back to that county. SSC # 10

Lack of parole/probation officer substance use disorder education While some SSCs relied on probation and parole officers, many discussed the officers lacked a general understanding of OUD, treatment options, and particularly misunderstood MAT. Ten of the SSCs mentioned that probation and parole officers needed more education on substance use disorders in general and/or MAT. Additionally, four of the SSCs stated probation and parole officers would not allow their clients to receive MAT. Three of these referred to buprenorphine specifically, and one discussed prohibition of methadone. One SSC explained how she saw the negative perceptions of MAT among officers:

Unfortunately, I feel like a lot of the treatment around here is just going and getting the medication and unfortunately I think that’s where the judges got the bad taste in their mouths for Suboxone® which bled over to our officers, because they saw so much abuse and so little success stories. But the way it works usually, and what I try to tell the officers is, when you have success stories they aren’t walking in our offices with new charges because they’re a success story so all we see if those clients who are not using successfully. SSC #10

Despite often sharing an office with the probation and parole officers, SSCs received completely different training, and to their knowledge, the officers did not receive any training on MAT or substance use disorders. There appeared to be a bureaucratic disconnect in who should be providing education for the officers, as some SSCs mentioned educating officers in their offices while others mentioned the need for officers to receive trainings. SSCs appeared willing to help officers when presented with questions as illustrated by the following SSC when asked about her suggestions for improvements:

Education for the clinicians and even the parole officers because they play a role in it too. I think all of us need to work together and so that we can work together for the benefit of the client. Because a lot of the officers, don’t even know what it is. They was asking me about it earlier this morning-what is Vivitrol®- and I explained it to them, what it is. But I think that if they, if their department kind of was educated about it, and present to them, it would help them more too. SSC #8

Given the high caseload and many counties of the SSCs, it is not unsurprising that a disconnect existed in who should be providing education for the officers.

Community level barriers

Three themes related to community level barriers emerged in the interviews. Barriers were classified as community-level if they were considered to exist as a direct result of the Appalachian communities in which the clients reside.

Easy access to opioids Three clinicians discussed the ease of drug availability as a significant barrier to engaging clients in OUD treatment. While not all SSCs referred directly to ease of access to opioids as a barrier, all but one stated that opioid use was rampant among their client caseloads. Some referred to clients who may have started with medically necessary prescription opioids and then transitioned to illicit use. One SSC relayed the following details, highlighting how economic strain among her clients led them to use heroin:

For instance if somebody’s spending three hundred eighty dollars a day for four OxyContins and you can run up to [large urban city] and get a packet of heroin for eighty-five dollars, you know what are you going to do. And that lasts a day and a half, what are you going to do. SSC #11

Transitioning from non-medical prescription opioid use to heroin is often driven by economic factors and availability but has significant public health impacts, because the purity of heroin is often unknown which can lead to increased risk for overdose.

Limited availability of treatment resources Nearly all of the SSCs expressed frustration over the limited availability of treatment resources in Appalachia (n = 13). Limited resources referred to the lack of physicians providing treatment, the limited amount of specialty inpatient and outpatient treatment programs, long waiting lists, and the limited availability of self-help group meetings. Often provision of treatment in the community was only available through DOC involvement with the support of an SSC, as explained by an SSC supervisor:

But if you go to the more rural areas in the Appalachia, it may take you a 20 mile drive to get to your closest AA [Alcoholics Anonymous] meeting, and that’s at a minimum. If you need a [comorbid care center], you have one or two options. Inpatient, well it’s not impossible if they’re going through us. If they’re going through the Department of Corrections we can get them treatment in a relatively decent time. But if they’re just a regular Joe on the streets, it’s really hard. SSC #1

The SSCs expressed frustration at the lack of resources that they faced in rural areas, which were particularly acute for individuals with co-occurring mental health needs:

This weekend I faced a crisis with a client that was terminated from the recovery center due to suicidal ideations, and nobody was at work, and the hospital didn’t want to take them. The only crisis center would only keep them for 23 h. So here I was with a client who has a substance use disorder, plus mental health, and there’s no services available for that client. SSC Supervisor #4

Lack of community support A few SSCs highlighted a unique and potentially important barrier in their rural communities. Despite the immense harm caused by opioid use in Appalachia, there was the perception that in general, communities did not acknowledge OUD as a chronic relapsing medical condition and knew little about the effectiveness of treatment (n = 5). The perception of substance use disorders in rural communities was described by one SSC, as follows:

I guess you can say maybe the community perspective of mental health and substance abuse. It’s the elephant in the county that they refuse to see…. People don’t perceive it well at all. ‘Just quit, you’re an addict.’ It’s not really welcome as much. It’s hard go to treatment or to seek treatment when you’re embarrassed to even enter a room. And even in small counties, you may see a person next to you that is your neighbor. That’s even more embarrassing in itself. SSC #14

Not only did the community stigma serve as a barrier, but one SSC stated there was little willingness to have addiction services located in the communities- a need that was critical given the lack of treatment resources, as previously discussed.

You know if there is some type of treatment center depending on, nobody wants that next to door to their business. Nobody wants that next door to their neighborhood, whatever type of treatment it is because then you got the folks that loiter outside, and they smoke. And so then it becomes a barrier to providing resources. SSC Supervisor #3

System level barriers

Lack of transportation All but one (n = 14) of the SSCs mentioned transportation was a significant barrier to their clients accessing treatment in the community upon release, particularly the lack of public transportation. Rural clients often were forced to rely on family networks for transportation to appointments, which can be even more problematic given the distance and rough terrain to reach providers in Appalachian counties. This was often cited as a source of stress for both the client and the family, as described in the following:

Transportation is a big deal. Even if I have a client whose nearest provider is the next county, which may only be twenty minutes or something twenty miles, we don’t have mass transit so everyone can’t just hop on a bus and get a ride. And a lot of the time some of the providers are actually in some of the more rural counties. So there’s no reason for grandma to have to go to the store in that county and thus give them a ride to that area…. So if there’s not a reason for them to go to that county, then they don’t have a ride there and so even if we can go through the steps of getting them an appointment, and getting their medical insurance signed up, and getting them an appointment- then a lot of times their ride falls through. SSC # 10

Limited transportation was primarily explained as a result of rural sprawl. SSCs also noted that many of their clients lacked a driver license and most experienced economic strain, which meant the entire household shared one car. Individuals were also limited due to the lack of public transportation in their communities:

Even if you’re highly motivated there’s not a bus to get on. Someone has to have a car and they have to be willing, and they have to be willing on the day that you need them to go. SSC Supervisor # 3

As the quote above illustrates, the lack of public transportation was perceived as a source of strain and potentially de-motivating even among the most motivated individuals. However, SSCs also mentioned the lack of driver licenses and reliance on social networks for rides, indicating a fluidity of this barrier as both occurring on the individual level yet strained by larger system structures in Appalachia.

Treatments are cost prohibitive OUD treatments were often viewed as cost prohibitive for clients, in part because of larger healthcare and pharmaceutical infrastructure issues. Ten of the SSCs mentioned treatment was hard to obtain due to cost, and the majority of these referred specifically to MAT, as discussed by one SSC when asked about the lack of use of MAT by her clients:

Well I think one, is the cost. Unfortunately I don’t think many know about all of the options for the medically assisted [treatment]. It’s primarily just the common Suboxone® and methadone and those are very expensive generally. They just can’t afford that. I’ve had several start in that program. And I mean, 300 to 400 dollars a month, that’s just very hard to maintain. SSC #15

Uncertain future of the Affordable Care Act (ACA) While all of the SSCs mentioned insurance in some capacity, some situated their comments within a context of the Medicaid program, Kentucky’s expansion of Medicaid to cover uninsured low-income adults, and the ACA. Nine of the SSCs mentioned how changes to insurance, ease of Medicaid enrollment, or the ACA specifically improved access to care for their clients, as illustrated here:

Before we had changes with the insurance we would have trouble finding payer sources. But the change in the Affordable Care Act helped with that. SSC Supervisor #4

At the time of the interviews, the nation was in the midst of the new presidency of Donald Trump who made a campaign promise to repeal the Affordable Care Act, and during data collection, the US Congress voted on a number of measures to change the ACA. This was reflected in some of the interviews, as SSCs perceived changes to the current system as a future barrier to access for clients: