“It didn’t hurt me”: patients’ and providers’ perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico

During the COVID−19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take−home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl−related overdose deaths and other drug−related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take−home−dose delivery. In−depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days. Patients were overwhelmingly male (84