Participant recruitment and data collection

Participants were recruited through purposive sampling to ensure the inclusion of individuals with experience of MOUD and displacement from frontline regions. The research team engaged MOUD providers at drug treatment clinics in each selected city, providing them with inclusion criteria for eligible participants and contact details for the interviewer (IP, MF) should potential respondents wish to reach out directly. In some cases, medical staff shared participants’ contact information with interviewers after obtaining their prior consent. When interviewers directly contacted potential respondents via phone, no refusals were recorded. After patient recruitment, seven medical staff members from government clinics were also invited to participate in in-depth interviews with the research team. The distribution of provider participants by location was as follows: Lviv (three participants), Ivano-Frankivsk (one participant), and Poltava (three participants). These locations were selected because they represented regions that, at the time, had received the highest influx of internally displaced persons (IDPs), making them critical areas for assessing the accessibility and continuity of MOUD services under displacement-related pressures.

Interviews were conducted with individuals who had been receiving MOUD at governmental and private clinics before Russia’s full-scale invasion on February 24, 2022 and who continued their MOUD uptake on governmental or private sites in the cities where they relocated. The recruitment strategy aimed to ensure representation across different geographical regions, socioeconomic backgrounds and treatment experiences. The number of interviews was determined by data saturation, which was reached in each study region when no new themes emerged from subsequent interviews. Data were collected from ten patients receiving MOUD (five men and five women) at governmental clinics and who had been displaced by the war. Prior to the invasion, these participants resided in four cities in eastern Ukraine that experienced significant enemy shelling – Slovyansk, Severodonetsk, Mariupol, and Kharkiv. Following displacement, they relocated to Lviv (three participants), Ivano-Frankivsk (four participants), and Poltava (three participants). Additionally, seven MOUD providers from the same governmental clinics, where participants are receiving MOUD now, participated in the study. Data collection took place between September and November 2022.

Participants received a financial compensation of approximately 8 USD for their time.

Ethical considerations and interview procedure

Eligibility was restricted to adults aged 18 or older who had been receiving MOUD prior to February 24, 2022. Before each interview, participants were thoroughly briefed on the study’s objectives, and oral informed consent was obtained and audio-recorded. The interviews were conducted remotely via online calls using participants’ preferred messaging applications at a convenient time. The Institutional Review Board approved the use of oral consent procedure due to the remote nature of data collection and the minimal risk involved, ensuring that participant rights and confidentiality were adequately protected.

The amount provided to participant (USD 8) was intentionally set at a modest level with the purpose of compensating participants for their time, rather than functioning as an undue incentive. To further mitigate potential bias, all participants were clearly informed that participation was entirely voluntary and that compensation would be provided regardless of the content of their responses. Confidentiality measures were strictly followed to minimize social desirability bias.

Interviews were held in Ukrainian or Russian, depending on the participant’s preference. Video conferencing was not used. Each interview, lasting approximately 40–60 minutes, was conducted by an experienced researcher with substantial expertise in qualitative interviewing of MOUD clients and providers.

The semi-structured interview guide for patients covered the following domains:

1. (a) Experiences with MOUD since the onset of the war
2. (b) Current MOUD treatment experiences
3. (c) Observed treatment experiences of others
4. (d) Other treatment experience, if any
5. (e) Communication with peers
6. (f) Barriers and facilitators of MOUD treatment

For medical providers, the interview guide included:

1. (a) Facility operations since the war’s onset
2. (b) Interaction with clients
3. (c) Challenges in treatment access after the full-scale invasion
4. (d) Intervention development questions
5. (e) Safety concerns for medical staff and clients

All interviews were audio-recorded and subsequently de-identified. Each respondent was assigned a study ID, which was used in all transcriptions and quotes. For accuracy and consistency, all quotes included in this study were translated into English and then back-translated into the original language by two independent research team members (IP, MF) to ensure the original meaning was preserved.

The study adhered to the qualitative research trustworthiness criterias: credibility, transferability, dependability, and confirmability [13]. We ensured credibility through triangulation and member checking; transferability through detailed contextual descriptions; dependability through maintaining a transparent audit trail; and confirmability by documenting analytic decisions and researcher reflexivity. Reporting followed COREQ/SRQR guidelines, and all ethical procedures were strictly observed [14,15].

Data analysis

Interviews were audio-recorded and analyzed directly using descriptive summaries aligned with the domains of the data collection instrument. The analytical approach emphasized the comparison of participant experiences across different cities, culminating in structured analytical summaries [16].

For both patients and providers, data analysis followed a Rapid Assessment Procedure (RAP) framework [17], which organizes and synthesizes data based on a pre-defined analytical structure. The analytical process comprised the following steps:

1. (a) The data analysis team (IP, MF) reviewed two interviews to establish key terms for categorization within the RAP matrix, ensuring alignment with the study’s objectives.
2. (b) IP developed a preliminary categorization matrix, which was pilot-tested by the analysis team using two interview transcripts. The matrix was refined accordingly.
3. (c) IP and MF reviewed all interviews and summarized them using the finalized matrix, resulting in two distinct matrices encapsulating all interviews across the defined categories.
4. (d) The data analysis team (IP, MF, OZ) convened to identify commonalities and discrepancies within the individual matrices.
5. (e) IP synthesized the matrices based on team discussions, noting any disagreements. Discrepancies were reviewed iteratively by the analytical team (IP, MF, OZ) and resolved through consensus.

The final RAP matrix was utilized to compare experiences across cities and organize findings into analytical categories, which are presented in the results section alongside key healthcare system responses to the identified challenges.

Socio-demographic characteristics

Provider participants worked in a variety of healthcare settings, including both private and governmental clinics. Four out of seven facilities specialized in addiction treatment, two (AIDS Center, Lviv and 100% Life private clinic, Poltava) out of seven specializing in HIV/AIDS and addiction treatment and care. One of the facilities (Lung Health Center (Lviv) was a multidisciplinary healthcare facility focusing on medical care for patients with tuberculosis and nonspecific respiratory diseases, as well as a full range of services for the detection and treatment of HIV, and provides MOUD for HIV-infected patients. Job responsibilities across participants are focused on healthcare provision, particularly in the field of addiction treatment and care. Six out of seven participants were MOUD providers directly involved in addiction treatment and harm reduction. One participant was a head physician, responsible for administrative and clinical oversight (Table 1).

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Table 1. Provider socio-demographic characteristics (N = 7).

https://doi.org/10.1371/journal.pone.0341182.t001

The sample of MOUD patients consists of 5 males and 5 females, ensuring a balanced gender distribution among the participants. All participants were receiving methadone as part of their MOUD, except for one female participant who did not specify her drug of choice. Prior to the full-scale invasion, participants lived in different regions of Ukraine, including cities in the Donetsk oblast (such as Slovyansk, Mariupol), Luhansk oblast (Severodonetsk), and Kharkiv city. All those cities and regions were severely affected by the war with permanent heavy shelling, and one of the cities (Severodonetsk) was fully occupied by Russian forces in June 2022, leading to significant displacement among residents.

Following the invasion, participants relocated to various safer Central and Western regions of Ukraine. Four participants moved to Ivano-Frankivsk city (Western region), three to Lviv (Western region), and three to Poltava city (Central region). This forced displacement reflects the impact of the war on the participants’ ability to remain in their original locations, influencing their access to healthcare and daily lives. The duration of time that participants have been receiving MOUD varies, ranging from 2 years to 14 years, indicating a wide range of experiences with MOUD (Table 2).

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Table 2. Patient socio-demographic characteristics (N = 10).

https://doi.org/10.1371/journal.pone.0341182.t002

1. Structural and policy factors related to MOUD provision after the full-scale invasion

Provider participants were employed across diverse healthcare settings, covering both private and governmental clinics. Their duties were focused on addiction care and harm reduction, with one head physician overseeing administrative and clinical operations.

2. Clinical and organizational factors related to MOUD provision after the full-scale invasion

3. Interpersonal and community-level factors accessing MOUD under wartime conditions

Five out of seven providers noted peer support networks helped IDPs navigate the system:

“Local MOUD patients really helped new IDPs — they showed them where to go…”

MOUD provider, Poltava

Patients consistently highlighted NGO and harm reduction support as crucial:

“At the train station, I got support from a harm reduction program.”

Patient Slovyansk → Ivano-Frankivsk

“A social worker met me with my medical chart and brought me to the clinic.”

Patient Kharkiv → Ivano-Frankivsk

Harm reduction services (sterile syringes, naloxone) were available to 8 out of 10 participants and helped prevent relapse and infections.

4. Individual-level factors accessing MOUD under wartime conditions

Discussion

This study examines the barriers and facilitators affecting MOUD access during the war in Ukraine from the perspectives of both service providers and patients. The findings highlight the significant challenges encountered in maintaining treatment services, as well as the strategies and supportive mechanisms that have helped sustain access.

The results provide an in-depth account of the lived experiences of patients and providers engaged in MOUD during the full-scale war in Ukraine. Through 17 qualitative interviews, we explored the multilevel barriers and facilitators shaping access, retention, and service adaptation across the treatment continuum. The findings confirm known structural weaknesses in the Ukrainian addiction treatment system and reveal novel dynamics introduced by wartime conditions. Below, we discuss how our results align with, expand upon, or diverge from existing literature.

1. Disruption and displacement as catalysts of treatment discontinuity

One of the most pronounced findings was the interruption of MOUD services due to forced displacement, regional clinic closures, and loss of continuity in care. Patients reported treatment gaps caused by evacuation without medications or documentation, mirroring earlier findings from crisis-affected regions. Our data strongly align with other research, where authors documented how Ukrainian MOUD patients displaced to European countries faced delays due to bureaucratic hurdles, geographic inaccessibility, and lack of coordination across systems [18].

Similarly, Dellamura et al. (2024) [19] emphasize that mobility and fragmentation – already common in fragile settings – are exacerbated during armed conflict, making the continuity of MOUD especially vulnerable. The challenges experienced by our participants, such as needing to re-enroll as “new patients” due to loss of medical records, are consistent with patterns observed in the HPTN 074 study, which showed that relocation often results in disengagement from HIV and MOUD services [20].

2. Provider overload and systemic inflexibility

Our provider interviews reflected a system pushed beyond its capacity. Staff described increased patient loads without accompanying human resource support. Clinics operated with reduced MOUD supply and hesitated to implement the MoH’s 30-day take-home policy due to fears of misuse, echoing concerns from earlier implementation studies [21,22].

This reflects what Dellamura et al. (2024) [19] call “precarious resilience” – Ukrainian MOUD programs that survived pre-war crises have some adaptive capacity but remain limited by rigid policies and chronic under-resourcing. Providers in our study employed informal coping strategies (e.g., ad hoc inter-clinic referrals or reduced dosing), reinforcing findings by Altice et al. (2022) [12] on provider ingenuity and ethical tensions under pressure.

3. Stigma, surveillance, and fear of narcological registration

Despite crisis conditions, structural stigma and legal anxieties continued to affect access to MOUD. Several patients voiced concern over being added to narcological registries, fearing repercussions such as loss of employment or driver’s license — an observation previously described by Makarenko et al. (2016) [22] and Carroll (2019) [23], who documented how MOUD participation in Ukraine is linked to bureaucratic surveillance.

Furthermore, patients reported social stigma from family members and peers, consistent with Bojko et al. (2015) [24], who described deeply entrenched narratives that methadone is “a life sentence”.

4. Critical role of peer and NGO referral pathways

In contrast to formal systems, informal and community-driven pathways emerged as essential facilitators. Nearly all patients learned about available MOUD sites through peer networks, volunteers at train stations, or NGO workers. These non-governmental actors served as intermediaries between displaced populations and overburdened clinics, echoing findings by Bojko et al. (2016) [25] and Nikitin et al. (2023) [18] on the value of peer support models and civil society in care continuity.

Patients’ reliance on unofficial channels underlines the ongoing importance of harm reduction infrastructure beyond MOUD delivery itself. In a context where formal systems are fragile or inaccessible, decentralized outreach remains a lifeline for many displaced PWID.

5. Innovations in crisis: Provider adaptability and micro-level solutions

Providers demonstrated notable adaptability in the face of war. While some adhered to state-issued guidelines, others deviated from protocol to maintain care – e.g., accepting verbal transfer confirmations, flexibly adjusting doses, or offering longer take-home regimens without full documentation. These micro-level innovations illustrate what Dellamura et al. (2024) [19] describe as “discretional autonomy,” where clinicians balance patient needs, structural constraints, and safety risks.

Such flexible practices reinforce the need to re-evaluate rigid policy structures. As Madden et al. (2017) [21] emphasized, successful MOUD scale-up requires systems that trust and empower providers rather than restrict them. Wartime adaptations offer a real-world test of such flexibility.

6. Conceptual interpretation through a socio-ecological lens

The findings of this study can be interpreted using the socio-ecological model (SEM), which conceptualizes health behaviors and treatment access as shaped by multiple, interrelated levels of influence [28]. This framework has been widely applied in addiction and HIV research to explain how individual, interpersonal, organizational, and policy-level factors collectively determine outcomes in complex systems [29].

At the individual level, MOUD patients experienced psychological distress, trauma, and financial insecurity that hindered adherence and continuity. Despite these challenges, individual motivation and perceived benefits such as reduced cravings, improved family relationships, and stable employment served as strong facilitators of retention.

At the interpersonal level, peer and family networks played a critical role in sustaining engagement. Informal support systems, including social workers and volunteers, often compensated for gaps in formal referral mechanisms. These findings underscore the importance of trust and social connectedness as protective factors during crisis.

At the organizational level, clinics demonstrated both fragility and adaptability. Providers faced increased workloads, reduced staff, and disrupted supply chains, yet many implemented flexible approaches: extended take-home doses, simplified intake, or ad hoc coordination between facilities to maintain services. These actions illustrate organizational resilience within an overstretched system.

At the policy and structural level, barriers such as documentation requirements, narcological registration, and limited national coordination revealed systemic rigidity. Conversely, temporary regulatory relaxations (e.g., extended take-home allowances) reflected an emergent adaptive capacity within Ukraine’s health system. Aligning these wartime innovations with permanent policy reform could strengthen national resilience and harmonize Ukraine’s MOUD response with global harm-reduction frameworks [6,26,27].

By situating the findings within the SEM, it becomes evident that sustaining MOUD access during conflict requires multilevel interventions addressing not only patient-level needs, but also institutional flexibility, cross-sector collaboration, and structural policy reform.

7. Policy implications and future directions

Findings from this study suggest several policy recommendations:

1. Codify emergency flexibility: Expand the legal basis for 30-day take-home dosing, decentralized prescribing, and mobile units—practices shown effective during wartime.
2. Protect patient confidentiality: Address registry-related fears by reforming narcological documentation and ensuring legal protections against employment or licensing discrimination.
3. Support provider well-being: Given the psychological burden and moral dilemmas faced by frontline staff, training, supervision, and safety measures must be prioritized.
4. Strengthen civil society partnerships: NGOs and peer-led initiatives have proven instrumental in reaching displaced and vulnerable populations. Their integration into the national MOUD strategy should be formalized and funded.
5. Enhance cross-regional linkage systems: To address fragmentation, there is an urgent need for a national digital registry (with secure consent protocols) allowing displaced patients to resume care without re-initiating as new patients.

The findings of this study should be interpreted within the broader context of international harm reduction and public health frameworks. The global UNAIDS 95-95-95 targets, aiming for 95% of all people living with HIV to know their status, 95% of those diagnosed to receive sustained ART, and 95% of those on ART to achieve viral suppression by 2030, cannot be achieved without adequate integration of MOUD into HIV prevention and care services. In Ukraine, only 5.8% of the estimated population of people who use opioids currently receive MOUD, falling far short of the WHO/UNODC/UNAIDS recommendation of at least 40% coverage for effective HIV prevention among people who inject drugs [5,6].

The wartime disruptions described in this study demonstrate how fragile health systems jeopardize progress toward the 95-95-95 targets [26]. Interruptions in MOUD access not only increase relapse and overdose risk but also threaten HIV care continuity, as many MOUD patients are also living with HIV and depend on integrated ART provision. Maintaining MOUD continuity under crisis conditions is thus a core component of Ukraine’s contribution to global HIV elimination goals.

Beyond HIV, the results align with the WHO and UNODC global standards for the treatment of drug use disorders, which emphasize human-rights–based and community-anchored care models [27]. The observed flexibility among Ukrainian providers, such as extended take-home dosing and peer-supported linkage mechanisms, reflects the spirit of these standards, even though many adaptations occurred informally and outside of existing regulations. Formalizing such practices in national policy could strengthen compliance with global harm-reduction principles that prioritize accessibility, dignity, and continuity of care.

8. Strengths and limitations

This study contributes novel insight into MOUD continuity during armed conflict through a dual-perspective approach (providers and patients). While the qualitative design allowed for rich thematic exploration, findings may not generalize to all regions or clinics in Ukraine.

Data were collected in 2022 in regions receiving internally displaced MOUD patients in areas minimally affected by the war. This sampling frame reflects the displacement patterns during the early phase of the conflict but may limit geographic representativeness. Future research should include regions not directly affected by hostilities to enhance external validity and generalizability. Additionally, the sample was limited to those who successfully re-engaged in MOUD; those who did not re-engage were not represented.

Conclusion

The war in Ukraine has laid bare long-standing vulnerabilities in the country’s MOUD system while also showcasing resilience, adaptability, and the potential for reform. Displacement, structural stigma, and bureaucratic rigidity continue to undermine access, yet providers and patients have mobilized remarkable strategies to stay connected to care. As Ukraine’s health system evolves under pressure, these lessons offer an opportunity to reimagine MOUD not just as emergency relief but as a foundation for a more inclusive and responsive system for drug dependence care.