AIM: A poorly understood challenge is why many women with opioid use disorder do not remain engaged with medications for opioid use disorder (MOUD; e.g., methadone, buprenorphine, naltrexone) long enough to achieve sustained benefits. We aimed to identify barriers and facilitators that impact women's MOUD adherence.

METHODS: We conducted in-person interviews and focus groups with 20 women who had received MOUD for at least 90 days in Springfield and Holyoke, Massachusetts in 2018. Using grounded theory, we inductively identified major themes and selected illustrative quotations.

FINDINGS: Gender-specific barriers to treatment are shaped by MOUD-related stigma stemming from multiple sources: (1) the internalization of messaging from social networks that equate pharmacotherapies to "substituting one drug for another;" (2) pharmacotherapy side effects related to weight gain, tooth decay, and interactions with anti-anxiety medications; (3) negative consequences from being discovered as a MOUD client, including loss of custody, children being bullied in school, workplace-related stigma, and being associated with sex-work. Women identified the following key facilitators of MOUD adherence: avoiding pain, sickness, and death; feeling "safe" in treatment settings, particularly for those with histories of interpersonal and sexual trauma; developing positive routines that replace opioid seeking behaviors and build self-esteem; maintaining healthy boundaries with friends, family, and partners who actively use opioids; and offering "relatable" peer support to other women as a source of recovery "hope."

CONCLUSION: Women encounter gendered stigma and support from individual, interpersonal, and community level sources that if addressed collectively, can inform improvements to MOUD engagement and adherence efforts.