Structural Racism and Coalition Decision-Making: A Qualitative Study of Opioid Prevention and Treatment Implementation.

Structural racism drives inequities in opioid use disorder, overdose, and treatment access. However, less is known about how it shapes coalition-led implementation of opioid prevention and treatment strategies. Using structural racism as a lens, this study examines how community coalition members described the selection and implementation of opioid-related evidence-based practices intended to reach racial and ethnic minoritized communities. This qualitative study used interview data from 355 coalition members involved in the HEALing Communities Study, a community-engaged, wait-listed, cluster-randomized implementation trial across four states. Interviews focused on coalition context and implementation of evidence-based practices. This secondary analysis examined a subset of data from Massachusetts, New York, and Ohio related to race, racism, coalition context, and intervention implementation. Analysis involved a thematic approach, drawing on PRISM/RE-AIM-informed code reports and emergent coding to identify patterns related to structural racism and implementation. Structural racism was applied as an interpretive lens. Three key themes emerged: (1) Culture over Structures, in which participants often explained inequities through community culture, mistrust, or individual attitudes rather than structural racism; (2) White Residential Homogeneity, in which local racial demographics were used to justify limited race-conscious action; (3) The Burden of Proof, in which missing or difficult-to-use data stalled equity-focused implementation. Some coalitions described strategies to address these barriers, including critical dialogue, inclusive hiring, targeted outreach, and partnerships with community and faith-based organizations. Coalition-led implementation may both mitigate and reproduce racial inequities. Policies and practices that support race-conscious, community-led implementation, equitable data systems, and diverse coalition leadership may strengthen opioid prevention and treatment efforts for racial and ethnic minoritized communities. Future research should examine how these dynamics differ across local contexts, including rural and urban communities.