Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review
Substance Abuse Treatment, Prevention, and Policy volume 17, Article number: 62 (2022)
People living in rural and remote communities in Canada are often disproportionately impacted by opioid use disorder. When compared to urban centres, rural and remote populations face additional barriers to treatment, including geographical distance as well as chronic shortages of health care professionals. This integrative review of the literature was conducted to explore the facilitators and barriers of OAT in rural and remote Canadian communities.
A search of the literature identified relevant studies published between 2001 and 2021.
The search strategy yielded 26 scholarly peer-reviewed publications, which explored specific barriers and facilitators to rural and remote OAT in Canada, along with two reports and one fact sheet from the grey literature. Most of the scholarly articles were descriptive studies (n = 14) or commentaries (n = 9); there were only three intervention studies. Facilitators and barriers to OAT programs were organized into six themes: intrapersonal/patient factors, social/non-medical program factors, family/social context factors (including community factors), infrastructure/environmental factors, health care provider factors, and system/policy factors.
Although themes in the literature resembled the social-ecological framework, most of the studies focused on the patient-provider dyad. Two of the most compelling studies focused on community factors that positively impacted OAT success and highlighted a holistic approach to care, nested in a community-based holistic model. Further research is required to foster OAT programs in rural and remote communities.
Opioid agonist therapy (OAT) is widely considered the gold standard treatment for opioid use disorder [1, 2]. While the accessibility of OAT has improved in some Canadian jurisdictions, its use and availability continue to lag in rural and remote communities . This lag is concerning because rural and remote populations are often disproportionately impacted by opioid use disorder and face additional barriers to treatment when compared to urban populations . In addition, rural and remote OAT services across Canada can vary widely in their quality and breadth, where some communities receive highly innovative care and others receive relatively ineffectual care [4, 5]. Inconsistent or ineffectual OAT programs can result in high rates of patient attrition, which can have a devastating impact on individuals, families, and communities . The purpose of this integrative review was to explore the facilitators and barriers of OAT in rural and remote Canadian communities. The findings of this review can provide a foundation for researchers, policy makers, and knowledge users to develop a shared research and practice agenda.
Rural and remote communities in Canada have been disproportionately impacted by opioid use disorder (OUD)  and the current opioid epidemic. People in these communities experience additional barriers to treatment, including geographical factors and chronic shortages of health care professionals, when compared to their urban peers [7,8,9,10]. In addition, OAT programs in these communities can be ineffectual or inconsistent with high rates of patient attrition.
OAT is considered the gold standard for patients with OUD. In OAT, patients substitute problematic illicit and extra-medical opioids (such as oxycodone and fentanyl) with an ongoing prescription for buprenorphine (with or without naloxone) or methadone, both of which are long-acting opioids that stimulate receptors in the brain to prevent withdrawal and reduce cravings . OAT is usually combined with in-clinic visits and daily witnessed ingestion of the medications at a pharmacy.
OAT can positively impact patients, families, and communities by reducing substance use, increasing family stability, decreasing crime rates, improving mental and physical health, and enhancing quality of life [6, 12]. Consistent and prolonged engagement in OAT is associated with lower morbidity and mortality as well as higher quality of life for patients seeking to reduce or cease opioid use [13, 14].
Retention of patients on OAT can be complicated due to a wide range of intrinsic, extrinsic, and environmental factors, such as shortages of health care personnel, lack of technology for telehealth, failure of medication doses to meet the patient’s needs, continued illicit drug use, and lack of social supports [8, 15,16,17,18,19]. Unfortunately, the premature cessation of OAT is associated with a variety of negative outcomes [20,21,22], including drug overdose, bloodborne infections, worsening substance use, and death [19, 23,24,25].
People in rural and remote communities have higher rates of OUD and experience greater difficulty accessing help when compared to their urban counterparts [19, 26]. Patients in rural and remote locations face barriers to OAT, including geographical distances to clinics and pharmacies, limited seasonal accessibility, chronic shortages of health care professionals, and poor access to complementary supports such as psychotherapy [7,8,9, 27]. Consistent with these findings, Rush and Furlong  advocated that people in rural and remote regions of Canada need better access to substance use care than is currently provided. Given the significant increase in opioid use that has arisen during the COVID-19 pandemic , this matter is both timely and urgent.
While best practices for OAT have been outlined by the Canadian Centre on Substance Use and Addiction , recommendations specific to rural and remote populations are still lacking. Nevertheless, some research regarding rural and remote OAT has been published in recent years. For instance, Venner et al.  reported on a key stakeholders’ meeting about the acceptability of OAT among Indigenous people in the United States, elucidating a considerable gap between Western medical perspectives/approaches (including OAT) and traditional/Indigenous healing approaches . The First Nations Health Authority  articulated some practical tips for rural and remote communities, such as: increasing the role of community health facilities; expanding the role of registered nurses in OAT; and, ensuring the availability of wraparound supports, including peer support, case management, and culturally relevant healing practices. Levine et al.  described an Indigenized approach to harm reduction that is both holistic and culturally safe. These are just a few examples of recommendations that need to be synthesized in the forefront of the scholarly literature and translated into practice settings.
The objective of this review was to explore the facilitators and barriers of outpatient OAT in rural and remote Canadian communities (some of which are Indigenous communities). Integrative reviews aim to address a research problem through compiling evidence from multiple study designs and types of data in order to more fully understand a phenomenon of concern [34, 35]. Integrative reviews explore how concepts are described in the literature, what work has been done and needs to be expanded, what relationships have been explored between concepts or other related phenomena, and what research approaches have been used to study the concept .
This integrative review was conducted according to the guidelines put forth by the Joanna Briggs Institute  and leading methodologists [34, 35]. The search terms were developed by the principal investigator with a health sciences librarian. The search terms included OAT (and its variant terms) medications as subject headings, key words describing geographic locations (rural, remote, and variants), and key words pertaining to Indigenous communities, since many rural and remote communities in Manitoba are predominantly Indigenous. Search terms for medications were limited to opioid substitution therapies; as a result, heroin, hydromorphone, and other opiates were not included in the search, as these drugs are associated with safe supply rather than substitution. A pilot search was conducted to refine the search terms and assess the final search results against a list of exemplar articles.
The literature search aimed to identify relevant studies published between 2001 and 2021, using MEDLINE (see Table 1), EMBASE, CINAHL, Cochrane Library, PubMed, Health and Psychosocial Instruments, Scopus, JBI Databases of Systematic Reviews and Implementation Reports, Cochrane, ERIC, Web of Science, Google Scholar, ScienceDirect and PsycINFO. Hand searches were conducted to identify grey literature in trial databases (Canadian Electronic Library, Health Services Research Projects in Progress, Canadian Institutional Repositories, ProQuest Dissertations and Theses) as well as on websites of relevant organisations (e.g. CRISM, BCCSU, CADTH), provincial and territorial health ministries, and federal health bodies (Health Canada, PHAC). Articles were included in the review if they met the following criteria: represented original research (qualitative, quantitative, and mixed methods as well as theses and dissertations) about OAT; written in English (due to lack of available translator[s]); based in Canada; and addressed a rural or remote issue pertaining to OAT. Literature was not limited to adults because OAT is also useful among pediatric patients.
Full texts were pulled by research assistants and Covidence  was used as an organizing and collaborating tool. The principal investigator and three research assistants independently reviewed titles and abstracts to assess for inclusion criteria related to the population, concept, and context as well as to remove duplicates. This process was followed by a more thorough reading to assess for inclusion. Any disagreements between team members regarding the inclusion of specific articles were discussed and resolved within the team .
Researchers recorded the following information for each article: author(s); year of publication; type of article (academic or grey); country of origin (in case the search needed to be expanded beyond Canadian literature); aim/purpose; study population and sample size; methodology/method; intervention type/duration and outcome measures; and key findings, specifically related to facilitators and barriers to OAT. Since this integrative review focused on exploring the facilitators and barriers of OAT in rural and remote Canadian communities, researchers commented on the quality of each article but did not omit less robust items, as would be done in a systematic review. Thus, this review was focused on relevance rather than quality.
While definitions of “urban”, “rural” and “remote” vary widely by source and application and there is no consensus on definitions , the Statistics Canada definition of “rural” was adopted for the purposes of this research. Statistics Canada differentiates between rural and population centres (formally “urban” centres) as follows. A population centre is defined as having a population of over 1,000 people and a density of 400 people per square kilometre. If an area does not meet these criteria, it is considered rural. Additionally, population centres are divided into small, medium and large, with small population centres having a population of 1,000 to 29,999 and a density of 400 people per square kilometre. Similarly, there is little consensus on what constitutes “remote” in the literature and the term is used to describe a range of communities that are significant distances from population centres and that lack access to services . We included articles that self-declared their communities to be “rural” or “remote” and then followed up with Statistics Canada to ensure the threshold of rurality was not exceeded.
The search strategy returned 230 records from all databases. Fifty-eight duplicate records were removed and 172 titles and abstracts were screened (excluding 123 references). Of the remaining 49 full-text citations, 29 references met all inclusion criteria. These references included 26 scholarly peer-reviewed publications, which explored specific barriers and facilitators to rural and remote OAT in Canada (see Table 2), and were comprised of 14 research studies, nine commentaries, one case report, and two review articles. Most of the studies were conducted in Ontario (n = 21) and British Columbia (n = 2).
The grey literature search strategy returned a total of 50 records from different websites (n = 11) and organizations (n = 6). Thirty-six (36) of the 50 records were duplicates from the databases and registers, which were not included in analysis but used to confirm the appropriateness of the search strategy. Fourteen items were included in the analysis (see Fig. 1). After screening titles and abstracts of executive summaries (where applicable), three full-text grey literature publications were included. The primary reasons for excluding items in this search were: lack of focus on rural, remote, and/or Indigenous settings (n = 6); lack of focus on barriers and facilitators of OAT (n = 3); and focus on an intervention other than outpatient OAT (n = 3).
Results by type
Included documents are in Table 2 and organized by type.
Of the 14 included research studies, 11 were descriptive studies that reported on the barriers and facilitators to OAT in rural, remote, and Indigenous contexts in Canada [7, 19, 27, 29, 51,52,53,54,55,56,57]; ten of these studies were conducted in Ontario, with the remaining one in New Brunswick. Seven studies used administrative data, either alone or in combination with other methods (n = 2). Two studies were qualitative and two studies used a mixed method design. One study used a community-based participatory research design.
Three articles described interventions to enhance access to and retention in OAT in rural, remote, and Indigenous contexts [6, 58, 59]. One intervention involved the use of telemedicine  and led to higher OAT retention rates. Kanate et al.  presented a compelling and promising community-developed program for First Nations communities that focused on traditional healing, substance use treatment, and substitution therapy. Katt et al.  discussed a community-based Suboxone taper to low dose maintenance program.
Nine of the articles were commentaries [41,42,43,44,45,46,47,48,49]. Six commentaries originated from work in Ontario, one from British Columbia, and two were general to Canada. Commentaries focused on the need to prioritize rural research (n = 1) and provide information about barriers, facilitators, and practice innovations (n = 8). It should be noted that the commentary by Webster  is essentially focused on the work of Katt et al. , a study that is described above. There was an overall emphasis on virtual care/telemedicine as a means to improve uptake and retention of OAT.
Other scholarly works
The grey literature search strategy resulted in two reports and a fact sheet, all of which included rural, remote, and Indigenous considerations for OAT. The Centre for Addiction and Mental Health (CAMH)  recommended collaborating with existing services and using telehealth in partnership with local resources. Wells et al.  authored a report for the Canadian Agency for Drugs and Technologies in Health (CADTH), which highlighted the numerous barriers to care in rural settings and suggested ways to enhance care. The First Nations Health Authority (FNHA)  generated a fact sheet on pharmaceutical alternatives and OAT in Indigenous communities.
Results by theme
Facilitators and barriers to outpatient OAT in rural and remote Canadian communities were organized into six themes: intrapersonal/patient factors; social/non-medical program factors; family/social context factors (including community factors); infrastructure/environmental factors; health care provider factors; and system/policy factors.
Intrapersonal factors were frequently mentioned across all the reviewed documents. Barriers to patient success included polysubstance use, injection drug use, concurrent mental disorders, lack of awareness of services, apathy, fear of being judged or labeled, fear of child apprehension, fear of law enforcement, fear of disappointing others, maladaptive coping, and economic difficulties [3, 19, 53, 55]. Intrapersonal facilitators included a connection to spirituality and traditional beliefs as well as self-motivation . Patient success was also fostered through: contingency planning; financial assistance for travel; access to stable and affordable housing; access to a community transportation system; incentives for attendance; access to formal substance use counseling; and logistical supports, such as assistance with health and identification cards, disability support applications, and appointments with child services workers/lawyers [2, 3, 19, 27, 41, 42, 56].
Social/non-medical services were considered important supports for those who were able to access them. In general, however, existing programs and services were described as disconnected, siloed, and lacking resources [48, 60]. As well, the COVID-19 pandemic limited or suspended traditional Indigenous healing practices that promoted success of OAT. OAT was enhanced by a range of medical and psychosocial interventions that aimed to achieve spiritual, emotional, mental, and physical healing and wellness . Traditional Indigenous healing practices facilitated cultural connectedness and were identified as important aspects of recovery [48, 56]. In addition, group participation, social support, and peer encouragement were significant facilitators of OAT retention [42, 54, 56]. Researchers recommended the application of a local Indigenous worldview in the development and implementation of clinical, research, and program priorities in order to build strengths and increase local capacity. Researchers ultimately suggested that community members and PWUD must be directly involved in the development and delivery of programs to ensure they meet the needs of the community [41, 55].
Family/social context factors
Barriers to successful OAT initiation and treatment included the presence of domestic conflicts, stigma associated with OAT, and misunderstandings about OAT within the family unit [43, 54]. Due to crowded living conditions in many Indigenous communities, individuals often had privacy concerns regarding the use of telemedicine and virtual care. Patients who had a strong support system, including those with family members who were supportive of OAT and those who had support from a peer group, were more likely to succeed with OAT, especially when their family’s concerns were addressed in a timely fashion [55, 57].
Several community factors were also noted to help or hinder people on OAT. Barriers to effective access and treatment included public opposition to OAT/harm reduction strategies, stigma associated with OUD and OAT, community concerns about the safety of long-term OAT, and misconceptions about how OAT fits with spiritual beliefs [33, 52, 54, 60]. In addition, there were concerns about confidentiality and privacy within small towns and settlements. Several articles described how these barriers could be overcome, such as by openly addressing the community’s concerns through public discussions and education as well as by applying a local Indigenous worldview to the implementation of clinical care in First Nations communities, which can increase local capacity .
Researchers recommended creating community working groups to strengthen alliances between First Nations and provincial health services staff . Community ownership of health programs generates buy-in, which translates into community support and better patient care [6, 46, 55]. Several authors underscored the necessity of helping communities understand that, since the opioid epidemic affects physical, mental, spiritual, and emotional well-being, community-wide healing strategies must address each of these elements [33, 46, 54]. Mamakwa et al.  described a particularly compelling model of care; while typical OAT programs are focused on the relationship between patient and HCP, the Sioux Lookout programs are a “community-wide welcoming back of addicted patients to their families and their previous roles” . This program is cohort-based and induction into the program is a community celebration.
Infrastructure and environmental factors, which are external to the patient but influence available services, were frequently mentioned across the literature. Barriers included the need to traverse significant geographical distances to access care, lack of transportation, extreme weather, seasonally accessible roads, lack of community services and resources, lack of local comprehensive treatment, under-resourcing of local services, and poor internet access (which limited access to telemedicine and virtual care) [3, 7, 27, 43, 48, 52, 56, 58]. These elements were particularly impacted by the COVID-19 pandemic, which limited patient care and patient monitoring, reduced access to withdrawal management, and disrupted all services and supports . Facilitators to OAT included the availability of ancillary non-pharmacological substance use treatment and recovery services as well as multi-pharmacy approaches to OAT, which effectively increased access points, facilitated consent, and provided opportunities to help complex patients [7, 52].
Health care provider factors
A frequently cited factor that influenced patient care in rural, remote, and Indigenous communities was the general shortage of health care providers as well as the lack of providers (both nurse practitioners and physicians) who were trained and authorized to provide OAT [3, 10, 42, 44, 46, 49, 50, 55, 60]. The lack of legally authorized and qualified providers creates a bottlenecking of service entry, with long waitlists being identified as a predictor of attrition . Even if a community has a qualified health care provider, access to OAT is dependent on many other external factors .
The current landscape is limited when it comes to renumeration models in substance use care and often providers are not compensated adequately for the time spent on complex issues they face when managing the health, trauma and social needs of those with substance use disorders . Health care providers may face challenges in providing medication carries (take home doses) to these patients due to provincial regulations and even concerns about safe transport, storage, dispensing, diversion, and misuse of medications . The literature highlighted a general shortage of physicians, nurses, addictions specialists, pharmacists, and pharmacies in rural areas, and noted that few providers were prepared to work with OAT patients. Rural pharmacies were often described as under-resourced, generally had very limited hours of operation, and did not routinely stock medications used in OAT [45, 47, 50, 52, 56]. Daily dispensing of OAT medications placed additional burdens on pharmacists and nursing stations, both of which are often closed on weekends [50, 52]. Finally, despite the staffing model outlined by Health Canada, Katt et al.  noted a distinct lack of long-term follow-up with patients in rural, remote, and Indigenous communities.
OAT was reported to be enhanced through: the use of a trauma-informed approach; higher doses of OAT to prevent withdrawal symptoms and discourage patients from self-medicating; unsupervised medication carries that provide pharmacists with greater flexibility in prescription deliveries; the use of telemedicine in partnership with local resources; education to increase the support and provide additional resources for physicians, nurse practitioners, and pharmacists to prescribe and manage OAT; strategies for safer home delivery of supplies; increased access to clinical mentorship opportunities for providers working with complex patients; and the provision of local, holistic, collaborative, and interdisciplinary care through the involvement of registered nurses, physicians, nurse practitioners, case managers, and addiction workers [2, 3, 27, 33, 48, 49, 52, 59]. The British Columbia Centre on Substance Use (BCCSU) and the University of British Columbia (UBC) offer a free, self-directed online course entitled “Provincial Opioid Addiction Treatment Support Program (POATSP)” that is recommended for health care providers involved in OAT . Similarly, CAMH offers an online course. Patients also benefit from a long-term, harm reduction perspective (rather than an abstinence goal) as well as greater ease of accessibility and flexibility, including more accommodating appointment times and walk-in style programming [42, 60].
The literature identified numerous bureaucratic and administrative barriers to OAT. For example, a comprehensive in-person evaluation of the patient must be completed before initiating OAT; this requirement is waived when telemedicine is used to compensate for distances and pandemic restrictions . In addition, the strict entry criteria for OAT often presents a barrier to patients . Furthermore, many physician compensation models are at odds with the complex needs of OAT patients . Another challenge in the system is that daily witnessed dosing can be onerous for many rural and remote patients who must travel long distances [10, 60]. In some cases, take-home doses would require the patient to travel to a clinic on a daily basis for up to eight months, while Non-Insured Health Benefits only offers subsidized funding for four months of travel-related expenses . As well, the requirement for nurse practitioners to obtain an exemption for prescribing opioids varies across the country, further reducing patient access. Lastly, Health Canada’s tendency to hire physicians on short-term contracts in Indigenous communities has contributed to opioid over-prescribing and subsequent crises in these communities . Overall, the literature demonstrated that clinical practice guidelines for OAT failed to consider the realities of rural and remote practice. The literature suggested that regulatory changes were needed to enhance patients’ access to timely and appropriate comprehensive treatment [10, 56].
This integrative review revealed several facilitators and barriers, as well as strengths and gaps, with regards to OAT programs in rural and remote communities in Canada. Most of the literature about Canadian rural and remote OAT programs was based out of Ontario, with a dearth of literature on this topic from other provinces (BC, n = 2; NB, n = 1; NWT, n = 1; and none from the prairie provinces). The authors of this manuscript are aware of several innovative approaches to rural and remote OAT in provinces that have been unrepresented in the literature; it is unclear as to the source of the disconnect between practice innovation and scholarly dissemination.
In terms of study design, most studies (n = 14) were descriptive in nature, and many used administrative and electronic medical record (EMR) data. Three of the articles were intervention studies and three were qualitative studies. Commentaries (n = 9) and reviews (n = 3) comprised around half of the articles. The grey literature search strategy resulted in two reports and one fact sheet.
The themes across all of the documents bore resemblance to the social-ecological framework [61,62,63]. The social-ecological model of health posits that outcomes can be organized into five nested levels: intrapersonal factors, interpersonal factors, institutional factors, community factors, and public policy. This framework recognizes that the patient-provider dyad is inseparable from and impacted by infrastructure, policy, family, and community because all of the factors are networked rather than nested together ; each aspect has a different level of influence over other aspects.
That said, most of the literature (n = 12) focused on the patient-health care provider dyad (Fig. 2). As a result, our visual depiction of the extant literature considers patient and healthcare provider as distinct from each other and from the strict interpretation of “interpersonal factors.” Although the patient-provider dyad is prominently featured in the literature, it offers a narrow biomedical focus that is quite reductionistic when examined alongside more holistic approaches to OAT, as confirmed by the work of Mamakwa et al. . Reductionistic perspectives are in direct conflict with the holism that typifies many Indigenous worldviews and approaches to care and, thus, may be a limiting factor in OAT success. Similarly, when reporting on a systematic review of OAT in American Indigenous communities, Mpofu et al.  describe the need for using multi-pronged interventions to manage OUD in these communities, establishing community-informed guidelines that are culturally appropriate ways, and capitalizing on community strengths that are rooted in traditions and culture.
Two of the most compelling studies [6, 55] in our review focused on community factors and highlighted a holistic approach to OAT care, nested within a community-based holistic model. Many authors suggested that programs be focused on a local Indigenous worldview and on strengthening local capacity. While most articles lacked sufficient detail on successful programs, Mamakwa et al.  described a community-centred and holistic model of OAT in which patients received connection and healing from their own community.
It is important that medical clinics not limit patient engagement and success to factors within the patient-provider dyad, as this will overlook the importance of community support, culture, social restoration, and belonging. Cultural awareness and creative and adaptive strategies are needed to respond to the geographical, cultural, and institutional circumstances that typify rural and remote communities [65, 66]. Although evaluation of OAT programs is typically centred on the patient-provider dyad, the Sioux Lookout OAT program is community-wide and focused on welcoming substance-dependent patients back to their families and previous roles. The Sioux Lookout program is cohort-based; induction into the program is revered as a community event whereby local leaders, friends, and relatives support the inductees. In addition, psychosocial treatment programs can provide culturally appropriate meeting places for patients to gather in healing circles and other traditional events. Research from the US also describes the need for holistic and culturally relevant care that is rooted in the local community with its history, traditions and support networks; authors agree that the opioid epidemic must be addressed at both the individual and community levels and address health policy factors that contribute to the opioid epidemic [31, 67, 68].
This review raises several key issues. First, policymakers and medical infrastructure must become catalysts for change to ensure OAT is more accessible to people in resource-poor rural and remote areas. Policy changes and evaluation research are needed to support innovative practices in rural and remote areas. This review is critical to the advancement of a targeted research and policy agenda to drive the provision of innovative and effective health services . In the US, Johnson et al.  report that federal regulations and local infrastructure exacerbates the transportation barrier and is a deterrent to care in rural communities. The US, like Canada, also structures rural and remote physician services under federal provision, which underscores the need for increased governmental support of health care in these settings .
Second, Indigenous-led participatory action research is required to investigate successful OAT programs. The success of these programs may be attributed to the fact that they are designed, led, and implemented by the community. In addition, the delivery of these Indigenous-led programs differs from that of non-Indigenous/Western programs, which are inherently reductionist. Community-based approaches require further investigation and broader implementation. Intervention research is also needed.
Third, the evaluation of community impacts is another important area of future research that aligns with a social-ecological perspective. Community-based programs were associated with high retention rates and positive community-wide results (i.e., lower crime rates, fewer child protection cases, higher school attendance rates, and fewer drug-related medical evacuations to hospital). By monitoring community-level data and linking it to substance use statistics (including treatment and OAT), important relationships can be explored and leveraged into action.
The COVID-19 pandemic has exposed gaps and weaknesses in existing systems, particularly within health care in rural and remote communities. Thus, the pandemic has exacerbated existing crises in communities that are already vulnerable; urgent action is desperately needed to reverse these dire trends. This integrative review demonstrated that while most OAT studies in Canada have focused on the patient-provider dyad as the locus of patient success, such a reductionistic perspective may be contributing to the problem. Rather, interventions that are holistic, deeply situated in the community, culturally embedded and rooted in traditional healing, may hold greater promise for helping individuals, families and communities to heal and experience restoration. Even if the path forward is unclear, there are powerful examples of Indigenous-led and community-based approaches to address the opioid crisis in rural and remote settings. These exemplars entreat further exploration, implementation and evaluation.
Availability of data and materials
Health care provider
Opioid agonist therapy
Opioid use disorder
People who use drugs
Srivastava A, Kahan M, Nader M. Primary care management of opioid use disorders: abstinence, methadone, or buprenorphine-naloxone? Can Fam Physician. 2017;63(3):200–5.
Centre for Addiction and Mental Health. Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder. Toronto: Author; 2021.
Franklyn AM, et al. Geography, treatment modality, and substance use: evaluating factors that impact opioid agonist therapy in Northern Ontario, Canada. J Addict Med Therapy. 2016;4(2):1023.
Socías ME, Ahamad K. An urgent call to increase access to evidence-based opioid agonist therapy for prescription opioid use disorders. Can Med Assoc J. 2016;188(17–18):1208–9.
Eibl JK, et al. The state of opioid agonist therapy in Canada 20 years after federal oversight. Can J Psychiat. 2017;62(7):444–50.
Kanate D, et al. Community-wide measures of wellness in a remote First Nations community experiencing opioid dependence: Evaluating outpatient buprenorphine-naloxone substitution therapy in the context of a First Nations healing program. Can Fam Physician. 2015;61(2):160–5.
LaBelle B, et al. Characterizing the use of telepsychiatry for patients with opioid use disorder and cooccurring mental health disorders in Ontario, Canada. Int J Telemed Appl. 2018;2018:7937610.
Snell-Rood C, Pollini RA, Willging C. Barriers to integrated medication-assisted treatment for rural patients with co-occurring disorders: The gap in managing addiction. Psychiatr Serv. 2021;72(8):935–42. https://0-doi-org.brum.beds.ac.uk/10.1176/appi.ps.202000312.
Marchildon GP, Allin S, Merkur S. Canada: health system review. Health Syst Transit. 2020;22(3):1–194.
Jumah NA, Graves L, Kahan M. The management of opioid dependence during pregnancy in rural and remote settings. Can Med Assoc J. 2015;187(1):E41–6.
Priest KC, et al. Comparing Canadian and United States opioid agonist therapy policies. Int J Drug Policy. 2019;74:257–65.
Gisev N, et al. The effect of entry and retention in opioid agonist treatment on contact with the criminal justice system among opioid-dependent people: a retrospective cohort study. Lancet Public Health. 2019;4(7):e334–42.
Morin KA, et al. Concurrent psychiatry for patients enrolled in opioid agonist treatment: a propensity score matched cohort study in Ontario Canada. Subst Abuse Treat Prev Policy. 2019;14(1):29.
Jones NR, et al. Reductions in emergency department presentations associated with opioid agonist treatment vary by geographic location: a retrospective study in New South Wales. Aus Drug Alcohol Rev. 2019;38(6):690–8.
Scorsone KL, et al. Overcoming barriers: Individual experiences obtaining medication-assisted treatment for opioid use disorder. Qual Health Res. 2020;30(13):2103–17.
Parchman ML, et al. Barriers and facilitators to implementing changes in opioid prescribing in rural primary care clinics. J Clin Transl Sci. 2020;4(5):425–30.
Lister JJ, et al. A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States. Am J Drug Alcohol Abuse. 2020;46(3):273–88.
White WL, et al. Patterns of abstinence or continued drug use among methadone maintenance patients and their relation to treatment retention. J Psychoactive Drugs. 2014;46(2):114–22.
Oukachbi S, Rizzo S. Individual factors associated with opioid agonist therapy retention in Northern Ontario. Can J Addict. 2020;11(1):19–29.
Timko C, et al. Retention in medication-assisted treatment for opiate dependence: a systematic review. J Addict Dis. 2016;35(1):22–35.
Eastwood B, Strang J, Marsden J. Effectiveness of treatment for opioid use disorder: a national, five-year, prospective, observational study in England. Drug Alcohol Depend. 2017;176(3):139–47.
Self B, Peters H. The benefits of methadone maintenance therapy: a case study of providing access to methadone in rural and northern British Columbia. eCOMMUNITY: Int J Mental Health Addict. 2004;2(1):15–21.
Meinhofer A, et al. Prescribing decisions at buprenorphine treatment initiation: do they matter for treatment discontinuation and adverse opioid-related events? J Subst Abuse Treat. 2019;105:37–43.
Lalic S, et al. Harms associated with extramedical use of prescription opioid analgesics in Australia: a scoping review. Res Social Adm Pharm. 2019;15(8):925–35.
Stone J, et al. Modelling the intervention effect of opioid agonist treatment on multiple mortality outcomes in people who inject drugs: a three-setting analysis. Lancet Psychiatry. 2021;8(4):301–9.
Canadian Centre on Substance Use and Addiction. Focused on the Future: Strategic Plan 2021–2026. Evidence. Engagement. Impact. Ottawa: Author; 2020.
Eibl JK, et al. Evaluating the effectiveness of first-time methadone maintenance therapy across northern, rural, and urban regions of Ontario. Can J Addict Med. 2015;9(6):440–6.
Rush B, Furlong A. Rapid Access Models for Substance Use Services: A Rapid Review. Ottawa: Canadian Centre on Substance Use and Addiction; 2020.
Morin KA, et al. Evidence of increased Fentanyl use during the COVID-19 pandemic among opioid agonist treatment patients in Ontario. Can Int J Drug Policy. 2021;90:103088.
Taha S. Best Practices across the Continuum of Care for Treatment of Opioid Use Disorder. Ottawa: Canadian Centre on Substance Use and Addiction; 2018.
Venner KL, et al. Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives. Addict Behav. 2018;86:111–7.
Levine S, Medley A, Norton A. Putting indigenous harm reduction to work: developing and evaluating “not just naloxone”. Int J Indig Health. 2021;16(2):244–66.
First Nations Health Authority. Pharmaceutical Alternatives and Opioid Agonist Therapy: Community Considerations. Vancouver: Author; 2020.
Broome M. Integrative literature reviews for the development of concepts. In: Rodgers BL, Knafl KA, editors. Concept Development in Nursing. Toronto: Saunders; 2000. p. 231–50.
Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53.
Aromataris E, Munn Z. JBI Manual for Evidence Synthesis. Adelaide: JBI; 2021.
Veritas Health Innovation. Covidence Systematic Review Software. 2021. Available from: www.covidence.org.
Moher D, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339(b3112):1-8.
Statistics Canada. Developing Meaningful Categories for Distinguishing Levels of Remoteness in Canada. 2020. Available from: https://www150.statcan.gc.ca/n1/pub/11-633-x/11-633-x2020002-eng.htm.
Alasia A, et al. Measuring Remoteness and Accessibility: A Set of Indices for Canadian Communities, in Reports on Special Business Products. Ottawa: Statistics Canada; 2017.
Bardwell G, Lappalainen L. The need to prioritize research, policy, and practice to address the overdose epidemic in smaller settings in Canada. Can J Public Health. 2021;112(4):733–6.
Buck-McFadyen E, Lee-Popham S, White A. Integrating services for people who use opioids in a rural primary care setting: the ROOT program. Can J Commun Ment Health. 2020;39(3):75–8.
Dorman K, et al. Community strengths in addressing opioid use in Northeastern Ontario. Can J Public Health. 2018;109(2):219–22.
Eibl JK, Morin-Taus KA, Marsh DC. Too much or never enough: a response to treatment of opioid disorders in Canada: looking at the ‘other epidemic’. Subst Abuse Treat Prev Policy. 2016;11(1):1–3.
Jumah NA, Bishop L, Franklyn M, Gordon J, Kelly L, Mamakwa S, O’Driscoll T, Olibris B, Olsen C, Paavola N, Pilatzke S, Small B, Kahan M. Opioid use in pregnancy and parenting: an Indigenous-based, collaborative framework for Northwestern Ontario. Can J Public Health. 2018;108(5–6):e616–20. https://0-doi-org.brum.beds.ac.uk/10.17269/cjph.108.5524.
Uddin F. Hope in Fort Hope: First Nations community is winning the battle against prescription drug abuse. Can Fam Physician Med de Fam Can. 2013;59(4):391–3.
Webster PC. Indigenous Canadians confront prescription opioid misuse. Lancet. 2013;381(9876):1447–8.
Wendt DC, et al. Commentary on the impact of the COVID-19 pandemic on opioid use disorder treatment among Indigenous communities in the United States and Canada. J Subst Abuse Treat. 2021;121:108165.
Weng A. The potential use of telemedicine to increase access to opioid agonist therapy in rural and remote communities. BC MED J. 2020;62(10):377–9.
Jones M, Quinn M. A buprenorphine-naloxone induction in the North. Can J Rural Med. 2020;26(1):35–7.
Dooley J, et al. Maternal opioid use disorder and neonatal abstinence syndrome in northwest Ontario: a 7-year retrospective analysis. Can J Rural Med. 2018;23(2):39–44.
Fonseca J, Chang A, Chang F. Perceived barriers and facilitators to providing methadone maintenance treatment among rural community pharmacists in Southwestern Ontario. J Rural Health. 2018;34:23–30.
Franklyn AM, Eibl JK, Gauthier G, Pellegrini D, Lightfoot NE, Marsh DC. The impact of benzodiazepine use in patients enrolled in opioid agonist therapy in Northern and rural Ontario. Harm Reduct J. 2017;14(1):6. https://0-doi-org.brum.beds.ac.uk/10.1186/s12954-017-0134-5.
Landry M, Veilleux N, Arseneault J-E, Abboud S, Barrieau A, Belanger M. Impact of a methadone maintenance program on an aboriginal community: a qualitative study. CMAJ Open. 2016;4(3):E431–5.
Mamakwa S, et al. Evaluation of 6 remote First Nations community-based buprenorphine programs in northwestern Ontario: Retrospective study. Can Fam Physician. 2017;63(2):137–45.
Russell C, et al. Assessing service and treatment needs and barriers of youth who use illicit and non-medical prescription drugs in Northern Ontario, Canada. PLoS One. 2019;14(12):e0225548.
Srivastava A, et al. Long-term treatment outcomes in a First Nations high school population with opioid use disorder. Can Fam Physician. 2020;66(12):907–12.
Eibl JK, et al. The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug Alcohol Depend. 2017;176:133–8.
Katt M, et al. Feasibility and outcomes of a community-based taper-to-low- dose-maintenance suboxone treatment program for prescription opioid dependence in a remote First Nations community in Northern Ontario. Int J Indig Health. 2012;9:52–9.
Wells C, Dolcine B, Frey N. Programs for the Treatment of Opioid Addiction: An Environmental Scan. Ottawa: CADTH; 2019.
Jalali MS, et al. The opioid crisis: a contextual, social-ecological framework. Health Res Policy Syst. 2020;18(1):87.
Bronfenbrenner U, Morris PA. The ecology of developmental processes. In: Damon W, Lerner RM, editors. Handbook of Child Psychology: Theoretical Models of Human Development. Hoboken, NJ, US: John Wiley & Sons Inc; 2006. p. 793–828.
Connell CM, et al. Social-ecological influences on patterns of substance use among non-metropolitan high school students. Am J Community Psychol. 2010;45(1–2):36–48.
Neal JW, Neal ZP. Nested or networked? Future directions for ecological systems theory. Soc Dev. 2013;22(4):722–37.
Mpofu E, et al. Trending the evidence on opioid use disorder (OUD) continuum of care among rural American Indian/Alaskan Native (AI/AN) tribes: a systematic scoping review. Addict Behav. 2021;114:106743.
Kiepek N, et al. Facilitating medical withdrawal from opiates in rural Ontario. Rural Remote Health. 2012;12:2193.
D’Amico EJ, et al. Integrating traditional practices and social network visualization to prevent substance use: study protocol for a randomized controlled trial among urban Native American emerging adults. Addict Sci Clin Pract. 2021;16(1):56.
Pro G, et al. Individual and health policy factors associated with positive heroin and opioid treatment response: United States, 2018. Am J Public Health. 2022;112(S1):S66–76.
Fox A, Gardner G, Osborne S. A theoretical framework to support research of health service innovation. Aust Health Rev. 2015;39(1):70–5.
Johnson Q, Mund B, Joudrey PJ. Improving rural access to opioid treatment programs. J Law Med Ethics. 2018;46(2):437–9.
Kvamme E, et al. Who prescribes buprenorphine for rural patients? The impact of specialty, location and practice type in Washington State. J Subst Abuse Treat. 2013;44(3):355–60.
The team would like to thank the Manitoba Centre for Nursing and Health Research (MCNHR) at the University of Manitoba for funding this project.
Manitoba Centre for Nursing and Health Research (MCNHR) at the University of Manitoba.
Ethics approval and consent to participation
Consent for publication
Competing of interests
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Pijl, E.M., Alraja, A., Duff, E. et al. Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review. Subst Abuse Treat Prev Policy 17, 62 (2022). https://0-doi-org.brum.beds.ac.uk/10.1186/s13011-022-00463-5