Table 2 Studies on facilitators and barriers to access to and retention on OAT in rural, remote and Indigenous Canadian communities

Peer-Reviewed

 Bardwell and Lappalainen (2021) [41]

Canada

Non-specific rural

N/A

Commentary

There are gaps in research and policy directives for safer supply and novel OAT programs in smaller settings. Smaller communities should explore virtual OAT and safer supply clinics, pharmacist or nurse-led OAT and safer supply home delivery services to overcome barriers to access. The involvement and inclusion of PWUD in the development and delivery of programs is necessary to create more effective programming.

 Buck-McFadyen et al. (2020) [42]

ON

4065

17.9/km²

Commentary

The Rural Outpatient Opioid Treatment program provides access to an interdisciplinary team, opioid agonist therapy, counselling, and peer support for people experiencing opioid use problems. The ROOT program provides wrap-around services with integrated medical, social, and peer supports.

 Dorman et al. (2018) [43]

ON

FN community; no data in Statistics Canada

No data

Commentary

A community working group can strengthen relationships and create a culturally relevant program. Investing in community-based opioid dependence treatment programs that incorporate cultural and land-based healing strategies and draw on First Nations teachings is essential for treating OUD in First Nations communities. There is a need for cultural-based treatment modalities that are based on collaboration between a local hospital, community members, and First Nations.

 Eibl et al. (2016) [44]

ON

Non-specific rural

N/A

Commentary

There is a general lack of services in rural and remote communities. OAT and other harm reduction strategies should be available to all opioid-dependent people as first-line treatments. OAT is the best practice for long term patient safety, social stabilization, and long-term health benefits. More resources (including more prescribers) are needed to enable comprehensive care to improve health outcomes.

 Jumah et al. (2018) [45]

ON

5839

15.4/km²

Commentary

Highlights the outcomes of workshops for health care providers of substance-involved pregnant and parenting women. Participants identified the need for improved transitions in care, facilitated access to buprenorphine treatment, improving postpartum care for mother and child, stable funding models for addiction programs and a focus on Indigenous-led programming. There is a need for a national strategy to address the effects of opioid use in pregnancy from a culturally safe, trauma-informed perspective.

 Uddin (2013) [46]

ON

977

4.1/km²

Commentary

Programs need to be developed by the people from the communities they serve. Community ownership of the program improves success rates. Support programs must incorporate Indigenous cultural values to ensure the program’s success and meet the needs of the participants. Prescription drug addiction programs must include healing that focuses on medicine wheel teachings (physical, mental, spiritual, and emotional well-being).

 Webster (2013) [47]

ON

108,243 and surrounding rural communities

332.1/km²

Commentary

The over-prescribing of opioids by physicians working on short-term contracts for Health Canada caused widespread addiction in many First Nations communities. The prescription opioid problem added more suffering for communities already experiencing poverty, unemployment, inadequate housing, polluted drinking water, and high suicide rates. The Government of Canada’s response to address OUD in First nations communities is slow.

 Wendt et al. (2021) [48]

North American, Canada

Non-specific First Nations communities

N/A

Commentary

The COVID-19 pandemic intensified opioid use problems within Indigenous communities. Increasing take-home carries for patients has created better access to OAT, lowered stigma, and promoted greater self-efficacy for patients. Indigenous-serving clinics have expanded telemedicine services, giving better access to treatment. The pandemic has limited the ability to participate in traditional Indigenous healing practices which are important for cultural connectedness and recovery.

 Weng (2020) [49]

BC

Non-specific rural

N/A

Commentary

A province-wide, centralized virtual care program for patients in rural and remote areas to access OAT can help combat the opioid overdose crisis. Telemedicine can reduce barriers to OAT and enhance retention for both OAT and addictions counseling.

 Jones and Quinn (2020) [50]

NWT

Non-specified remote

Case Report

Buprenorphine/naloxone might not be regularly stocked in rural pharmacies, and business hours may be limited. Nurses may be unfamiliar with OAT in remote settings. More education and acceptance of OAT prescribing is required for ongoing OAT. The safety profile of buprenorphine enables more liberal dispensing if a patient is living in a remote community.

 Franklyn et al. (2016) [3]

ON

Non-specific rural, remote and First Nations

N/A

Review

In Northern Ontario, OAT success is impacted by geography, treatment modality, and concurrent polysubstance use among OAT patients. Rural and remote communities can benefit from alternative modes of care, such as telemedicine. Better infrastructure is needed, as physicians in these communities need authorization to prescribe OAT, and mentorship from addiction and pain specialists. Benzodiazepine use and cocaine use among OAT patients can often correlate with early dropout from OAT programming.

 Jumah et al. (2015) [10]

ON

Non-specific rural, remote and First Nations

N/A

Literature review

Indigenous Canadians are disproportionately affected by opioid misuse. Methadone maintenance therapy (MMT) has logistical limitations in rural and remote settings, but buprenorphine and slow-release Kadian maintenance therapies are feasible alternatives. Regulatory changes are needed to enhance access treatment for pregnant women to access OAT treatments during pregnancy and after giving birth. Post-partum treatment for opioid dependency is often not provided to women living in rural or remote communities, therefore, better access to OAT could help prevent relapse and involvement with child and family services.

 Dooley et al. (2018) [51]

ON

5839

15/4/km²

Research, Descriptive

Pregnant females in treatment with buprenorphine-naloxone had better pregnancy outcomes than females with illicit opioid use and similar outcomes to females who were not using opioids during pregnancy. A retrospective chart review at the Sioux Lookout Meno Ya Win Health Centre catchment area indicates that lower rates of neonatal abstinence syndrome may be due to rural community-based prenatal, OAT and addictions services.

 Eibl et al. (2015) [27]

ON

Various rural, remote and First Nations; rural defined by Rurality Index of Ontario

Unspecified

Research, Descriptive

An observational cohort study using administrative health care databases for patients who began methadone maintenace therapy revealed regional differences in retention rates and mortality of first-time MMT. Patients with limited access or geographical barriers to OAT treatment experience higher retention rates when they access therapy. Self-motivation to seek help and access treatment is likely an important factor in the higher retention rates from patients in Northern regions.

 Fonseca et al. (2018) [52]

ON

9512, 12,595

14.2/km², 17.7/km²

Research, Descriptive

Semi-structured individual interviews with 11 rural pharmacists found that providing OAT at a community pharmacy is associated with increased workload, longer operating hours, challenges hiring staff with OAT training, and concerns about safety. Coordinating MMT services across multiple community pharmacies in the area could help improve access to treatment, as more OAT providers are needed in rural communities.

 Franklyn et al. (2017) [53]

ON

Various unspecified rural, remote and First Nations

Unspecified

Research, Descriptive

A retrospective cohort study using anonymized EMR from 58 clinics offering OAT in Ontario found that benzodiazepine use at baseline was predictive of increased attrition. Patients with benzodiazepine-positive urine samples drop out of OAT treatment more often than patients who have no benzodiazepine use. Northern patients who overcome barriers to treatment entry may be more motivated to succeed in treatment.

 LaBelle et al. (2018) [7]

ON

Various unspecified rural, remote and First Nations

Unspecified

Research, Descriptive

A retrospective cohort study using an administrative database revealed that telemedicine is increasingly being utilized throughout Ontario for delivering mental health treatment. Similar barriers exist in Northern Ontario between people seeking out psychiatric care and people seeking OAT treatment. OAT can be delivered via telemedicine to increase access to rural patients with OUD, and it is viewed as beneficial for both the patient and provider.

 Landry et al. (2016) [54]

NB

2062

134.1/km²

Research, Descriptive

A qualitative study using semi-structured focus group discussions with health care professionals, community members and patients found that there are widespread misconceptions about OAT in the community. OAT was associated with improvements in community-level outcomes (e.g. crime reduction). Community education initiatives about OAT can enhance community buy-in and reduce stigma.

 Mamakwa et al. (2017) [55]

ON

6 remote communities

N/A

Research, Descriptive

A retrospective cohort study in six First Nations communities in northwestern Ontario explored the interventions of OAT and First Nations healing programming. Treatment retention rates and negative urine drug screen results were higher than those reported for most OAT programs. Success was fostered by community-based programming that incorporates cultural practices and healing circles. Sustainable core funding is needed.

 Morin et al. (2021) [29]

ON

Unspecified rural communities

N/A

Research, Descriptive

Electronic medical record (EMR) data from a chain of 67 OAT clinics in Ontario found that the use of fentanyl increased by 108% among OAT patients in Ontario during the COVID-19 pandemic. Reduced monitoring may have decreased OAT effectiveness and negatively impacted patient outcomes. In the future, infection control measures should be implemented rather than reduced monitoring.

 Oukachbi and Rizzo (2020) [19]

ON

108,843

332.1/km²

Research, Descriptive

Face-to-face interviews using an adapted version of the Addictions Severity Index (ASI) with OAT patients at an outpatient clinic in Thunder Bay. Risk factors for attrition include having a criminal record, using heroin, experiencing a family conflict and living with someone who uses substances. There is a need for individualized, holistic care and integration of support services into OAT programs.

 Russell et al. (2019) [56]

ON

52,662

2902

41,145

1200

8057

14,967

7466

7388

5839

108,843

72,051

166.9/km²

0.1/km²

13.9/km²

6.0/km²

95.9/km²

70.7/km²

292.2/km²

112.7/km²

15.4/km²

332.1/km²

324.6/km²

Research, Descriptive

A mixed-methods study on treatment barriers for youth who use illicit drugs or misuse prescription drugs. Qualitative analyses from the study found an overall lack of services in the area; barriers to accessing treatment and services included lack of motivation for treatment, stigmatization, long waitlists and transportation/mobility issues. There is a need for harm reduction-based services, low-threshold programs, specialized programming, and peer-based counselling.

 Srivastava et al. (2020) [57]

ON

108,843

332.1/km²

Research, Descriptive

A survey of high school graduates who were on a school-based OAT program found that offering OAT to youth with OUD in a high school clinic might be an effective strategy for promoting positive long-term health and social outcomes. Retention was associated with recent formal substance use counseling.

 Eibl et al. (2017) [58]

ON

Various

N/A

Research, Intervention

This non-randomized cohort comparison study used an administrative database for patients who started OAT via telemedicine, finding that patients treated via telemedicine were more likely to remain in therapy than patients receiving treatment in-person. A significant barrier to telemedicine-delivered OAT treatment is that current Ontario guidelines require physicians to have an in-person appointment with all telemedicine patients within 6 weeks of starting OAT, which can hinder patient retention due to transportation issues.

 Kanate et al. (2015) [6]

ON

921

10.3/km²

Research, Intervention

Quantitative measurements of community wellness and OAT in a remote First Nations community reveal that one year after the community-developed program of First Nations healing, addiction treatment, and OAT, criminal offences decreased, child protection cases decreased, and school attendance increased.

 Katt et al. (2012) [59]

ON

Various rural and remote First Nations

N/A

Research, Intervention

A pilot study examining the feasibility and outcomes of a community-based Suboxone taper-to-low-dose-maintenance program for adults with prescription opioid dependence was conducted in a First Nation in Northern Ontario. The study determined the program is feasible and effective as an initial treatment, although abstinence is difficult to achieve and longer term maintenance may be required for some patients.

Grey Literature

 Centre for Addiction and Mental Health (2021) [2]

Canada

N/A

N/A

Report

The purpose of this document was to reach consensus regarding recommendations from existing clinical OAT guidelines. This document is comprised of guidelines blended with expert opinions and evidence-based literature. There is a need to collaborate with existing local services to prescribe OAT in a safe, accessible way (e.g. nurse practitioner, pharmacist). Telehealth expands the reach of OAT to people in rural communities. Buprenorphine improves retention and outcomes where access is limited.

 Wells et al. (2019) [60]

Canada

N/A

N/A

Report

A literature search and a survey informed this environmental scan. Facilitators to timely access to OAT include walk-in style programming, transportation, increased staffing, lowered stigma, flexible appointment times, integrated treatment services, and the use of telehealth. Barriers to care include a lack of addiction services, stigma and judgment, long wait times, strict entry criteria, and a limited number of HCPs. Fee-for-service physicians may not want to risk no-show appointments (loss of income) and may view OAT patients as more complex and time-consuming patients to treat.

 First Nations Health Authority (2020) [33]

BC

N/A

N/A

Fact sheet

Treatment options for OUD include different medical and psychosocial interventions to achieve spiritual, emotional, mental and physical healing and wellness. Health care providers must use a trauma-informed approach when working with clients who are experiencing substance use problems. BCCSU and UBC offer a free, self-directed online course “Provincial Opioid Addiction Treatment Support Program (POATSP)” that is recommended for HCP working in OUD care