A community-based telemedicine program in Montréal was established to provide low-barrier access to opioid agonist therapy (OAT) through a collaboration between a community-based harm reduction organization and a hospital. The program’s primary aims are to facilitate access to care, reduce participants’ overdose risk and improve their life conditions through individualized plans to meet participant-defined treatment goals. A recent study found that 54% of participants were retained in OAT treatment continuously for 12 months. When treatment interruptions were disregarded, 71% of participants were receiving OAT at 12 months. The high rate of retention in the program was attributed to the patient-centered model of care and the diversity of medication options offered.
Program description
The program uses community-based telemedicine to engage and retain individuals in OAT. It was co-designed and is jointly operated by the hospital Centre hospitalier de l’Université de Montréal (CHUM) and CACTUS Montréal, a well-established community-based organization offering harm reduction services. CHUM provides addiction medicine physicians and nurses and the video conferencing software required for the program. CACTUS provides physical space at their office for the teleconferencing, a program coordinator and on-site nurses. Building on CHUM’s existing low-barrier OAT program, the model of care was informed by harm reduction and patient-centered principles. The program was implemented in response to regulatory changes introduced during the COVID-19 pandemic that permitted the use of telemedicine for OAT initiation and continuation, as well as “risk mitigation” prescribing of pharmaceutical opioids to people using illicit opioids.
Interested clients connect with the program through CACTUS. The program coordinator screens prospective participants through a standardized eligibility assessment. If the individual is eligible to participate, an intake appointment is scheduled. The CACTUS program coordinator is responsible for promoting the program to prospective participants, completing a pre-evaluation to assess their eligibility, scheduling, facilitating appointments (i.e., establishing the video connection and introducing the client, accompanying them when requested) and providing comprehensive patient support. The on-site CACTUS nurses provide testing for sexually transmitted and blood-borne infections, vaccinations and wound care.
Participants must meet the following eligibility criteria: they must be using opioids and want to start OAT, they must be known to CACTUS staff, they must not be receiving OAT via another service (exceptions are made for people unable to continue with their existing treatment provider because of extenuating circumstances) and they must be enrolled in the Quebec public prescription drug insurance plan. Intake appointments are held within 24 hours to one week after screening.
Intake and follow-up appointments are held at the CACTUS office via teleconference with members of the CHUM medical team, supported by the CACTUS program coordinator. To address privacy and confidentiality concerns, appointments are scheduled before CACTUS’s harm reduction equipment distribution services open. The program holds telemedicine clinic appointments two days per week from 1:30 p.m. to 3:30 p.m., offering four 30-minute appointments.
Clinical decisions prioritize participant-defined treatment goals and participant safety. While reducing illicit opioid consumption is considered an important goal, participants are not expected to abstain from illicit opioid use. A form of long-acting OAT is required for all participants, clients choose between methadone, buprenorphine/naloxone and slow-release oral morphine. Co-prescription of a short-acting oral opioid (hydromorphone) is also available as appropriate (e.g., to manage withdrawal). Individuals choose a community pharmacy for their prescription to be sent to. A CHUM physician prescribes medication and monitors the treatment plan. Participants’ progress in meeting their goals is regularly reviewed during appointments, and treatment plans are revised where necessary. While many health concerns requiring in-person care (e.g., wound care) are addressed by the nurses at CACTUS, the CHUM nurses coordinate most aspects of care, including across services.
For any unforeseen health concerns that arise outside of the standard appointment times, participants have the option to either directly contact the CHUM medical team or contact them through the CACTUS program coordinator. Following contact, participants can access same-day appointments with medical staff by way of teleconference at the CACTUS location, by phone or with an in-person appointment at CHUM. Navigation services are available for people choosing to access in-person services at CHUM.
Results
The study utilized a mixed methods design to evaluate outcomes and experiences, combining electronic medical record data with semi-structured individual patient interviews.
Between April 2020 and March 2022, 69 people initiated OAT through the program: 45 cisgender men, 22 cisgender women and two transgender people. At intake, most program attendees (96%) had injected in the past month, many were homeless (36%) or unstably housed (20%) and some had either experienced overdose recently (16%) or in their lifetime (32%). Most had previously been prescribed OAT (71%), with almost half having tried two or more medication options.
Patients were able to choose which long-acting medications they were prescribed, with hydromorphone co-prescribed where appropriate:
- 54% initiated methadone (76% of these individuals were also co-prescribed oral hydromorphone)
- 35% initiated slow-release oral morphine (96% of these individuals were co-prescribed oral hydromorphone)
- 12% initiated buprenorphine/naloxone (38% of these individuals were co-prescribed oral hydromorphone)
The study’s primary outcome was the proportions of participants who remained engaged on their initial OAT treatment episode at one, three, six and 12 months. Retention in the initial OAT episode was as follows:
- 83% at one month after enrolment
- 74% at three months
- 67% at six months
- 54% at 12 months
The study authors note that measuring retention as a single, uninterrupted period of treatment does not reflect the reality that some people stay engaged in care despite having breaks in their treatment. For this reason, the study looked at a secondary outcome, the number of patients with an active OAT prescription, regardless of any previous treatment breaks:
- 87% at one month after enrolment
- 83% at three months
- 77% at six months
- 71% at 12 months
Of the 69 people who initiated OAT in the program, 48 (70%) were tested for HIV within 12 months of intake, and another five (7%) had a recent test on record. Of the three participants known to be HIV positive, one had an undetectable viral load at intake, one started treatment within 12 months and one did not start treatment despite multiple attempts to link them to care.
A total of 50 participants (72%) were tested for hepatitis C within 12 months of intake, with another five (7%) already having a positive antibody result on record. Among 33 antibody-positive participants, 27 were tested for hepatitis C RNA, 15 were RNA positive, 13 were prescribed treatment, and 10 achieved sustained virologic response.
The researchers also conducted 11 semi-structured interviews between March and May 2021 to explore participants’ experiences and perceptions of the program in the context of the COVID-19 pandemic. Six main themes emerged from these interviews:
- The trusted community-based harm reduction setting was a key factor in participants’ engagement and retention in OAT.
- Collaborative relationships between participants, clinical staff and non-clinical staff contributed to participants’ individual needs and flexible treatment goals being supported.
- Participant-directed treatment plans, including the ability of participants to influence which medications they were prescribed, facilitated engagement and retention.
- Participants expressed mixed feelings regarding telemedicine as the model for regular appointments. For some, it was uncomplicated and practical. Others found it cold and limiting.
- While participants appreciated the ability to choose a preferred community pharmacy for their prescriptions, the need to go to the pharmacy frequently and pharmacy-specific concerns were described as barriers to participants’ success by some interviewees.
- Positive experiences with this program created valuable connections to health services, and helped foster a more positive view of these services among some participants.
What does this mean for service providers
The program demonstrated success in retaining participants in an OAT program delivered by telemedicine within a community setting, many of whom had previously tried but disengaged from OAT. This study suggests connecting individuals to low-barrier OAT care in a trusted setting, while offering flexible medication options with additional comprehensive health services, contributed to the retention of clients.
The accessibility of the program was enhanced through its integration within a community-based harm reduction setting: the setting was convenient for participants, and they had already developed trust with the CACTUS organization and its staff. This trust strengthened the potential for a positive therapeutic relationship with the medical team. The medical team’s use of harm reduction and patient-centered principles established foundations for connection and collaboration with participants.
Shared decision-making and collaborative treatment planning together with a diversity of medication options were foundational to participants’ satisfaction with the program. Giving participants options for long-acting opioid medications, alongside the option of short-acting opioid medication, allowed the program to respond directly to participant-identified priorities.
Related resources
What is opioid agonist therapy? – CATIE article
What makes Canada’s illegal drug supply dangerous? – CATIE article
CATIE statement on safer supply – CATIE statement
CATIE statement on the need for a spectrum of substance use services – CATIE statement
Reference
Høj SB, Coignard-Friedman R, Sako A et al. Harnessing telemedicine to deliver patient-centered opioid agonist treatment within a community-based harm reduction service: a mixed methods evaluation. Harm Reduction Journal 2025;22(1):182. Available from: https://doi.org/10.1186/s12954-025-01328-3