Harnessing telemedicine to deliver patient-centered opioid agonist treatment within a community-based harm reduction service: a mixed methods evaluation

Background: Patient-centered approaches may facilitate retention in opioid agonist treatment (OAT) but are challenging to implement in rigid or stigmatizing service contexts. We evaluate a telemedicine program delivering flexible, patient-centered OAT from a community-based harm reduction setting in Montreal, Canada. Methods: An OAT clinic was established in a community-based harm reduction setting with hospital-based addiction medicine services delivered remotely via telemedicine. Community workers screened clients, established telemedicine connections, and offered holistic patient follow-up. The medical team offered individualized OAT and other health services. Patients chose between treatment with methadone, buprenorphine/naloxone, or slow-release oral morphine. Hydromorphone co-prescription was also available. Effectiveness was assessed via longitudinal chart review and semi-structured interviews (n = 20). A convergent mixed method design was used to quantify retention rates and blood borne infection care up to 12 month follow up, and to examine patient reported program experiences. Results: Sixty-nine patients (46 men, 23 women; median age 38) initiated OAT between April 2020–March 2022. Most (96%) were injecting opioids, 56% were unstably housed, and 71% reported prior OAT. Patients typically initiated treatment with methadone (54%) or slow-release oral morphine (35%); 78% also received hydromorphone. Continuous retention in the first OAT episode was 83% at one month, 74% at three months, and 54% at 12 months. Disregarding prior treatment interruptions, 71% of patients were receiving OAT at 12 months. Most patients were assessed for HIV (77%) and HCV (78%), and 13/15 confirmed as HCV-positive initiated antiviral treatment. Trust, respect, and the alignment of practices with patient-centered care and harm reduction principles were critical to success. Integrating treatment within a community-based harm reduction setting enhanced accessibility and care coordination, and created a welcoming service environment. Diverse medication options, collaborative treatment planning, and a non-judgmental/non-punitive approach were key to developing positive therapeutic relationships. Conclusion: Our community-based telemedicine program presents a novel framework for OAT delivery that efficiently bridges the health and community sectors. Working collaboratively around the patient, program partners leveraged their strengths to improve treatment experiences and promote retention.