Opioid agonist therapy in and beyond the COVID-19 pandemic: A descriptive policy analysis across Canadian jurisdictions

Background The COVID-19 pandemic prompted widespread rapid changes to opioid agonist therapy (OAT) policy in Canada, reshaping how care was delivered to people with opioid use disorder. To better understand how OAT policy changes varied across jurisdictions, we conducted a comparative policy analysis identifying federal, provincial, and territorial OAT policy changes that occurred during and after the COVID-19 pandemic. Methods Policy documents (n = 88) were sourced from grey literature, targeted website searches, and recommendations from relevant knowledge experts conducted between June-July 2024 and May-July 2025. A combined content and thematic analysis approach was employed to organize identified policy changes (n = 300) into eight policy areas: expanded prescribing permissions, take-home dosing, witnessed dosing, medication delivery, urine drug screening, virtual care, slow-release oral morphine, and injectable OAT. Results Across jurisdictions, policies governing OAT evolved considerably during and after the COVID-19 pandemic, though the scope and durability of these changes varied significantly. Federal exemptions enabled policy changes, specifically in expanding prescribing authorities and medication delivery. These authorities were translated differently across regions spanning narrow renewal-focused roles to broader clinical discretion. Policies addressing take-home dosing and monitoring requirements showed the greatest divergence, with provinces such as Ontario and Nova Scotia adopting more permissive approaches, while Saskatchewan and Manitoba maintained more restrictive, structured approaches. Conclusions Pandemic circumstances supported the implementation of OAT policy changes that increased flexibility and permissiveness of OAT delivery. However, uneven implementation risks the perpetuation of geographic and equity-based disparities, emphasizing the need for coordinated and equity-focused OAT policy.