“Whatever time they show up is the right time”: a Canada-wide qualitative analysis of client, provider, and administrator perspectives on person-centered and equitable substance use disorder care

Canada’s unregulated drug supply continues to impose severe harms on people living with opioid use disorder (OUD). While opioid agonist therapy (OAT) is an effective intervention, fewer than 30% of people with OUD initiate treatment and fewer than half remain engaged beyond six months. Restrictive service models, structural inequities, and fragmented systems continue to undermine equitable access and sustained engagement. Qualitative research on how person-centered and equity-oriented care is enacted in practice across diverse Canadian OAT settings remains limited. This study examined how therapeutic relationships, wraparound supports, and housing-treatment integration function as mechanisms through which OAT care becomes accessible, meaningful, and sustainable for people with complex needs. This study presents a secondary qualitative analysis of interview data originally collected as part of a national report on diversified opioid prescription programs in Canada. Semi-structured interviews were conducted with 70 participants, including 23 service users and 47 providers and administrators, across 11 OAT program sites in five Canadian provinces, including programs offering oral and injectable OAT options. Interviews were analyzed using reflexive thematic analysis, guided by an integrated person-centered care and health equity framework. Analysis proceeded inductively across participant groups and sites using NVivo (version 15). Three cross-cutting themes were identified: (1) therapeutic alliance as a relational foundation and entry point to care; (2) building care around the client: team-based, wraparound responses to complex and intersectional needs; and (3) bridging housing and substance use treatment within structurally fragmented systems. Findings describe how trust, shared decision-making, medication flexibility, peer support, outreach, and integrated housing models functioned together as a coordinated ecosystem enabling person-centered care across diverse contexts. Flexibility emerged as an equity practice through which providers actively adapted care to meet clients where they were. Person-centered, equity-oriented OAT is enacted through coordinated relational and structural practices, not individual interventions alone. These findings offer transferable insights for substance use disorder (SUD) programs seeking to advance equitable, client-centered care across diverse geographic and organizational contexts in Canada and beyond.