Barriers and facilitators to methadone dispensing for opioid use disorder in community pharmacies: A scoping review

Abstract

Background

Methadone, an evidence-based medication for opioid use disorder (MOUD), is available through prescription at community pharmacies in countries like Canada, Australia, and the United Kingdom, but not in the United States (U.S.). The objective of this scoping review was to summarize barriers and facilitators related to dispensing methadone in community pharmacies to inform future implementation efforts in the U.S.

Methods

A scoping review was conducted using PubMed, Embase, SCOPUS, and CINAHL. Original research articles related to barriers and/or facilitators around community pharmacy-based methadone dispensing were included. No search limits (year of publication, geographic boundaries) were applied to the search strategy. Two independent researchers screened all articles for eligibility, extracted data, and met to reach consensus. Data were extracted on 12 items, with a particular focus on barriers and facilitators to dispensing methadone in community pharmacies.

Results

Forty-one articles were included in the review. The most common barriers to methadone dispensing were workload (n = 14), safety concerns for staff and property (n = 13), concern about patient behavior and interactions (n = 12), financial hardship (for pharmacists and patients) (n = 11), and stigma and discrimination towards patients (n = 11). The most common facilitators were pharmacist training and education (n = 14), positive pharmacist-patient relationships (n = 14), and privacy (n = 10).

Conclusions

The findings from this review can be used to address barriers and incorporate known facilitators into future protocols or practice of pharmacy-based methadone dispensing. Further research is needed to identify U.S. and state-specific anticipated needs for pharmacy-based methadone dispensing.

Highlights

• •Workload impacts pharmacists’ willingness and ability to dispense methadone for OUD.
• •Safety concerns related to staff or property pose a barrier to dispensing methadone.
• •Training pharmacists can improve patients’ experience in the pharmacy.
• •Future research should explore U.S. and state specific anticipated needs for pharmacy-based methadone dispensing.

1. Introduction

Opioid misuse is a global issue, with an estimated 60 million people who engaged in non-medical opioid use in 2021 (UNODC, 2023). In the last 30 years, the incidence of opioid misuse, and opioid use disorder (OUD) specifically, has increased by nearly 50 % globally (Tuo et al., 2025). Given the global impact of disease, the World Health Organization has recommended opioid agonist maintenance treatment (which includes methadone and buprenorphine) for most patients with OUD since 2009 (Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, 2009).

Methadone is a highly effective treatment for OUD, particularly among those exposed to fentanyl (Saloner et al., 2023, Stone et al., 2020, Wakeman et al., 2020), and has been shown to have better treatment retention than buprenorphine (Degenhardt et al., 2023). Given the efficacy of methadone as an OUD treatment, countries such as Australia, Canada, and the United Kingdom (U.K.) offer this medication to patients through community pharmacies. Most commonly, primary care or addiction specialty providers can prescribe methadone to patients, where community pharmacists can then observe doses at the pharmacy or dispense take-home doses for self-administration (Calcaterra et al., 2019; Pew, 2023a).

In contrast, in the United States (U.S.), methadone for OUD treatment is only available through Opioid Treatment Programs (OTPs), of which there are around 1900 in the U.S. (AATOD, 2022). OTPs are specialized facilities that provide treatment for OUD and are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) (CMS). Patients have described experiences with methadone treatment in OTPs as “liquid handcuffs” and report experiencing stigma and frustration adhering to restrictive policies (such as mandatory counseling and limited dosing hours) (Carl et al., 2023, Frank et al., 2021, Simon et al., 2022). During the COVID-19 pandemic, federal regulation for OTPs became less restrictive to accommodate safety concerns regarding the virus’s contagiousness. In doing so, take-home allowances increased, and telehealth services expanded. These flexibilities benefitted patients without increasing harm, and in 2024, the temporary flexibilities became permanent (Harris, 2024; SAMHSA, 2024). Yet, with an estimated 6 million people ages 12 and older in the U.S. with OUD and fewer than 2000 OTPS able to offer methadone treatment, therein lies a need to expand treatment access (SAMHSA, 2023).

Several recent U.S. studies have examined community pharmacies as a potential avenue for expanding methadone treatment and found that access to community pharmacies, compared to OTPs, is greater for people with OUD (Iloglu et al., 2021, Joudrey et al., 2020, Kleinman, 2020). In recent years, there have been two U.S.-based pilot studies that assessed the feasibility of community pharmacy-based methadone dispensing (observed dosing in the pharmacy and provision of take-home doses), each of which yielded positive results related to treatment adherence, retention, and patient satisfaction (Brooner et al., 2022, Wu et al., 2022). Although research and advocacy towards U.S. pharmacy-based methadone dispensing is growing (Jarrett et al., 2023, Joudrey et al., 2021), stigma towards OUD patients at pharmacies (Luty et al., 2010), limited pharmacist capacity to incorporate additional services (Alvarez et al., 2025), and state and federal regulations that currently prohibit pharmacy-based dispensing in the U.S. are considerable concerns around this treatment model.

Two potential options for U.S. pharmacy-based methadone dispensing include OTP-pharmacy partnerships through medication units, or a prescription-based model, which is currently being proposed at the federal level under a bill called the Modernizing Opioid Treatment Access Act ("MOTA," 2023). As a medication unit, pharmacies would operate as satellite sites of OTPs to observe methadone dosing and dispense take home doses (SAMHSA). Alternatively, under a prescription-based model, eligible physicians could prescribe methadone to be dispensed at the community pharmacy for take-home administration. Pharmacy-based medication units are legally permissible in the U.S., yet seldom used, while a prescription-based model is not currently legal.

To prepare for the potential implementation of pharmacy-based methadone dispensing in the U.S., research is needed to understand the barriers and facilitators related to methadone dispensing in community pharmacies. There is already a breadth of research on this topic from other countries as well as several pilot studies in the U.S. To these authors’ knowledge, there have been no scoping reviews seeking to synthesize the barriers and facilitators to methadone dispensing in community pharmacies. Other scoping reviews related to methadone dispensing in pharmacies focus on attitudes or treatment outcomes (Hernandez et al., 2024, McCarty et al., 2021, Muzyk et al., 2019). The objective of this scoping review is to summarize the barriers and facilitators related to dispensing methadone for OUD in community pharmacies.

2. Methods

2.1. Protocol

A research protocol was developed and followed based on the PRISMA-ScR guidelines (Tricco et al., 2018). The protocol can be accessed on UNC Dataverse (Shubel, 2025).

2.2. Eligibility criteria

Articles were assessed for eligibility based on the following inclusion criteria: (1) reported original research, (2) reported barriers or facilitators to methadone dispensing for the treatment of OUD in the community pharmacy, (3) included community pharmacies/pharmacists. Community pharmacy was defined as a healthcare facility in which a pharmacist provides care to patients including dispensing prescription medications for patients outside of hospital or institutional settings. The exclusion criteria included: (1) studies unrelated to community pharmacies or pharmacists, (2) meta-analysis, systematic, narrative, or scoping reviews, (3) methodological protocols or program descriptions without original data, (4) opinion pieces, abstracts, or conference posters, (5) system analysis or quality improvement papers, and (6) non-English papers.

The authors chose not to limit the search to a particular geographic area or time range because preliminary review of the literature found that several barriers and facilitators to pharmacy-based methadone dispensing persisted across time and location.

2.3. Information sources & search

Four databases were searched: PubMed, Embase, SCOPUS, and CINAHL. The search was executed on November 20th, 2024. No search limits were applied in the search strategy. Two keywords were used to identify articles. In consultation with a university librarian, a search string was created for each database (Appendix A).

2.4. Selection of sources of evidence

Search results were imported into Covidence (Covidence, 2025). Two reviewers (CS and MN) independently screened titles and abstracts using the inclusion and exclusion criteria. The reviewers met to reach consensus on any disagreements. Full texts were obtained for the articles that progressed past the abstract screening and were reviewed again by two independent reviewers (CS and MN) using the eligibility criteria. The reviewers met to discuss any disagreements until consensus was reached.

2.5. Data charting process & data items

Data were independently extracted by two researchers (CS and MN). Researchers met frequently to reach consensus on the data items for each included study. The full text articles were consulted if there were disagreements during the data extraction process. Extracted information included: author, year, geographical location, study population, study design, study objective, results, barriers, facilitators, limitations, recommendations, and future directions. When survey studies reported frequencies of all barriers and/or facilitators, only the top three most endorsed barriers and/or facilitators were included in the review.

2.6. Critical appraisal of individual sources of evidence

Quality assessments were conducted to assess bias, which may decrease the validity and reliability of research results. Cross-sectional studies were assessed using the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (NHLBI, 2013), which includes 14 questions to assess the sampling method and analysis, among others. This checklist helps researchers determine a quality score of “good”, “fair” or “poor”. Qualitative studies were assessed using the National Institute for Health and Care Excellence (NICE) Quality appraisal checklist (NICE, 2012), which includes 14 questions to assess the appropriateness of the qualitative methodology, quality of the data collection, and rigor of the analysis. This checklist helps researchers determine a score of “+ +”, “+ ”, or “-”. Descriptive studies were assessed using the JBI Critical Appraisal Checklist for Prevalence Studies (Munn et al., 2015), which includes nine questions regarding sampling and analysis to help researchers determine whether to “include” or “exclude” a study. Two independent reviewers (CS and MN) reviewed each study using the appropriate quality assessment checklist and reached consensus on each quality rating.

2.7. Synthesis of results

One researcher (CS) used frequency counts to identify the most common barriers and facilitators. The researcher created short memos to identify each barrier and facilitator mentioned in the extracted text then grouped memos by similarity to identify frequencies of barriers and facilitators in the included articles.

3. Results

3.1. Selection of sources of evidence

A total of 1224 articles were identified and imported into Covidence; 677 duplicate articles were removed. A total of 547 titles and abstracts were screened using for eligibility. Of these, 107 articles were deemed eligible for full-text review. Sixty-six articles were excluded (Fig. 1).

Fig. 1.

PRISMA Flow Diagram.

3.2. Characteristics of sources of evidence

Of the 41 eligible articles, 27 were qualitative studies, seven were cross-sectional survey studies, and seven were descriptive or prevalence studies. The high proportion of qualitative studies aligns with the research goals of this scoping review, as barriers and facilitators are often subjective experiences and perceptions best explored using qualitative methodologies (Hammarberg et al., 2016). Publication dates ranged from 1998 to 2024, with nearly half (n = 19) published in the last 10 years. Most articles were based in Australia (n = 15) and the United Kingdom (n = 12), while seven articles were based in the U.S. The remaining articles were from Canada, New Zealand, Switzerland, Ireland, and Scotland. Most articles included perspectives from community pharmacists (n = 26). Nine articles included views from patients receiving medications for OUD, including methadone. Four articles included perspectives from people who use drugs (PWUD). Four articles included prescriber perspectives. Other articles included pharmacy students, OTP staff, members of the community or pharmacy customers, public hospital pharmacists, senior nurses, pharmacy staff, social workers, and peer recovery coaches.

3.3. Results of individual sources of evidence

The barriers and facilitators are presented in Table 1, while the results, limitations, recommendations, and future research directions are summarized in Appendix B.

Table 1.

Barriers and facilitators of pharmacy-based methadone dispensing.

Article, year (citation)	Geographical location	Study Population (number of respondents)	Study Design	Study Objective	Barriers	Facilitators
Berbatis et al. (2007)	Australia	Managers and owners of community pharmacies (n = 1131)	Cross-sectional survey	To report the frequency of 27 enhanced pharmacy services (EPS) in community pharmacies and analyze barriers and facilitators for providing services.	Time shortage, pharmacist shortage, cannot find locums, and no extra renumeration	Dedicated study time, accreditation, closed counselling area, and access to patient notes
Bui et al. (2015)	Australia	Senior nurses from public opioid substitution treatment clinics (n = 9)	Semi-structured qualitative interviews	To explore the perspectives of senior nurses in public opioid substitution treatment (OST) clinics regarding client transfers to community pharmacies.	Barriers to transferring patients: difficulty motivating reluctant clients, clients unwilling to pay for dispensing, lack of convenient pharmacies & “unstable” clients (who are not qualified for transfer).	Strong relationships and a good rapport between the pharmacist and clinic are considered essential for the success of the client's transition to the pharmacy.
Caruana (2024b)	New South Wales, Australia	Opioid agonist treatment (OAT) consumers (n = 15) and pharmacists (n = 10)	Semi-structured qualitative interviews	To explore how OAT consumers experienced social inclusion and stigma in this setting and how pharmacists can dispense OAT in ways that minimize perceived, enacted, and felt stigma.	Pharmacists’ stigma and refusal to dispense have negative impacts on the public perception of the service. Stigma attached to treatment-seeking itself, including its constraints on autonomy. Lack of service availability, discriminatory rules, and excessive requirements to maintain OAT access contribute to a sense of futility and despair.	Positive and supportive relationships with pharmacists make the pharmacy a safe place. Clear but fair conduct expectations and a personable approach can mitigate “poor behavior”. Educating pharmacy staff enables positive and rewarding relationships. Choice between counter dosing or private room helped privacy. Connection from pharmacist helps patients’ empowerment and counters internalized stigma.
Caruana (2024a)	New South Wales, Australia	Opioid agonist treatment (OAT) consumers (n = 15) and pharmacists (n = 10)	Semi-structured qualitative interviews	To explore consumer and pharmacist experiences of OAT services, identify the social and structural elements that enhance or impair treatment and professional satisfaction, and analyze how these are influenced by trust.	Burdensome fees are a major source of consumer hardship and primary cause of conflict with pharmacists. Paperwork requirements are tedious and laborious. Prescribers are difficult to contact, which leads to conflict or consumer distress.	Pharmacist connection was attributed by some consumers as improving their treatment effectiveness and motivation to stay in treatment.
Chaar et al. (2013)	Australia	Community Pharmacists (n = 35)	Semi-structured qualitative interviews	To further investigate factors influencing pharmacists’ participation in provision of opioid substitution treatment (OST) in the community pharmacy setting.	Fear, prejudice, and stigma led to negative attitudes towards OST clients. Pharmacists encountered financial difficulties when clients fell behind with payments, which negatively impacted their relationship with clients. When risk (e.g. theft, debt, “misbehavior”) outweighed financial benefit, pharmacists ceased OST services.	Positive relationships between the pharmacist and patient facilitated success. Good relationships between the pharmacist, patient, and prescriber made OST services professionally rewarding. Training can help pharmacists with management skills and confidence. Subsidizing OST could alleviate the risk of debt. Mutual respect develops a high quality, non-stigmatizing experience and professional satisfaction.
Cheetham et al. (2023)	Australia	Pharmacists (n = 11), prescribers (n = 6), and patients (n = 8)	Semi-structured qualitative interviews	To better understand enablers and barriers to a collaborative model for Medication Assisted Treatment for Opioid Dependence (MATOD) to inform implementation in regions where increases in treatment capacity are urgently needed.	Pharmacist involvement barrier: time constraints, increased workload, and pharmacy infrastructure. Collaborative care barrier: poor communication between pharmacists & prescribers. Debt impacts pharmacists' opportunity to develop a therapeutic relationship.	Training can improve pharmacists’ confidence and ability, particularly among those with less experience. Accessibility of pharmacists improved continuity of care. Patients identified it was important to have a pharmacist who genuinely cared about and did not treat them differently. Protocols engender confidence in the pharmacist and mitigate medicolegal risks.
Comanici et al. (2023)	Indiana, USA	Peer recovery coaches (n = 10), community pharmacists (n = 10), and prescribers (n = 6)	Semi-structured qualitative interviews	To identify barriers, facilitators, and opportunities for improvement in Indiana community pharmacy MOUD (medications for opioid use disorder) care practices from the perspectives of peer recovery coaches, community pharmacists, and prescribers to optimize patient care.	Pharmacist stigma and restrictive policies limit patient access at the pharmacy. Negative pharmacist-patient relationships decrease patient satisfaction. Limited time with pharmacist limits the ability for pharmacist-patient relationships. Lack of access to patient specific health information leads to a lack of empathy from pharmacists.	Friendly staff, convenient hours, proximity, and insurance coverage influenced choice in pharmacy among patients. Positive prescriber-pharmacist relationships contributed to collaborative care.
Fatani et al. (2021)	Canada	Individuals who had experienced substance use and accessed community pharmacy services (n = 20)	Focus groups	To explore the perspective of patients living with substance use disorders (SUDs) or who used substances nonmedically regarding community pharmacist services and the delivery of services in a community pharmacy setting.	The busy environment prevents people from seeking out healthcare advice. Barriers to communication: lack of time and lack of privacy. Barrier to pharmacist-patient relationship: lack of consistency with pharmacist. Stigma leads to poor patient experience. Separate spaces for OAT make patients feel alienated. Lack of consistency in procedures leads to poor patient experience.	Respectful communication can improve the pharmacist-patient relationship. Patients reported that education and training on SUD could help pharmacists better serve patients.
Fonseca et al. (2018)	Ontario, Canada	Rural community pharmacists (n = 11)	Semi-structured qualitative interviews	To identify rural community pharmacists perceived barriers, motivations, and solutions to offering methadone maintenance treatment (MMT) to their patients.	Barriers to implementing or providing MMT: Pharmacy workload due to administrative and regulatory requirements, prospect of dealing with “aggressive patients”, community resistance, maintaining patient confidentiality in small town, lack of training, extending operating hours, staff safety, and availability of rural prescribers.	Professional satisfaction and potential patient and community impact were the only strong motivations for offering MMT services. Training could help better prepare pharmacists for engaging with the patient population and implementing a new service.
Gidman and Coomber (2014)	Scotland	Members of the public (users and non-users of pharmacies) (n = 26)	Focus groups	To consider the public opinion of community pharmacy services and discuss attitudes to harm reduction services in the context of stigmatization of addiction and people who use drugs.	Barriers to community acceptance of opioid substitution therapy (OST) services in the pharmacy: lack of privacy/confidentiality and negative public opinion of people who use drugs.	None listed
Hodgson et al. (2024)	British Colombia (BC), Canada	People who use drugs who reside in a rural and coastal community (n = 27)	Semi-structured qualitative interviews	To identify and characterize the unique factors that influence access to OAT in a rural and coastal community in BC disproportionately impacted by toxic drug deaths.	Daily supervised consumption was a barrier to patient satisfaction. Patient-prescriber power imbalances and not feeling like a partner in OAT decisions negatively impacted the patient-pharmacist relationship.	Access facilitators: proximity to pharmacy, pharmacy extended hours of operation, and pharmacy delivery services.
Hohmeier et al. (2021)	Southeastern United States	Student pharmacists (n = 45)	Qualitative focus groups	To explore U.S. pharmacy students’ perspectives on pharmacists as providers of methadone-based medications for opioid use disorder treatment.	The current pharmacy curriculum is inadequate. Time constraints limit the ability to assess patients' needs. The dual role of the pharmacist as a regulatory enforcer and provider promotes stigma and stereotyping.	Pharmacist accessibility is a facilitator to destigmatization by promoting patient access to treatment.
Irwin et al. (2012)	United Kingdom, Scotland	Registered pharmacists with a minimum of 3 years’ work experience (n = 16)	Critical incident interviews	To assess the perceived impact of methadone patient aggression on pharmacy practice.	Young and newly registered pharmacists are less able to deal with aggression.	Facilitators to managing “aggressive interactions” with patients include remaining firm, calm, speaking quietly, repeating certain key phrases until the patient backed down, maintaining eye contact, support from staff, and having a relationship with the patient.
Laird et al. (2016)	Scotland	Patients receiving opioid substitution therapy (OST) (n = 508)	Semi-structured questionnaires	To describe OST in terms of patients, pharmacies and services within the UK’s largest health authority, NHS Greater Glasgow and Clyde, Scotland.	None listed	Facilitators of choice in pharmacy: receiving health care advice, staff attitude, privacy, proximity to home, waiting times, additional health services offered.
Lawrie et al. (2004)	Scotland	Pharmacy customers (n = 10)	Semi-structured qualitative interviews	To determine whether pharmacy customers are deterred from using a pharmacy that offers services to drug users.	None listed	Privacy is of benefit to patients and customers
Lawrinson et al. (2008)	Australia	Community pharmacists (n = 50)	Randomly selected survey	To examine the practices, experiences, attitudes and intentions of a sample of South Australian pharmacists involved with the provision of opioid substitution treatment (OST).	There was a strong positive correlation between the number of regular clients seen and the problems experienced by pharmacists.	Pharmacists who provided more information to clients on issues related to OST treatment, harm reduction strategies or general health and well-being were more willing to take on additional clients.
Le and Braunack-Mayer (2019)	Australia	Opioid substitution treatment (OST) patients (n = 14)	Semi-structured qualitative interviews	To explore OST patients’ perceptions of privacy in a community pharmacy setting, with a particular focus on the layout of the community pharmacy.	None listed	Front counter dosing, separate entrances, and having a separate area in the main pharmacy were all considered facilitators to privacy by participants. Positive relationships with pharmacists mitigated concerns over privacy.
Le and Hotham (2006)	Australia	Rural community pharmacists (n = 15)	Qualitative focus groups	To ascertain how well public health policies relating to the provision of clean needles and opioid pharmacotherapies fit with the imperatives of business.	Lack of financial gain is a barrier to continuing the provision of services. Troublesome clientele hinders business operations.	Professional obligation and fulfillment facilitate continuing service. Increasing pharmacist training, collaboration with allied health services (like counselors), private consulting areas, financial incentives, and tailoring treatment can improve service provision.
Le and Hotham (2008)	Australia	Rural community pharmacists (n = 25)	Semi-structured qualitative interviews	To explore how the provision of opioid substitution treatment (OST) services and/or sterile injecting equipment impacts community pharmacists.	“Unpleasant incidents” impact work morale and staff confidence. Security fears and the social stigma of being a service provider can be a possible deterrent for customers.	Financial incentives can maintain pharmacists' interest in continuing providing services.
Luger et al. (2000)	England	Community pharmacists (n = 17) and patients taking methadone (n = 8)	9-month pilot study that included interviews, focus groups, and a survey	To examine the feasibility and acceptability of supervised consumption of methadone service from local community pharmacies.	Lack of privacy made patients feel uncomfortable taking methadone in the pharmacy.	Longer operating hours in pharmacies allowed patients flexibility in managing their time. Trust between pharmacists and patients results in a good working relationship.
Lukey et al. (2020)	New Zealand	Community pharmacists that provide opioid substitution treatment (OST) services (n = 13)	Semi-structured qualitative interviews	To explore the role of community pharmacists in the provision of opioid substitution treatment and how they perceive their role as part of the wider opioid substitution treatment team.	Lack of access to health care information and fragmented care prevents pharmacists from fulfilling their role. Poor communication with prescribers is a collaborative care barrier. Inability to contact health providers is a communication barrier. Inadequate funding impacts the financial viability of the service.	Good communication with the OST team improves service delivery and relationship building.
Lutnick et al. (2012)	San Francisco, USA	Injection drug users (n = 11)	Semi-structured qualitative interviews	To explore perspectives on proposed health services and interventions offered in pharmacy settings, as well as facilitators and barriers to service delivery.	None listed	Private rooms for services would increase the likelihood of participating in methadone dispensing in the pharmacy. Training pharmacists on how to work with injection drug users in a culturally competent and non-judgmental manner.
Mackie et al. (2004)	Ireland and Scotland	Community pharmacists (n = 258)	Anonymous survey	To determine the extent of pharmacists’ participation in methadone services, type of services provided, views on current service provision, and suggestions for future service developments.	Business reasons (risk to staff, property, theft), concern that other customers would object, and premise not suited for supervised consumption are barriers to providing the service.	Professional responsibility, request by clinics to provide service, and support of the provision of services to drug misusers are facilitators to providing the service. Demand/need for service are facilitators to start providing the service.
Matheson (1998)	United Kingdom	Illicit drug users using a community pharmacy or drug agency (n = 124)	Semi-structured qualitative interviews	To consider drug users' perspective and the practical relevance to pharmacists currently providing harm reduction services.	Stigma leads to negative self-image and perception by pharmacists. Supervised consumption is a barrier to privacy. Lack of privacy leads to stigmatization of patients.	None listed
Matheson et al. (1999)	Scotland	Pharmacists who manage community pharmacies (n = 865)	Cross- sectional postal survey questionnaire	To assess the relationship between pharmacists' attitudes towards drug misusers and the availability and provision of services for drug misusers.	None listed	Renumeration, having a private area, and if pharmacists thought it was decreasing drugs sold on the street were motivators to begin provision of methadone treatment services.
Matheson et al. (2002)	Scotland	Pharmacists managing community pharmacies (n = 969)	Cross-sectional survey	To assess current levels of participation in needle exchange provision, dispensing any drugs for drug misuse, methadone dispensing practices, involvement in health promotion for drug misusers, and levels of training in drug misuse.	None listed	Improved renumeration, having a private area for supervised consumption, and if pharmacists thought it would stop selling methadone on the street, were motivators to begin provision of methadone treatment services.
McCormick et al. (2006)	New Zealand	Community pharmacists (n = 898)	Cross-sectional survey	To explore levels of training, attitudes towards providing services for drug users, and associations with current and past practice.	“Difficult clients”, increased risk of burglary, and not being good for business (time consuming, not well paid, decreased reputation, no demand) were reasons that pharmacists ceased providing methadone dispensing or needle/syringe exchange services.	None listed
O'Dwyer et al. (2020)	Australia	Community pharmacists (n = 5), Queensland opioid treatment program (QOTP) employees (n = 4), and public hospital pharmacists (n = 5)	Semi-structured qualitative interviews	To explore the effects of Queensland (QLD) cyclones on opioid treatment programs within Queensland community and hospital pharmacies from three perspectives.	Interruption of normal opioid replacement therapy (ORT) services leads to instability or relapse. Lack of coordination between providers (OTPs, pharmacies, hospitals) is a barrier to continuity of service. Legislative requirements lead to limited access during a disaster.	Communication in the aftermath of natural disasters can improve continuity of services for clients. Disaster protocols can help disaster preparedness for ORT services.
Patil Vishwanath et al. (2019)	Australia	Consumers of opioid replacement therapy services (n = 16)	A qualitative interview design	To describe the experiences of opioid replacement therapy consumers living in rural and regional areas of the state.	Lack of privacy in the pharmacy setting made patients feel unsafe and contributed to stigma. The cost of treatment imposed a financial burden on consumers.	Positive relationships with pharmacists helped privacy and having a positive experience in the pharmacy.
Peterson et al. (2007)	Australia	Rural pharmacists (n = 400) and doctors in rural Victoria & Tasmania (n = 425)	Cross-sectional postal survey	To determine barriers to implementation, access to, and success of harm minimization strategies, as seen by health professionals.	Lack of time is a barrier to maintaining treatment services. Safety concerns, lack of time/staff, and past “bad experience” were reasons for not participating or ceasing participating in services.	None listed
Radley et al. (2017)	Scotland	Individuals who received ORT from a community pharmacy or were the carer of someone prescribed ORT (n = 41)	Focus groups	To explore experiences of service users attending a community pharmacy to receive opiate replacement therapy (ORT).	Stigma caused patients to be treated unfairly. Discrimination caused a negative experience in the pharmacy. Time waiting for service made it difficult to maintain employment. Lack of privacy made patients feel disrespected.	Being treated with dignity and respect improved patient well-being. Using the same consultation room as others helped facilitate better privacy in treatment.
Roberts et al. (2007)	Scotland	Pharmacists 1997 (n = 112) 2000 (n = 184) 2001 (n = 162) 2002 (n = 177) 2003 (n = 178)	Cross-sectional surveys from 1997 to 2003	To determine the pharmacists in Glasgow that dispensed methadone, supervised its consumption, and document attitudes to the provision of this service.	Concern that other customers would object, risk to staff or property, and the pharmacy being unsuitable for supervised consumption were reasons for not providing service.	Support of provision of services to drug misusers, professional responsibility and requests from General Practitioners (GPs) motivated pharmacists to provide the service.
Rosenblom et al. (2003)	United Kingdom	Lead pharmacists in East London & City Health Authority (n = 167)	Cross-sectional survey	To investigate the nature of community pharmacists' services to opiate misusers in a metropolitan area.	Reasons for not dispensing methadone: staff security and shoplifting. Barriers to supervised consumption: lack of space, not wanting to deal with “addicts”, and lack of time.	None listed
Samitca et al. (2007)	Switzerland	Pharmacists 1991 (n = 194) 1994 (n = 197) 1997 (n = 163) 2003 (n = 195)	Surveys conducted in 1991, 1994, 1997, and 2003. Semi structured interviews conducted in 2003.	To assess changes over 10 years in the role of pharmacies in the care of drug misusers – needle/syringe provision and methadone treatment supervision.	Not being convinced of treatment efficacy, perceived risks (robbery, threats, overall burden), and not wanting “drug misusers” in pharmacy were barriers to observed dosing. Lack of knowledge about good supervision, lack of follow-up of the treatments by doctors and lack of collaboration with the doctor, workload and the time needed to supervise methadone consumption were difficulties to observed dosing.	Pharmacists identified several needs and resources that could improve their work, including be better recognized as partners and more integrated into the care of “drug misusers”, be informed about what is being done in the network, and have regular contact with doctors. Training on drug misuse and guidelines for collaboration with doctors to improve observed dosing services.
Snoswell and Hollingworth (2016)	Australia	Pharmacy students (n = 64)	Cross-sectional survey	To examine the knowledge and attitudes of final year pharmacy students toward opioid substitution therapy (OST).	Attracting an “undesirable clientele”, “poor” client behavior, insufficient time and resources (staff, space), fear of “patient aggression” affecting staff safety, and OST not profitable were barriers to provision identified by pharmacy students.	More education can increase positive association with OST.
Tuchman et al. (2003)	New York, USA	Community pharmacists (n = 16)	Cross-sectional survey	To assess pharmacists’ readiness to collaborate with physicians in an office-based methadone dispensing pilot study.	Extra work, interference with business operations, increased record keeping, maintaining confidentiality, possible additional security needs, and handling “difficult patients” associated with methadone dispensing were perceived to impact the pharmacy work routine.	None listed
Tuchman et al. (2005)	New Mexico, USA	Medical providers (n = 18), community pharmacists (n = 9), social worker (n = 1)	Cross-sectional survey from a pilot study	To assess knowledge, attitudes, and expectations about methadone maintenance.	Extra work, interference with business operations, increased record keeping, maintaining confidentiality, possible additional security needs, and handling “difficult patients” associated with methadone dispensing were perceived to impact the pharmacy work routine.	Education can increase knowledge.
Winstock et al. (2010)	Australia	Community pharmacists (n = 669)	Cross-sectional survey	To explore service provision and the range of problems that community pharmacists providing opioid substitution treatment (OST) have experienced with clients and prescribers.	Difficulty contacting doctors and prescribing take aways to patients who were considered “unstable” to pharmacist were identified communication issues.	Having the ability to return “unstable” clients to a specialist service, confidence that referred clients were stable, and increased financial return were considered facilitators for pharmacists to take on additional clients.
Wu, John, et al. (2023)	North Carolina, USA	Patients taking part in a pilot study (n = 20)	Semi-structured qualitative interviews	To conduct a qualitative interview of patient participants of the parent trial on pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) to understand patient perspectives of implementation related factors for PADMOUD.	Lack of communication between the pharmacist and prescriber and lack of counseling at the pharmacy were identified as barriers to pharmacy-based methadone dispensing. Stigma was identified as a barrier for willingness of pharmacists to dispense/administer methadone in the pharmacy.	Less stigmatizing settings can help patients recover. Proximity to and extended hours of pharmacy influenced the decision to receive methadone at the pharmacy. Being non-judgmental and having resources available for people with OUD can support patients who receive methadone at the pharmacy. Pharmacist training and privacy in the pharmacy were identified as important facilitators for implementation.
Wu, Mannelli, et al. (2023)	North Carolina, USA	Pharmacy staff (n = 6) and OTP staff (n = 8)	Semi-structured qualitative interviews	To understand implementation-related factors for providing pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) in the US.	Having to go to multiple locations for care is a barrier to receiving methadone in the pharmacy. Increased pharmacy workload could be a barrier for pharmacists’ willingness to participate.	Streamlined workflow can facilitate proper operations. Pharmacy training can mitigate potential liability and facilitate implementation. Building trust between pharmacists and patients can improve skills in discussing substance use. Collaborative practice agreements, more pharmacy staff, access to medical records, proper infrastructure, and reimbursement can facilitate implementation.
Yadav et al. (2019)	United Kingdom	Community pharmacists (n = 24)	Semi-structured qualitative interviews	To explore what UK community pharmacists think about their role in preventing opium substitution-related deaths, their understanding of the risks associated with this substitution therapy and their views on what else community pharmacists could do to reduce such deaths.	Difficulty in prompt communication and lack of support makes it difficult for pharmacists to contribute to clinical decision making. Lack of training on risk factors’ ability to assess overdose risk. Pharmacist workload could cause potential harm to the patient. Safety concerns could lead to decisions that prioritize staff safety over patient safety. Stigmatizing behavior towards patients decreases the quality of care.	None listed

Table note: The language in this table is provided “as is” from the included articles, but these authors recognize some of the language used is now understood to be stigmatizing toward people with substance use disorders/people who use drugs.

3.4. Critical appraisal within sources of evidence

Out of 27 qualitative articles, only two were given a lower quality rating of “+ ”. Low ratings were due to lack of triangulation or using only one researcher to code and analyze data (Le and Hotham 2008; Matheson, 1998). One of seven cross-sectional studies was given a “fair” quality rating (Winstock et al., 2010) due to the lack of sample size justification and accounting for confounding variables in the analysis. No descriptive studies were excluded based on the JBI Critical Appraisal Checklist. Despite limitations, these three studies were still included in the review because there were no methodological fatal flaws that would render the identified barriers and facilitators unreliable.

3.5. Barriers

The five most common barriers were workload (n = 14), safety concerns for staff and property (n = 13), concern about patient behavior and interactions (n = 12), financial hardship (n = 11), and stigma and discrimination (n = 11) (Table 2).

Table 2.

Most common barriers noted across studies.

Barriers	Example	Frequency
Workload	Increased pharmacy workload was a barrier for pharmacists’ willingness to participate in pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) (Wu, Mannelli, et al., 2023).	14
Safety and security concerns for staff and property	Staff safety was a barrier to implementing or providing methadone maintenance treatment (MMT) services in the community pharmacy (Fonseca et al., 2018).	13
Concern about patient behavior and interactions	When risk, including perceived misbehavior from patients, outweighed financial benefit, pharmacists ceased OST services (Chaar et al., 2013).	12
Financial hardship	Lack of financial gain is a barrier to continuing provision of services (Le and Hotham, 2006).	11
Stigma and discrimination	Stigma caused patients on opiate replacement therapy to feel like they were treated unfairly compared to other patients with chronic and “self-inflicted” diseases (e.g., diabetes and heart disease) (Radley et al., 2017).	11
Lack of time	Lack of time was a barrier to maintaining adequate treatment services for patients (Peterson et al., 2007).	10
Poor pharmacist-prescriber communication	Sub-optimal communication with health providers was a barrier to achieving collaborative care (Lukey et al., 2020).	10
Lack of privacy	Lack of privacy made patients feel uncomfortable taking methadone in the pharmacy (Luger et al., 2000).	9
Training and knowledge gaps	Lack of training and knowledge on risk factors prevents pharmacists from being able to assess the risk of overdose (Yadav et al., 2019).	6
Unsuitable pharmacy infrastructure	Barriers to pharmacist involvement in medication assisted treatment for opioid dependence (MATOD) included pharmacy infrastructure (i.e., lack of private space) (Cheetham et al., 2023).	6
Inaccessibility	Lack of opioid agonist treatment service availability in community pharmacies contributed to a sense of futility and despair among patients (Caruana, 2024b).	4
Poor pharmacist-patient relationships	Negative pharmacist-patient relationships decreased patient satisfaction (Comanici et al., 2023).	4
Community resistance	Community resistance was a barrier to implementing methadone maintenance treatment (MMT) services in the community pharmacy (Fonseca et al., 2018).	4
Lack of staff	Lack of staff was a main reason for not participating in methadone maintenance programs among pharmacists (Peterson et al., 2007).	3
Legislative/regulatory requirements	The dual, conflicting role held by the pharmacist as both a regulatory enforcer and patient care provider was seen to promote stigma and stereotyping (Hohmeier et al., 2021).	3
Fragmented care	Lack of counseling at the pharmacy was identified as a barrier to pharmacy-based methadone dispensing among patients (Wu, John, et al., 2023).	3
Lack of access to patient health information at the pharmacy	Lack of access to health care information and fragmented care prevented pharmacists from fulfilling their clinical role (Lukey et al., 2020).	2
Supervised consumption (i.e., observed dosing)	Supervised consumption was a barrier to patient privacy (Matheson, 1998).	2
Other	Interruption of normal opioid replacement therapy services could lead to client instability in the aftermath of a natural disaster (O'Dwyer et al., 2020).	2

3.5.1. Workload

Six articles found that increased workload (such as record keeping and interference with business operations) impacted pharmacists’ willingness or ability to provide methadone dispensing and observed dosing (Cheetham et al., 2023, Fonseca et al., 2018, Samitca et al., 2007, Tuchman et al., 2003, Tuchman et al., 2005, Wu et al., 2023). Two articles noted that the busy work environment associated with methadone treatment resulted in negative impacts such as diminished care and patients feeling like they were imposing on busy pharmacists if they asked for healthcare advice (Fatani et al., 2021, Yadav et al., 2019). One article mentioned that the workload associated with methadone dispensing decreased pharmacists’ satisfaction in providing the service, and another found that the more clients being treated at the pharmacy correlated with increased “problems“ experienced by pharmacists, such as “disturbances” by patients, theft, and “aggressive” behavior (Caruana, 2024a, Lawrinson et al., 2008).

3.5.2. Safety and security concerns

Among articles that identified safety and security concerns as a barrier to providing methadone, concerns related to staff or property were most common (Chaar et al., 2013, Fonseca et al., 2018, Mackie et al., 2004, McCormick et al., 2006, Peterson et al., 2007, Roberts et al., 2007, Rosenblom et al., 2003, Samitca et al., 2007). Pharmacy students identified staff safety, especially among female pharmacists, as a reason for not dispensing methadone (Snoswell and Hollingworth, 2016). One article found that security concerns might deter other customers from coming to the pharmacy (Le and Hotham, 2008). Two articles from Tuchman et al., found that among pharmacists in New Mexico and New York, the possibility of additional security needs would impact their work routine (Tuchman et al., 2003, Tuchman et al., 2005). Finally, pharmacists in a U.K. study expressed that concerns over staff safety might jeopardize patient safety, such as the pharmacist providing an intoxicated person their methadone dose to avoid a negative interaction (Yadav et al., 2019).

3.5.3. Patient behavior and interactions

Six articles found that pharmacists’ reasons for not providing methadone treatment were due to not wanting to deal with what they described as “aggressive”, “troublesome”, and “difficult” patients or having had a bad experience with a patient in the past (Chaar et al., 2013, Fonseca et al., 2018; Le and Hotham, 2006; McCormick et al., 2006; Peterson et al., 2007; Rosenblom et al., 2003; Samitca et al., 2007). Pharmacy students also perceived that “poor client behavior” was a reason for not providing methadone treatment (Snoswell and Hollingworth, 2016). One article reported that “unpleasant incidents” impacted work morale and staff confidence, and two articles identified that “handling difficult patients with perceived low levels of frustration tolerance” would impact their work routines (Le and Hotham, 2008; Tuchman et al., 2003; Tuchman et al., 2005). Finally, one study that explored the perspectives of nurses who work in opioid substitution treatment (OST) clinics found that motivating “reluctant” and “unstable” patients presented barriers to a person being transferred to the pharmacy (Bui et al., 2015).

3.5.4. Financial hardship

Issues around cost were expressed by both pharmacists and patients. Inadequate funding and debt impacted the pharmacists’ ability to provide methadone treatment due to lack of financial viability (Berbatis et al., 2007, Chaar et al., 2013; Le and Hotham, 2006; Lukey et al., 2020; McCormick et al., 2006). Pharmacy students also perceived that lack of profitability was a reason for pharmacies not providing the service (Snoswell and Hollingworth, 2016). For patients, the cost of methadone dispensing posed a financial hardship and impacted their willingness to receive care at the pharmacy (Bui et al., 2015, Patil Vishwanath et al., 2019). Other studies mentioned that costs associated with methadone treatment were a source of conflict between the pharmacist and patient and impacted their ability to develop a therapeutic relationship (Caruana, 2024a, Chaar et al., 2013, Cheetham et al., 2023).

3.5.5. Stigma and discrimination

Stigma and discrimination towards people who use drugs and patients taking methadone impacted pharmacy-based methadone dispensing in multiple ways. Most commonly, stigma and discrimination impacted patients because it led to negative attitudes and perceptions towards them, decreased patient satisfaction, and caused them to be treated unfairly (Chaar et al., 2013, Fatani et al., 2021, Matheson, 1998, Radley et al., 2017, Yadav et al., 2019). Stigma towards MOUD and people with OUD may also impact pharmacists’ willingness to dispense and observe dosing of methadone (Comanici et al., 2023, Wu et al., 2023). Finally, stigma was noted to impact the public perception of methadone treatment, and pharmacists cited fears that it could deter other customers from using the pharmacy (Caruana, 2024b; Le and Hotham, 2008).

3.6. Facilitators

The top five most common facilitators were training and education (n = 14), positive pharmacist-patient relationships (n = 14), privacy (n = 10), adequate financial coverage (n = 8), and positive pharmacist-prescriber relationships (n = 5) (Table 3). There were 12 facilitators identified that were not mentioned anywhere else. Examples of such facilitators include having resources available for people with OUD, setting boundaries with patients, demand for service, and tailoring treatment to individual needs.

Table 3.

Most common facilitators noted across studies.

Facilitators	Example	Frequency
Training and education	Further training could improve confidence and ability, particularly among pharmacists with less experience (Cheetham et al., 2023).	14
Positive pharmacy-patient relationships	People with positive and supportive relationships with pharmacists described the pharmacy as a safe place (Caruana, 2024b).	14
Privacy	Participants had divergent views about how the layout of the pharmacy (i.e., dosing at the front counter, in a room with a separate entrance, or in a screened-off area in the pharmacy) shaped their sense of privacy (Le & Braunack-Mayer, 2019).	10
Adequate financial coverage	Increased financial return was considered a facilitator for pharmacists to take on additional clients who use opioid substitution treatment (OST) services (Winstock et al., 2010).	8
Positive pharmacy-prescriber relationships	Strong relationships and good rapport between the pharmacist and clinic were considered essential for success of the client transition to the pharmacy (Bui et al., 2015).	5
Protocols for workflow	Streamlined workflow process between pharmacy, OTP, and patients facilitated proper operations of methadone dispensing (Wu, Mannelli, et al., 2023).	4
Staff support	Support from pharmacy staff was considered a facilitator to managing aggressive patient interactions (Irwin et al., 2012).	4
Flexible pharmacy hours	Longer operating hours in pharmacies allowed patients flexibility in managing their time (Luger et al., 2000).	4
Pharmacy proximity	Proximity to pharmacy facilitated access to opioid agonist treatment services in a rural community (Hodgson et al., 2024).	4
Professional satisfaction	Professional obligation and fulfillment facilitate continuing services (Le and Hotham, 2006).	4
Patient impact	Potential patient and community impact was a strong motivation for offering methadone maintenance treatment (MMT) services among rural community pharmacists (Fonseca et al., 2018).	3
Non-stigmatizing pharmacy	The less stigmatizing pharmacy setting can help stable patients transition away from the clinic for recovery (Wu, John, et al., 2023).	2
Access to health records	Access to patient notes facilitated the provision of enhanced pharmacy services, including methadone dispensing (Berbatis et al., 2007).	2
Pharmacist availability	Pharmacist accessibility was a facilitator to destigmatization by promoting patient access to treatment (Hohmeier et al., 2021).	2
Receiving health care advice from the pharmacist	Choice in pharmacy by patients was influenced by receiving health care advice from the pharmacist (Laird et al., 2016).	2
Collaboration with other health services	Increased collaboration with allied health services (like counselors) improved service provision (Le and Hotham, 2006).	2
Request by prescribers to provide service	Request by clinics to provide service facilitated providing the service among community pharmacists (Mackie et al., 2004).	2
Decrease drugs on the street	A motivator to begin provision of methadone treatment services was if community pharmacists thought it would decrease drugs sold on the street (Matheson et al., 1999).	2
Other	Tailoring treatment for individuals needs improved service provision (Le and Hotham, 2006).	12

3.6.1. Training and education

Training and education around methadone treatment and PWUD were identified as facilitators to improving the patient experience in the pharmacy. Different ways training can improve patient experience include promoting positive relationships with pharmacists, creating supportive environments, having empathy and cultural competency when working with patients, increasing positive associations with methadone treatment, and reducing stigma (Caruana, 2024b, Fatani et al., 2021, Lutnick et al., 2012, Snoswell and Hollingworth, 2016). Training and education were also facilitators for implementation, provision, and improvement of providing methadone treatment in the pharmacy (Berbatis et al., 2007, Fonseca et al., 2018; Le and Hotham, 2006; Samitca et al., 2007; Wu, John, et al., 2023; Wu, Mannelli, et al., 2023). Additionally, training and education were perceived as a mechanism to increase confidence, teach new skills, and increase knowledge of methadone treatment among pharmacists (Chaar et al., 2013, Cheetham et al., 2023, Tuchman et al., 2005).

3.6.2. Positive pharmacist-patient relationships

Positive relationships between pharmacists and patients were perceived to benefit both groups. Among pharmacists, positive working relationships can help mitigate “poor behavior” and manage “aggressive patients”, counter internalized stigma in patients and promote a non-stigmatizing environment, improve skills in discussing substance use, and contribute to the success of the service as well as professional satisfaction (Caruana, 2024b, Chaar et al., 2013, Irwin et al., 2012, Wu et al., 2023). Among patients, trust and respectful communication were perceived to promote a positive working relationship (Fatani et al., 2021, Luger et al., 2000). Good working relationships led to improved patient satisfaction, care experience, and well-being, and helped motivate patients to stay in treatment (Caruana, 2024a, Cheetham et al., 2023, Patil Vishwanath et al., 2019, Radley et al., 2017). Several patients noted positive relationships with pharmacists created a safe space for them and helped mitigate issues around privacy (Caruana, 2024b; Le & Braunack-Mayer, 2019; Patil Vishwanath et al., 2019).

3.6.3. Privacy

Adequate privacy in the pharmacy was a facilitator to improve the provision of services (Berbatis et al., 2007; Le and Hotham, 2006; Matheson, 1998; Matheson et al., 1999). The type of privacy preferred by patients differed across studies. In one study, patients appreciated having the choice between discrete counter dosing or using a private room, while another study noted that using the same consultation room as other customers led to better privacy (compared to a consultation room designated solely for people taking methadone) (Caruana, 2024b, Radley et al., 2017). In contrast, patients in Australia had differing privacy preferences including counter dosing, using a separate entrance in the pharmacy, or having a separate area in the main pharmacy for dispensing methadone (Le & Braunack-Mayer, 2019). Among PWUD in San Francisco, participants said that adequate privacy would increase their willingness to participate in methadone dispensing and observed dosing in the pharmacy (Lutnick et al., 2012), and patients in Scotland noted their choice in pharmacy was influenced by sufficient privacy (Laird et al., 2016). Finally, pharmacy customers suggested privacy for observed dosing is of benefit to patients and other customers (Lawrie et al., 2004).

3.6.4. Adequate financial coverage

While financial hardship was identified as main barrier to methadone dispensing, adequate financial coverage was simultaneously found to facilitate community pharmacists’ willingness to provide the service (Le and Hotham, 2006, Le and Hotham, 2008; Matheson et al., 1999; Matheson et al., 2002), take on more clients (Winstock et al., 2010), and mitigate the risk of debt for providing the service (Chaar et al., 2013). In addition, proper insurance coverage was perceived to be important to patients in choosing a pharmacy (Comanici et al., 2023). Finally, pharmacists and OTP staff in a U.S. pilot study perceived proper reimbursement as important for future implementation of pharmacy-based methadone dispensing (Wu, Mannelli, et al., 2023).

3.6.5. Positive pharmacist-prescriber relationships

Good communication between pharmacists and prescribers was considered paramount for improving methadone service delivery (Lukey et al., 2020, Samitca et al., 2007). Pharmacists also described good relationships with prescribers facilitated collaborative care and made their work more professionally rewarding (Chaar et al., 2013, Comanici et al., 2023). Finally, nurses at an OST clinic in Australia felt that positive pharmacist-prescriber relationships were essential for successful client transition to the pharmacy (Bui et al., 2015).

4. Discussion

This scoping review is the first to comprehensively document barriers and facilitators of pharmacy-based methadone dispensing identified by multiple key informant groups across several countries. Several of the most reported barriers to methadone dispensing in community pharmacies are similar to barriers identified in a recent systematic review of buprenorphine dispensing in the U.S. (Rawal et al., 2025), including workload and financial constraints. Likewise, stigma towards OUD and MOUD, which is well documented in U.S.-based literature and pervasive across health care settings (Magnan et al., 2024), limits the availability of methadone and buprenorphine services and impedes the quality of care for patients (Rawal et al., 2025). The ubiquity of these barriers to MOUD dispensing in community pharmacies suggests that the addition of methadone services in the U.S. could further exacerbate known barriers to buprenorphine dispensing. To create a sustainable model for pharmacy-based methadone dispensing in the U.S., efforts to mitigate these barriers will be important for community pharmacy buy-in and widespread implementation.

Other main barriers to methadone dispensing in community pharmacies include safety and security concerns over staff and property and concerns over pharmacist-perceived customer behavior and interactions. However, it is important to consider such reports within the context that pharmacist stigma toward PWUD can contribute to negative perceptions of patients (Chaar et al., 2013, Fatani et al., 2021, Matheson, 1998, Radley et al., 2017, Yadav et al., 2019), which may contribute to unpleasant interactions between pharmacists and patients. This is further reinforced in that positive pharmacist-patient relationships, a key facilitator in this review, may mitigate pharmacist concerns over patient behavior (Caruana, 2024b, Chaar et al., 2013, Irwin et al., 2012). Safety and security concerns could be of particular concern to independent pharmacies in the U.S. who do not have the backing of a corporation to offset costs related to additional security measures, store theft, or property damage. However, adequate financial reimbursement for methadone dispensing, another key facilitator identified in this review, may incentivize community pharmacies to dispense methadone. The amount of reimbursement that would make methadone dispensing economically viable for U.S. community pharmacies is worth exploring.

The facilitators identified in this review are relevant to a U.S. context and will be important to consider for those seeking to integrate methadone services into U.S. community pharmacies. Training pharmacists to prepare for methadone dispensing and serving patients with OUD is widely supported by other literature, which has found substance use disorder training can reduce stigma, improve attitudes, and increase knowledge (Carpenter et al., 2024, Irwin et al., 2024, Sulzer et al., 2022). Likewise, positive pharmacist-prescriber relationships should be prioritized in future implementation efforts for U.S. pharmacy-based methadone dispensing, as poor communication with and distrust of clinicians are common barriers to buprenorphine dispensing (Rawal et al., 2025).

While privacy was identified as an important facilitator in the provision of observed methadone dosing, lack of privacy was also a barrier that contributes to stigmatization and disrespect, and makes patients feel uncomfortable or unsafe in the pharmacy (Gidman and Coomber, 2014, Luger et al., 2000, Matheson, 1998, Patil Vishwanath et al., 2019, Radley et al., 2017). As a growing number of pharmacy services (e.g., immunizations, HIV testing, and long-acting injectable medications) in the U.S. can benefit from privacy, further research to identify patient preferences for privacy in the pharmacy is warranted.

In the U.S., barriers to MOUD are significant (Bremer et al., 2023; Nguyen and Kubiak*, 2024; Pasman et al., 2022), and many patients with OUD are not receiving any form of evidence-based MOUD (Dowell et al., 2024). If methadone can be expanded to community pharmacies, patients will have greater access to and choice in where they can access this medication. However, implementing pharmacy-based methadone services may pose challenges, such as those identified in this review and U.S. and state-specific barriers. Specifically, medication units would add observed dosing to a pharmacist’s workflow as well as new protocol to partner and communicate with an OTP. Although this pathway has existed for years, to these authors’ knowledge there are few pharmacy-based medication units operating in the U.S., likely due to the logistical challenges and lack of regulatory guidance on their implementation. The prescription-based model (e.g. the MOTA Act), better fits into a pharmacist’s workflow, but there is ambiguity in how OTPs would fit into this model. Furthermore, the MOTA Act in its current form suggests that patients may be prescribed up to 30 days of methadone for take-home administration, which is significantly different to other countries’ dispensing practices, many of which still require observed dosing for patients (Pew, 2023b, Pew, 2023c). For these reasons and more, the association representing more than 1400 OTPs in the U.S. is opposed to this bill (AATOD, 2023). Regardless of the path for expanded methadone treatment in U.S. community pharmacies, the barriers and facilitators most reported across the 41 articles included in this review can help ensure that disparities in access to methadone are not exacerbated through limited pharmacy-based uptake and implementation.

4.1. Limitations

This review has several limitations. Most articles were from countries other than the U.S., and there are legal and other systematic differences in pharmacy-based methadone dispensing in the U.S. Nevertheless, the results demonstrate that several barriers and facilitators persist across geographic boundaries. Relatedly, this review sought to gather all relevant barriers and facilitators to community pharmacy dispensing regardless of pharmacy type, location, or key informant perspective; thus, future research may seek to differentiate between independent and chain pharmacies, pharmacists and patients, or by country, to gather more nuanced perspectives. Furthermore, there are limited OTP staff perspectives included in this review, which is important since methadone dispensing in the U.S. is currently limited to OTPs. Several articles discuss buprenorphine and/or methadone without clearly distinguishing between them; it is possible the barriers and facilitators identified may have been about buprenorphine dispensing instead of methadone dispensing. However, the researchers who extracted data made efforts to differentiate between the medications when sufficient context was provided. As a large sample size was not an article inclusion criterion, many articles had small samples, which may limit the review’s generalizability. Finally, it is possible that barriers and facilitators to methadone dispensing were missed or excluded during the data charting process.

5. Conclusion

The main barriers to methadone dispensing in community pharmacies identified in this review were workload, safety and security concerns, concern about patient behavior and interactions, financial hardship for pharmacists and patients, and stigma towards patients. The main facilitators were training, positive pharmacist-patient and pharmacist-prescriber relationships, patient privacy, and adequate financial coverage. Findings from this review can be used to preemptively address barriers and incorporate known facilitators into future protocols or practice of pharmacy-based methadone dispensing. Further research is needed to identify U.S. and state-specific barriers and facilitators to methadone dispensing in community pharmacies. Researchers should consider conducting statewide assessments of key informants (including pharmacists, OTP staff, providers, and people with lived and living experience of OUD) to better understand their unique perspectives, motivations, and challenges to pharmacy-based methadone dispensing. Exploring how state-level methadone policies impact interest in and feasibility of implementing pharmacy-based methadone dispensing among key informants could provide insights into what next steps are logical to pursue related to pharmacy-based methadone dispensing in each state.

Author disclosures

None.

CRediT authorship contribution statement

Grace Marley: Writing – review & editing. Bayla Ostrach: Writing – review & editing, Funding acquisition. Caroline Shubel: Writing – review & editing, Writing – original draft, Investigation, Formal analysis, Conceptualization. Mary Ava Nunnery: Writing – review & editing, Investigation. Delesha M. Carpenter: Writing – review & editing, Supervision, Funding acquisition.

Funding

Research reported in this publication was supported by the NC Collaboratory, which funded the co-authors’ time on this review. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NC Collaboratory.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Glossary

Methadone

A long-acting full opioid agonist and schedule II-controlled medication. Methadone is used to treat opioid use disorder (OUD) and can only be dispensed through a SAMHSA (Substance Abuse and Mental Health Services Administration) certified OTP (Opioid Treatment Program) in the United States.

Community Pharmacy

A type of pharmacy that is typically located in a retail setting, such as a drugstore or grocery store, or an independent proprietor. Community pharmacies dispense prescription medication to patients, counsel patients on medication use, and can provide vaccines and other health-related screenings.

MOTA

The Modernizing Opioid Treatment Access (MOTA) Act, in its current form (as of 06/04/25) would allow board certified addiction medicine and addiction psychiatrists to prescribe methadone to be dispensed at a community pharmacy in the United States.

OUD

Opioid Use Disorder (OUD) is defined as the chronic use of opioids that causes clinically significant distress or impairment.

Medications for Opioid Use Disorder (MOUD)

FDA-approved medications that can help people stop or reduce opioid use, including methadone, buprenorphine, and naltrexone.

OTP

Opioid Treatment Program (OTP) is defined as a program or practitioner engaged in opioid treatment of individuals with an opioid agonist medication.

Appendix A. Search string for PubMed

Keyword	Terms
Methadone	("Opiate Substitution Treatment"[Mesh] OR “opiate substitution*”[tw] OR “opioid substitution*”[tw] OR “opiate maintenance treatment*”[tw] OR “opioid maintenance treatment*”[tw] OR “opiate replacement*”[tw] OR “opioid replacement*”[tw] OR “medication-assisted treatment*”[tw] OR “medication assisted treatment*”[tw] OR "Methadone"[Mesh] OR methadone[tw] OR "MOUD"[tiab] OR "medications for opioid use disorder"[tw])
Community Pharmacy	((Preventive Health Services[mesh] OR "community"[tiab] OR "preventative health*"[tiab] OR "preventative care"[tiab] OR Community Health Services[mesh]) AND (Pharmacy[MeSH] OR Pharmacies[MeSH] OR Pharmacists[MeSH] OR "Pharmacy Administration"[Mesh] OR "Community Pharmacy Services"[Mesh] OR pharmacy[tiab] OR pharmacies[tiab] OR pharmacists[tiab] OR pharmacist[tiab])) OR ("Independent pharmacy"[tiab:~4] OR "Independent pharmacies"[tiab:~4] OR "Retail pharmacy"[tiab:~4] OR "Retail pharmacies"[tiab:~4] OR "Chain pharmacy"[tiab:~4] OR "Chain pharmacies"[tiab:~4] OR "Community pharmacy"[tiab:~4] OR "Community pharmacies"[tiab:~4] OR "Community pharmacist"[tiab:~4] OR "Community pharmacists"[tiab:~4] OR "Independent pharmacist"[tiab:~4] OR "Independent pharmacists"[tiab:~4] OR "Retail pharmacist"[tiab:~4] OR "Retail pharmacists"[tiab:~4] OR "Chain pharmacist"[tiab:~4] OR "Chain pharmacists"[tiab:~4])

Appendix B. Extracted data from 41 scoping review articles

Article, year	Results	Limitations	Recommendations	Future Research Directions
Berbatis et al. (2007)	More than 40 % of pharmacists offered methadone as an enhanced pharmacy practice. Pharmacies with younger managers or owners were more likely to offer at least one enhanced pharmacy service (EPS).	Data are self-reported	Implement policies and programs that increase uptake of EPS and are in line with National Health Priorities.	None listed
Bui et al. (2015)	Four themes revealed: clinic transfer procedures, barriers to transfer, pharmacy relationships, and client post-transfer experience. Nurses generally view client transfer (to pharmacy) as a complex process.	Small sample size; not generalizable	Professional development points where pharmacists are credited for efforts related to clinic engagement.	None listed
Caruana (2024b)	Five themes revealed: 1. Stigma is pervasive and harmful 2. Pharmacists act in fair and unfair ways 3. Connection and understanding helps 4. Privacy is key but needs negotiation 5. Empowerment counters internalized stigma	Small sample size; social desirability bias; not generalizable	More training and information-sharing between pharmacists to increase awareness of ways to offer more equitable, inclusive, and efficient opioid agonist treatment (OAT) services, and training in trauma-informed care approaches to better support people with histories of substance dependence.	Future research could aim to provide clearer evidence of what features and approaches to OAT services are most conducive to creating positive experiences for OAT patients.
Caruana (2024a)	Burdensome fees, pharmacy service problems, and system opportunities were generated as themes of subjection, and socially inclusive care and person-centered approaches as themes of connection.	Self-selection bias, small sample size, not generalizable	Pharmacists can support greater inclusion and connection in their delivery of opioid agonist treatment (OAT) services by demonstrating non-differential processes and person-centered care.	None listed
Chaar et al. (2013)	The main themes were: (i) perceptions of the need to provide the opioid substitution therapy (OST) service; (ii) attitudes towards OST clients/service; (iii) relationships: with OST clients and other stakeholders; (iv) finances: participants’ views on the financial impact of OST; and (v) recommendations: strategies suggested to increase pharmacy-based OST.	Social desirability bias, not generalizable	None listed	Research to explore whether there is any difference in pharmacist responses according to their experience of providing OST, to further explore why there is an imbalance of distribution of OST clients among pharmacies and to investigate any difference between professional views and patient perspective on the provision of the service.
Cheetham et al. (2023)	There was strong motivation among healthcare professionals to participate in a collaborative model of care, with the main perceived benefits including improvements in accessibility, convenience, and continuity of care, and leverage of pharmacists’ high level of patient engagement.	Small sample size; focus on single geographic area	Subsidizing OST costs could increase access to care for both pharmacies and patients.	Further exploration of the feasibility and acceptability of a collaborative model of care for medication assisted treatment for opioid dependence.
Comanici et al. (2023)	Interviews identified barriers, facilitators, and opportunities for improvement in current medications for opioid use disorder (MOUD) care practices. Stigma was a major barrier identified by all groups.	Lack of representation among rural prescribers; did not reach target sample size	Pharmacist knowledge on MOUD was identified as a major opportunity for improvement in providing better patient care. Increased education for pharmacy technicians is required. Establishing more formal partnerships and collaborations with prescribers.	None listed
Fatani et al. (2021)	The four emergent themes were: 1) conflicted experiences with community pharmacists, 2) lack of knowledge concerning community pharmacists’ extended services, 3) negative experiences in Opioid Agonist Therapy (OAT) program, and 4) needs from community pharmacists.	Not generalizable, non-random sampling	There is a need for community pharmacists to become public health advocates and sources of medical advice. Health care providers, including community pharmacists, should be trained to address patients’ needs while properly delivering patient-centered care for optimum outcomes.	None listed
Fonseca et al. (2018)	Participating pharmacists felt that rural regions had fewer methadone maintenance treatment (MMT) prescribers and that rural community members had greater apprehension about addiction-treatment services than those in urban communities.	This study was limited by the coding and concept-distillation processes.	A multicenter, collaborative model can distribute workload evenly and give patients more than one access point to address confidentiality concerns.	Physician-pharmacist relationships were not explored in this study but could be a focus for future research.
Gidman and Coomber (2014)	Three thematic categories were identified: methadone service users in community pharmacies, attitudes to harm reduction policies, and contested space.	Small sample size; recruited from a small geographical area	None listed	The negative views expressed warrants further investigation.
Hodgson et al. (2024)	This study demonstrated that patient satisfaction with opioid agonist treatment (OAT) service access in a rural and coastal setting was multifactorial, and geographic proximity alone does not fully explain OAT accessibility issues in these settings.	COVID-19 may have impacted interview length, rapport, and recruitment; small sample size; not generalizable	Greater innovation in OAT dispensing that is tailored to treatment goals is urgently required to improve OAT access and uptake in rural and coastal Canadian communities.	Research that specifically explores barriers that may be exacerbated for racialized and isolated communities.
Hohmeier et al. (2021)	Student pharmacists desire exposure to therapeutic knowledge and lived experiences related to opioid use disorder (OUD) and methadone treatment. Students perceive stigmatizing views held by pharmacists. Pharmacists should play a role in methadone treatment.	Social desirability bias, not generalizable	Pharmacy curricula should emphasize stories of lived experiences of patients with OUD, therapeutic knowledge and guidelines related to MOUD, and the regulatory environment surrounding OUD treatment.	None listed
Irwin et al. (2012)	Several barriers and facilitators to appropriately engage with an aggressive patient were identified in the interviews.	Self-recollection, based on a single data source	Further training programs based on nontechnical skills should aid pharmacists in the provision of supervised administration.	Further research should be conducted to further validate the results reported here using data triangulation.
Laird et al. (2016)	Positive staff attitudes, privacy and the provision of additional health services were key factors influencing the choice of pharmacy.	Self-selected sample may limit generalizability of findings	Further development of enhanced services in community pharmacies is encouraged.	Further research is needed to examine whether pharmacy service delivery promotes retention in treatment and whether it makes an independent contribution to improving health outcomes.
Lawrie et al. (2004)	Pharmacy customers were generally supportive of pharmacies offering services to drug users. The study found a wide range of positive attitudes towards the provision of drug misuse services (substitute dispensing and needle exchange) from community pharmacies.	Not generalizable	Educating community members on methadone patients could increase comfortability with dosing in the community pharmacy.	None listed
Lawrinson et al. (2008)	Pharmacists indicated high levels of support for the opioid substitution therapy (OST) program, and most intended to continue providing OST. There was a strong positive correlation between the number of regular clients seen and the problems experienced by pharmacists.	Selection bias	Policies aimed at retaining pharmacists, particularly in resource poor rural areas, such as embracing a shared-care approach between general practitioners and pharmacists.	Ascertaining the views of those not providing OST is an important topic for future research.
Le and Braunack-Mayer (2019)	Most participants were concerned about privacy and considered that the pharmacy layout could enhance or hinder privacy. Pharmacy layout and pharmacist relationships were most impactful in shaping client perspectives on privacy.	The study only included metropolitan clients; sample had reduced sensitivity to privacy issues.	Improving pharmacist relationships with consumers could be one way to improve consumers’ perception of privacy.	None listed
Le and Hotham (2006)	Professional obligation played a key role in motivating rural community pharmacists to be involved with service provision. Dissonance existed between the sense of fulfilment by participating in a major public health initiative and the recognition of the negative financial impacts.	Small sample size	More appropriate remuneration and effective support programs must be implemented.	Research into the cost-effectiveness and impact of consulting rooms on service provision and business imperatives.
Le and Hotham (2008)	Exploration of service issues in the context of rural pharmacy practice found that the geographical closeness of a small community may improve rapport with local prescribers. Servicing opioid substitution therapy (OST) clients can have a negative impact on pharmacy business and is not profitable for rural pharmacies.	Small sample size, social desirability bias	Access to adequate renumeration without increasing treatment costs. Appropriate funding models for South Australian community pharmacies to ensure that clients’ needs are met with sufficient distribution of service.	None listed
Luger et al. (2000)	Most pharmacists (67 %) found it satisfying working with methadone clients. Most clients (85 %) felt they were treated well by their pharmacists.	None listed	None listed	None listed
Lukey et al. (2020)	Pharmacists provided accessible support to a population with known barriers to accessing health care. Participants identified challenges with communication and a perceived lack of understanding of the pharmacist's role as barriers to collaboration with the wider opioid substitution treatment team.	Not generalizable	None listed	Further research could examine the views of clients, prescribers and the wider treatment team on privacy, stigma, and the pharmacist’s role in providing additional health services.
Lutnick et al. (2012)	Most had reservations about expanding services to pharmacy settings, with reasons ranging from concerns about anonymity to feeling that San Francisco already offers the proposed services in other venues.	Social desirability bias, nonrandom sample	Appropriate, nonjudgmental services delivered in pharmacies to injection drug users (IDUs) have significant potential to improve the health of this vulnerable population.	None listed
Mackie et al. (2004)	Most pharmacists participating in methadone services felt they had a professional responsibility to provide such services. Participation in methadone services was considerably higher in Glasgow than in Dublin.	None listed	None listed	None listed
Matheson (1998)	Patient stigmatization is linked to the level of privacy in the pharmacy. Lack of privacy was particularly troublesome for the methadone client and attempts from the pharmacist to provide privacy were appreciated. Mixed views on whether providing a designated private area was the solution.	None listed	Changes to pharmacy practice can reduce stigmatization and promote a more harmonious relationship between drug users and pharmacists to the benefit of both parties.	None listed
Matheson et al. (1999)	Pharmacists who provided needle exchange programs, sold syringes, dispensed methadone, supervised consumption, and provided health promotion services to drug misusers were more likely to have more positive attitudes towards drug misusers. Attitude was an independent predictor of methadone being provided.	None listed	Training initiatives may be needed to meet different needs and willingness to participate. Increased renumeration may promote better attitudes. Addressing pharmacists’ negative attitudes could encourage pharmacists to provide services.	None listed
Matheson et al. (2002)	Methadone dispensing and supervised consumption of methadone increased significantly from 1995 to 2000.	Direct comparison of pharmacists was not possible as the surveys were anonymous.	None listed	None listed
McCormick et al. (2006)	Four principal factors explained 57 % of the variance within the attitude questions. These were attitudes towards: general results of dispensing methadone to opioid misusers; the effect of opioid-dependent clients on a pharmacy; reducing harm associated with drug use; and engaging with drug users.	Bias in measurement of attitude	Ensuring that pharmacists fully understand and take on board the concept of methadone maintenance treatment as a harm-reduction intervention is important.	None listed
O'Dwyer et al. (2020)	The two themes that emerged from the manual coding process were disaster preparedness and continuity of service.	Limited to impacts of cyclones; did not explore the lived experience of opioid replacement therapy (ORT) clients.	A review of the legislation controlling the number of days of ORT supply allowed during disasters is recommended to improve the continuity of ORT services during cyclones.	The ORT supply chain and impacts of cyclones on ORT stock as a factor of client stability or risk of relapse requires further exploration.
Patil Vishwanath et al. (2019)	Findings centered on themes of consumers' experience of becoming recipients; consumer perceptions of pharmacists and pharmacy settings and psychosocial impacts on consumers.	Lack of generalizability	There is an urgent need for medical professionals who are qualified to work with consumers on opioid replacement therapy (ORT).	None listed
Peterson et al. (2007)	Both methadone prescribers and dispensers believed the methadone maintenance programs were highly valuable to the community but not without problems.	It is possible that the sample was skewed to include a much higher proportion of methadone maintenance program (MMP) pharmacies than General Practitioners (GPs).	None listed	Further research is required to establish approaches to both increasing participation in the MMP and reducing the barriers impacting those who are already involved.
Radley et al. (2017)	People prescribed opiate replacement therapy (ORT) may be treated differently from others accessing care through pharmacies. Participants felt they experienced stigma and discriminatory practices in pharmacies, elsewhere within the healthcare environment, and more generally in society.	Findings could have been influenced by the group dynamic; descriptions of poor experiences may have been better accepted.	Education and training as well as role support are required as steps to change organizational cultures within pharmacies and healthcare in general.	None listed
Roberts et al. (2007)	Over the years (1997 and then 2000–2003), the community provision of substitute medication and needle exchange service to drug users has grown considerably. In addition, there have been changes in the views and opinions of participating pharmacists in relation to the provision of such services.	Individual data were not paired across surveys; non-random sample	Recognition of the nature of the changing views and beliefs around methadone treatment can be used successfully to address fears and issues of concern and can result in an increase level of pharmacists’ participation in both methadone programs and needle exchange schemes.	None listed
Rosenblom et al. (2003)	Several logistical, social, and economic factors were listed as factors for those not dispensing or supervising consumption of methadone; 84 % dispensed methadone and 41 % observed dosing.	None listed	None listed	None listed
Samitca et al. (2007)	Pharmacies played an important role in frontline services for drug users. They were included in the supervision of two thirds of the methadone treatments. They did not feel integrated enough in the network of care for drug users and asked for more training and better recognition of their role.	Self-report bias	To fulfil their role in the frontline services to drug misusers with adequate quality, pharmacists need specific training.	none listed
Snoswell and Hollingworth (2016)	Respondents indicated a positive association with the opioid substitution therapy (OST) program, but only 33 % of respondents said they would be comfortable providing OST as a new graduate.	Nonrandom sample; low response rate	This study highlights a need for further education around a professional service that is provided in two out of five Australian pharmacies.	Further research is needed to identify gaps in the pharmacy curriculum.
Tuchman et al. (2003)	Seventy five percent of the pharmacists were “comfortable” with the idea of managing the care of drug users in their community pharmacies. Sixty-three percent were both convinced of methadone’s effectiveness and support methadone maintenance treatment of all heroin users who wanted methadone.	Small sample size	None listed	None listed
Tuchman et al. (2005)	Many of the providers surveyed strongly supported methadone maintenance treatment (MMT) for all heroin users who wanted methadone.	Small sample size	There is a need to educate and train providers, pharmacists, and social workers to improve the provision of services.	None listed
Winstock et al. (2010)	In the preceding month, 41 % of pharmacists had refused to dose a client for any reason, due most commonly to expired prescriptions (29 %) or 3 missed doses (23 %). Terminating a client’s treatment in the past month was reported among 14 % of respondents, due most commonly to inappropriate behavior and missed doses.	Social desirability bias; did not assess the number of occurrences of the problems noted	None listed	Future research is needed on whether the identified differences in the frequency of problems have an overall impact on treatment outcome.
Wu et al. (2023)	The distance (convenience), office hours, and cost were considered factors most influencing their decision to receive methadone from a pharmacy.	Not generalizable to all patients taking methadone in the US.	Establishing medication units at pharmacies in rural and underserved areas could increase utilization of methadone for both existing and first-time patients.	None listed
Wu et al. (2023)	Pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) was considered to increase access for patients, provide additional opportunities and revenues for pharmacies, enhance the capability of OTPs to treat more new patients, and reduce patients’ cost when receiving medication at a pharmacy relative to an OTP. Pharmacy and OTP staff were perceived to be supportive of the implementation of PADMOUD.	Not generalizable	Leveraging ubiquity of community pharmacies in the US to implement PADMOUD could meaningfully increase the number of methadone dispensing locations without the burden of establishing new OTPs.	None listed
Yadav et al. (2019)	While pharmacists felt their role to be essential in providing opioid substitution therapy (OST), they did not feel part of an integrated system. Pharmacists’ ability to act in risk-situations was affected by their knowledge, confidence in intervening, as well as the support they receive in providing the service.	Not generalizable	Mandatory training for pharmacists, harmonizations of local policies, better integration in the service provision and support providing the service could improve the role of community pharmacists in preventing OST-related deaths.	None listed