Exploring oral health challenges and integration strategies in opioid treatment programs: perspectives from clinicians and clients
Grace Wong
A B C * , Anna Cheng A , Kyle Cheng A B , Angela Masoe D , Sanjana D’Hary A and Mark Enea Montebello E F G
A
B
C
D
E
F
G
Abstract
Despite the paramount importance of oral health, individuals undergoing treatment for opioid use disorder face unique challenges beyond traditional addiction care. This qualitative study explores the challenges Opioid Treatment Program (OTP) clients in Australia encounter when accessing oral health care, aiming to understand the underlying factors and identify effective strategies for integrating oral health into an OTP.
Semi-structured interviews were conducted with OTP clients, OTP clinicians and oral health clinicians using tested interview guides. Thematic analysis identified patterns and themes across participants’ responses.
Client behaviour and traits such as inadequate health prioritisation, crisis-driven care and lack of motivation, shaped by a complex social environment, contribute significantly to inconsistent care and neglected oral health. Addiction exacerbates oral health issues as clients prioritise drug use over oral care and financial constraints, resulting in poor oral hygiene and a higher prevalence of dental problems. Psychological barriers such as dental anxiety deter clients from seeking care, while access issues including administrative burdens and system barriers, lost phones and unstable living conditions hinder consistent management of oral health. Stakeholders recommend actionable steps to address OTP clients’ challenges, including integrating holistic care, establishing collaborative support systems, improving awareness and education and enhancing accessibility and flexible scheduling.
This study established a framework for improving OTP clients’ oral health through integrated, holistic strategies. By addressing gaps in existing research, it supports the development of public health policies integrating oral health care into OTPs, aiming to foster collaboration, improve access and advance client education for better health outcomes.
Keywords: delivery of health care, facilities and services utilisation, health disparities, health services accessibility, integrated care, opioid use disorders, oral health, social determinants of health.
Introduction
Oral health, an integral component of overall well-being, is crucial for maintaining an individual’s general health (Baiju et al. 2017). Its significance extends beyond the confines of the mouth, as poor oral health has been linked to various systemic diseases (Kapila 2021). This is particularly concerning for individuals with opioid use disorder (OUD), as substance use exacerbates oral health problems and compounds the risk of systemic diseases, a link that recent research has increasingly highlighted (Rossow 2021). Untreated oral health issues can lead to prolonged pain, discomfort and systemic complications, which may significantly impact the quality of life (COAG Health Council 2015). These problems are even more severe for those with OUD, who face the highest burden of oral diseases and encounter significant barriers to accessing necessary oral health services (Robinson et al. 2005; Watt et al. 2019). Early intervention is essential to prevent the escalation of oral diseases, which can otherwise result in more serious, costly conditions and contribute to a cycle of deteriorating well-being (Listl et al. 2015).
The NSW Opioid Treatment Program (OTP) in Australia provides opioid replacement therapy for people who are dependent on opioids such as heroin and/or opioid pain medications (e.g. morphine and oxycodone). This program offers supervised medications to reduce withdrawal symptoms and cravings, with treatment administered daily, weekly or monthly depending on clients’ needs. In addition, a range of supportive services are available including counselling, medical care and social support in helping individuals manage opioid use and regain control of their lives. To effectively meet the multifaceted needs of those with OUD, it is important to develop approaches that integrate oral health care beyond traditional treatment boundaries (Hovden et al. 2020; Carlsen et al. 2022). The integration is essential for facilitating recovery, promoting long-term stability and improving their quality of life by addressing oral health needs alongside addiction treatment (Centres for Disease Control and Prevention 2021).
Building upon our previous study, which examined the oral health status and oral health-related quality of life among Australian OTP clients, we identified significant oral health concerns in this population group (Wong et al. 2024). Despite the evident demand for oral health interventions, only a fraction of clients adhered to their scheduled dental appointments, revealing a critical disparity between identified needs and actual utilisation of oral health services. This discrepancy highlights the need to understand the barriers to seeking oral health care, as documented in previous studies (Robbins et al. 2010; Åstrøm et al. 2022). Consequently, there is an urgent need to explore effective strategies to overcome these barriers and improve oral health outcomes for OTP clients.
This qualitative investigation aims to explore oral health challenges and integration strategies in OTPs by identifying obstacles and developing solutions to improve OTP clients’ engagement with oral health services. Insights from OTP clients, OTP clinicians and oral health clinicians will inform interventions that support clients in seeking and adhering to oral health treatments. By synthesising perspectives from all stakeholders, this study aims to develop targeted strategies for integrating oral health into OTPs and promoting comprehensive health care within this context.
Methods
Study design
This descriptive qualitative study employs semi-structured interviews to explore strategies for integrating oral health into the OTP. Interviews were conducted with a diverse sample including public oral health clinicians, OTP clinicians and OTP clients, all within the urban Northern Sydney Local Health District. Interview guides were developed and pilot-tested for usability and clarity. All interviews were audio-taped and transcribed verbatim to capture nuances and ensure data accuracy. This study adheres to ethical guidelines, ensuring confidentiality, voluntary participation and respect for participant autonomy.
Participants and recruitment
Purposive sampling was used to recruit participants for this study. Clinicians from two public dental clinics and two OTP clinics in the Northern Sydney Local Health District were invited via email. The research team attended the OTP during opening hours to promote the study and recruit clients, supported by prominently displayed posters and comprehensive explanations of the study by clinicians. OTP clients were recruited from the same participant pool as our previous study, ensuring a thorough exploration of their perspectives. Recruitment continued until the theoretical data saturation was reached for each group; at this point no new information emerged and further coding and categorisation were deemed unnecessary (Queirós et al. 2017).
Data collection
Data were collected between September and October 2023 through semi-structured, in-depth face-to-face interviews conducted in private consultation rooms at the OTP clinics, using an open-ended interview guide. The interview questions were developed based on a literature review and refined through feedback from the research team and pilot testing. Three members of the research team (GW, AC, SD) conducted the interviews, with each interviewer focusing on one group of participants to avoid cross-contamination of ideas.
Before the interview, participants received study information and signed consent forms. Each interview lasted 30–40 min and was audio-recorded and transcribed using the Microsoft TEAMS online platform. The interviewers used reflective probes to encourage participants to elaborate on their statements, ensuring adequate coverage of the topics. Field notes were also taken to capture non-verbal cues to aid in data interpretation.
Data analysis
Thematic analysis was conducted using the framework established by Braun and Clarke (2006). Discussions were recorded, transcribed and anonymised to ensure participant confidentiality. A research team member (KC) began with an initial inductive analysis using NVivo 14 for Windows, manually coding the data to create themes and subthemes without predefined categories. A manual verification process was employed to ensure the generated themes and subthemes aligned with the data’s content and context. Table 1 shows examples of analysis. The research team then deliberated on the identified themes and subthemes, reaching a consensus on categories and their interrelations. Preliminary themes and subthemes were reviewed by team members to ensure an accurate reflection of their meanings. Relationships among themes were further examined for coherence and to establish an overarching theme. Pseudonyms were used throughout to maintain participants’ anonymity and confidentiality.
| Meaning unit | Condensing meaning unit | Code | Subcategory | Theme | |
|---|---|---|---|---|---|
| ‘Oral health care is low on people’s priorities, to the point where unless they are in agony, they’re unlikely to seek care’ (Oral health clinician, female 2) | Addiction affects health priorities | Low oral health priority unless in pain | Crisis-driven care | Client behaviour and traits | |
| ‘I feel almost like having a panic attack while waiting’ (OTP client, female 6) | Panic attacks during dental visits | Panic attacks | Psychological distress | Psychological barriers |
Rigour and researcher positionality
Numerous strategies were implemented to strengthen the reliability of the data collection and analysis process. The coordinating principal investigator (CPI) oversaw the recruitment process and the scheduling of interviews, ensuring consistency across all stages. Interviews were conducted by the CPI and two co-investigators (CIs), each responsible for a specific group of interviewees (oral health clinicians, OTP clinicians and OTP clients), ensuring data integrity. Regular meetings between the CPI and Cls facilitated ongoing reflection and adjustment until data saturation was achieved. Each subset of interviews was reviewed by each interviewer. All transcripts were meticulously reviewed by the CPI to ensure dependability and accuracy.
The researchers also reflected on their positionality to enhance transparency and minimise bias throughout the study. The CPI’s expertise in oral health promotion and integration contributed to the study’s design and analysis, focusing on identifying strategies for integrating oral health into OTPs. The Cls contributed to shaping the study by advising on the research methodology and analysis process. Collaboration with the OTP director, a co-author with extensive experience in addiction treatment delivery, provided valuable context about the operational and logistical barriers within OTP settings. Reflexive discussions and triangulation across stakeholders, including the OTP clients, ensured that diverse perspectives were considered, strengthening the credibility of the findings.
Results
Six oral health clinicians (four females and two males), six female OTP clinicians and 11 OTP clients (five females and six males, aged 29–68 years) participated in this study. All OTP clients were actively participating in the OTP and represented diverse sociodemographic backgrounds, including varying levels of education, employment status and length of time in the program. These factors provided valuable context for understanding their perspectives and experiences with oral health care.
Challenges faced by OTP clients – perspectives from stakeholders
The study explores key themes and insights from the in-depth interviews with stakeholders to uncover the nuanced challenges, perceptions and experiences related to oral health care among OTP clients. We identified several interconnected themes, including client behaviour and traits, the impact of addiction on oral health care, psychological barriers and access issues. These interconnections underscore the complex nature of the challenges OTP clients face in managing their oral health. By synthesising these insights, we highlight the common concerns shared by OTP clients, OTP clinicians and oral health clinicians, providing a comprehensive view of the obstacles OTP clients face in obtaining oral health care and identifying key areas for improvement. For ease of reading, grammatical inconsistencies were corrected but no substantial changes were made.
A significant theme that emerged is the lack of understanding regarding health prioritisation among OTP clients. An OTP clinician highlights this, stating, ‘I think there is a lack of understanding about how much oral health impacts their general health’ (female 3). Another OTP clinician reinforces this point, noting:
They don’t think about oral health as much as physical health, they go to the doctor when they don’t feel well but may not think the same about going to the dentist. (female 4)
This indicates a widespread tendency among clients to prioritise physical health over oral health due to low health literacy and awareness.
Episodic and crisis-driven care is another critical issue. Clients seek treatment only when they are in severe pain, neglecting regular follow-up and comprehensive care. An oral health clinician describes this pattern: ‘Very episodic care, just relief of pain, it’s hard for them to come back to finish treatment’ (male 1). Another oral health clinician echoes this challenge, saying, ‘It is a struggle just getting them to come back regularly for their appointments and they fail to come back once, they fall off from the system’ (female 5). An OTP clinician shares, ‘Oral health care is low on these people’s priorities, to the point where unless they are in agony, they’re unlikely to seek care’ (female 2). An OTP client also reflects this reality, sharing, ‘Oral health hasn’t been my top priority because I am homeless at the moment’ (male 3). These factors collectively result in a cycle of intermittent care and unresolved oral health issues.
The social environment factors significantly influence clients’ ability to manage their oral health. One OTP client describes the impact of personal circumstances:
I am trying to manage like just having a roof over my head with all these family arguments going on. It is a bit messy in my life and I cannot think about anything else now. (male 7)
This highlights how complex living situations and social conflicts divert attention from health needs. Conversely, stable social support can have a positive impact, as noted by another client who attended her dental appointments, ‘I have a stable boyfriend now and I now have a stable part-time job that helps me to focus on my health’ (female 9) These narratives illustrate how both adverse and supportive social environments can shape health behaviours and priorities among OTP clients.
These issues highlight the importance of health literacy, awareness and consistent support in shaping oral health outcomes. Social determinants also play a role in influencing clients’ ability to manage their oral health effectively.
Addiction profoundly affects individuals in ways that extend beyond substance use, impacting their ability to prioritise self-care, including oral health. As expressed by one OTP client, ‘Being in addiction, things aren’t like what normal people do. I kind of neglect looking after myself’ (male 4). This neglect often stems from addiction’s overwhelming demands, where managing immediate survival and substance dependence take precedence over preventive health behaviours. Another OTP client admitted, ‘Everything is not a priority at this stage; on top of this, I picked up alcohol and it just savagely got me’ (male 6), illustrating how substance use can become a coping mechanism, overshadowing concerns about long-term health consequences such as oral hygiene.
Oral health clinicians have observed a concerning prevalence of dental caries and noticeable calculus deposits among OTP clients, indicating suboptimal oral hygiene practices and potential neglect. One oral health clinician noted, ‘Their oral hygiene is very poor with so much dental caries. They don’t care about what’s happening in the back teeth’ (female 5). This reflects the impact of drug use, including opioid treatments, on oral health. This poor oral health is compounded by unstable living conditions as an OTP clinician pointed out, ‘Many of these clients have poor oral hygiene because they’re not in a stable living situation where they can regularly brush their teeth or have access to dental supplies’ (female 1). Such instability undermines consistent oral care practices, contributing to deteriorating oral health.
Financial constraints further exacerbate oral health neglect. An OTP client revealed:
I am collecting bottles to make ends meet because, by the time I pay rent, I have $30 a week for groceries, so I cannot afford to lose any time for anything else. (female 8)
This highlights how immediate survival needs overshadow dental care. Financial instability also hampers access to regular dental services, emphasising the difficult choices individuals face due to limited resources.
Medications like methadone, essential in OTPs, pose additional challenges to oral health care. As noted by an oral health clinician:
Methadone sort of numbs the pain so they’re not going to be mindful of things like tooth decay until maybe much later on when it might be too late to fix. (male 6)
This numbing effect delays the recognition of dental issues, allowing them to progress unchecked.
Competing priorities such as mental health challenges or domestic issues further marginalise oral health care. An oral health clinician highlighted:
A lot of other things going on in their lives, mental health or domestic violence or something else happening ... oral health seems like at the bottom of their list they need to get done. (female 4)
This complex interplay of addiction, socioeconomic factors and broader life challenges collectively undermine efforts to maintain good oral hygiene among OTP clients.
These findings highlight the multifaceted barriers to maintaining good oral hygiene within the context of opioid treatment. These barriers underscore the complexity of addressing oral health in this population, as they continue to impede consistent care and contribute to the worsening of oral health outcomes.
Psychological barriers play a significant role in preventing clients within the OTP from seeking and maintaining oral health care. A common barrier is dental anxiety, as illustrated by an OTP client who says, ‘I am scared of the dentist, very weird, that’s something with my nerves that makes me want to throw up’ (male 6), reflecting a deep-seated fear that deters individuals from attending dental appointments. Another client shares discomfort with dental procedures, noting, ‘I cannot explain it, it’s just the noise of the drill, don’t like the sensation’ (male 7), highlighting how sensory discomfort contributes to dental anxiety.
Psychological distress during dental visits also poses a significant barrier. One OTP client describes, ‘I get anxious by just waiting, sometimes they say half an hour but it feels much longer’ (female 2), demonstrating how waiting anxiety exacerbates reluctance to seek care. Another client mentions, ‘I feel almost like having a panic attack while waiting’ (female 6), indicating severe psychological distress that can deter individuals from attending necessary appointments. Additionally, the fear of receiving bad news creates psychological barriers to seeking dental care. An OTP clinician observes, ‘I think he’s just frightened to go and see anyone in case the news is really bad’ (female 2), reflecting how the anticipation of negative outcomes leads to avoidance of dental visits.
Moreover, procrastination and lack of motivation further impede oral health care among OTP clients. One oral health clinician notes, ‘It’s like they put it into the hard basket and put it off for another day, they don’t want to think about it’ (female 3), indicating a tendency to delay dental care. Another OTP clinician adds, ‘Because of their lack of motivation, they find it difficult to prioritise self-care or may be it is forgetfulness’ (female 6), highlighting how motivation issues and forgetfulness hinder clients from prioritising oral health.
In summary, these psychological barriers significantly impact OTP clients’ willingness and ability to seek oral health care. These factors contribute to the difficulties clients face in accessing and maintaining dental care.
Access barriers pose significant challenges for OTP clients in obtaining necessary oral health care. One prominent barrier is the administrative burden associated with accessing dental services, as highlighted by an OTP clinician who explains:
They cannot go to the dental clinic in person: they have to call the Call centre [Oral Health Service Contact Centre]. However, they won’t do it because it’s just too much work to talk to another person. (female 1)
This complexity discourages clients from seeking necessary care due to the daunting process involved.
System barriers also critically limit clients’ ability to receive dental care. An OTP client describes his challenge:
My difficulty is I lost my phone, but when I go along there and don’t have a phone number for them, they’ll say come back when you got a phone number. (male 5)
This shows how the lack of a phone number hinders access to services, adding another layer of difficulty for clients already facing significant hurdles. Furthermore, an OTP clinician points out, ‘We have to address those who do not have a place to live or do not have a phone; it’s hard as they slip through the cracks’ (female 2). This emphasises how unstable living conditions and a lack of contact result in missed opportunities for essential care.
In general, access barriers such as administrative burdens and system limitations significantly impede OTP clients’ access to oral health care. These challenges, compounded by unstable living conditions, highlight the difficulties clients face in navigating the existing systems to secure necessary dental services.
Strategies to improve oral health access – perspectives from stakeholders
In the semi-structured interviews, oral health and OTP clinicians proposed strategies for empowering OTP clients to manage their oral health and adhere to dental appointments, while OTP clients shared the support they need to access oral care. These inquiries aimed to gather diverse perspectives on improving oral health outcomes for OTP clients. The strategies revealed several key themes addressing OTP clients’ challenges and feedback, including practical solutions for improving engagement, overcoming access barriers and supporting regular dental visits. Appendix 1 shows the theme map and recommendations.
The proposed strategy aims to address the pressing need for integrating oral health into OTPs by focusing on holistic care and establishing a collaborative support system. Central to this strategy is the incorporation of oral health evaluation into the initial assessment process for clients entering opioid treatment. This proactive approach not only identifies and addresses oral health concerns early but also promotes better overall well-being for clients by integrating oral health into their overall treatment journey.
The strategy also emphasises establishing a collaborative support system between the OTP and oral health clinicians. This system will include regular communication channels and a well-defined referral pathway for addressing oral health concerns and providing interventions. Feedback from OTP clients highlights a desire for a streamlined dental appointment process and a collaborative support system that caters to their needs and preferences. By implementing these strategies, the proposal aims to enhance the client experience and improve adherence to oral health care, thereby contributing to better health outcomes for individuals undergoing opioid treatment.
Improved awareness and education are highlighted as key recommendations by both OTP and oral health clinicians. The proposed initiatives focus on developing educational materials such as posters and pamphlets that address the specific oral health needs of OTP clients. These materials will cover essential topics, including basic oral hygiene practices, the importance of regular dental check-ups and strategies for managing oral health during opioid treatment, such as dealing with dry mouth symptoms and addressing opioid-related dental complications.
The primary aim of these educational materials is to promote preventive measures and raise awareness about oral health risks associated with opioid use, such as increased susceptibility to dental caries, gum disease and oral infections. Displaying these materials in the OTP clinic will remind clients of the importance of maintaining oral health and encourage them to integrate oral care into their overall well-being. Evidence from previous studies supports the effectiveness of posters as messaging tools in healthcare settings (Ilic and Rowe 2013).
Collaborative efforts between oral health clinicians and OTP clinicians are crucial for providing comprehensive education. OTP clinicians will focus on the importance of seeking oral health care, while oral health clinicians will emphasise the necessity of completing treatments to prevent deterioration of their oral health. This coordinated approach ensures that clients receive consistent, targeted oral health education that addresses their needs and concerns.
Enhancing accessibility and implementing flexible scheduling are essential strategies for facilitating oral health care for OTP clients. Key recommendations include offering more flexible scheduling options for dental appointments to accommodate the unique challenges OTP clients face. For instance, allowing clients to schedule appointments directly at the dental clinic and establishing a consistent weekly time slot specifically for OTP clients will help manage their schedules and ensure they do not miss appointments. This approach aims to promote consistency in dental care and encourage clients to adhere to dental appointments.
To further support clients, OTP clinicians will be provided with appointment information to remind clients about their upcoming visits. This support addresses clients’ needs for appointment reminders and acknowledges the challenges in navigating the healthcare system, such as managing appointments without a phone.
Additionally, incorporating support or peer workers into the dental care process significantly benefits OTP clients. Support workers can assist with scheduling appointments, accompanying clients to dental visits and providing emotional support to reduce anxiety associated with dental procedures.
The collective recommendation underscores the significance of a holistic and integrated approach to oral health care for OTP clients. By focusing on accessibility, flexible scheduling and robust support systems, this approach seeks to reduce barriers to oral health services, promote treatment adherence and improve overall health outcomes for OTP clients.
Discussion
This qualitative enquiry provides unique insights from oral health clinicians, OTP clinicians and OTP clients within the Australian context. A previous study (Cheah et al. 2017) conducted in 2014 in Australia revealed insights from inpatients at a drug and alcohol treatment facility concerning oral health practices and access to dental services. Similarly, a 2022 study in Norway (Åstrøm et al. 2022) focused on reasons for non-dental attendance among clients with substance use disorders. While both studies recommended the need for closer collaboration between oral health and OTPs, they lacked a comprehensive framework for implementing this collaboration.
Subsequent research in Norway (Carlsen et al. 2022) investigated facilitators for accessing oral health services for OTP clients but did not fully address the integration of oral health within the OTP context. In contrast, our study provides a comprehensive examination of oral health issues within the OTP framework, encompassing holistic care integration and a collaborative support system, increased education and awareness, as well as enhanced accessibility and flexible scheduling. Our findings extend beyond the facilitation of service use, addressing key components necessary for effective oral health integration within OTPs.
A recent scoping review (Poudel et al. 2023) in Australia identified a gap in research regarding the lack of evidence of effective interventions for integrating oral health care into alcohol and other drugs treatment. Our study presents the first proposal for this integration in the Australian context, making a significant contribution to addressing oral health challenges comprehensively within OTPs. This approach promotes breaking down the barriers between oral health services and drug and alcohol services, creating opportunities for oral health professionals to become more involved and share responsibility in meeting the unmet oral health needs of this vulnerable population.
However, to fully contextualise the findings from this study, it is important to acknowledge the systemic challenges within the public dental service that may hinder OTP clients’ access to oral care. The public dental service in NSW enforces eligibility criteria that can limit access, along with long waiting periods, scheduling difficulties and unclear referral pathways. These systemic barriers contribute to the dental neglect observed in this vulnerable population, who already face significant challenges accessing appropriate care. Addressing these challenges is essential if we are to make meaningful progress toward integrating oral health within OTPs.
The concept of integrating oral health into primary health care is not new and has gained global recognition. This was evident at the 7th World Health Organization (WHO) Global Conference on Health Promotion – Towards Integration of Oral Health in 2009 (Petersen and Kwan 2010), where the WHO supported the concept of integrating oral health into the healthcare system. The recent Landmark global strategy on oral health adopted at World Health Assembly 75 (WHO 2022) further emphasised the importance of integrating oral health with primary health care, aligning with our study’s objectives.
While our study represents a pilot initiative within the OTP, its significance lies in paving the way for broader health integration efforts. It is crucial to pilot this approach not only within OTPs but also with private opioid treatment prescribers and other drug and alcohol treatment settings. Standardising this integration across various care settings has the potential to contribute to improved health outcomes and quality of life for individuals undergoing opioid treatment. By ensuring consistent and comprehensive oral healthcare delivery, we aim to address a critical aspect of their overall well-being.
Limitations
A significant limitation of this study is related to the generalisability of findings, given the variability of OTPs nationally and internationally. This variability limits the broader applicability of our results across different settings, whether private or public health contexts. Additionally, selection biases may be present, where more motivated participants are potentially overrepresented, which could skew the findings.
The reliance on self-reported data can introduce potential recall biases. Participants’ subjective accounts of their experiences and barriers related to oral health care may not always provide a fully accurate description due to inherent biases.
Despite these limitations, our findings offer valuable insights as they were derived from interviews conducted with three distinct groups of stakeholders. Therefore, our research should interest policymakers, healthcare providers and researchers aiming to enhance the integration of oral health care into OTPs and improve client outcomes.
Conclusion
This study provides compelling evidence regarding the numerous challenges encountered by OTP clients, offering a nuanced understanding of their experiences. Insights gathered from oral health clinicians, OTP clinicians and OTP clients reveal the multi-faceted nature of these challenges, highlighting their interconnectedness within the OTP context. Addressing these challenges in isolation is insufficient; instead, a comprehensive approach and ongoing support through integrated strategies are essential. This underscores the imperative for holistic solutions to effectively meet the oral health needs of individuals undergoing opioid treatment.
Data availability
The data that support this study will be shared upon reasonable request to the corresponding author.
Acknowledgements
The authors extend their heartfelt appreciation to Velda Sturt and Dr Megan Ghaffari from the Oral Health Executive Unit for their invaluable support. We also express our sincere gratitude to Andrea Taylor from the Mental Health and Drug and Alcohol Services, Northern Sydney Local Health District. Additionally, we thank the oral health clinicians, OTP clinicians and OTP clients who participated in the interviews for this study. Your insights and collaboration were instrumental in the completion of this research.
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