Background: Opioid agonist treatment (OAT) in New South Wales Australia involves prescribed consumption of methadone or buprenorphine formulations and is commonly accessed through community pharmacies. People with a history of drug use often feel mistrusted and this can deter them from starting or staying in treatment. This study sought pharmacist and consumer perspectives to understand how treatment engagement can be best supported.

Objective: To explore consumer and pharmacist experiences of OAT services, identifying the social and structural elements that enhance or impair treatment and professional satisfaction and analyzing how these are influenced by trust.

Methods: Semi-structured interviews were conducted in 2021–2022 with 10 pharmacists and 15 consumers. Transcripts were analyzed using a realist thematic approach.

Results: 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. OAT consumers felt more inclusion when pharmacy practices did not differentiate or demean them and when pharmacists communicated in a personable and caring manner, and pharmacists recognized these aspects as contributing to greater professional fulfillment and less service problems.

Conclusion: OAT delivery in community pharmacies provides opportunities for greater social inclusion, particularly when trust and fairness are demonstrated.