Supervised Injectable Opioid Treatment (SIOT) targets people experiencing opioid dependence who have not benefited from existing treatments. In this population, SIOT has been demonstrated to be efficacious and effective, yet this modality of treatment has only been taken up in a few countries. In this commentary we describe the socio-political context and history to the recent establishment of an implementation trial of injectable hydromorphone in Sydney, Australia. These factors influenced choices about the trial design, including integration of SIOT within an existing opioid agonist treatment program, time-limited treatment, and an assessment of feasibility, acceptability, safety and cost. While all new drug policy initiatives occur within a specific socio-political and historical context, we hope this commentary provides reflections for other places considering the introduction of SIOT.