Opioid agonist therapy was introduced in Canada in 1959 with the use of methadone for the treatment of opioid dependence. The regulation of methadone was the responsibility of Health Canada until 1995, when oversight was transferred to the provincial health systems. During the more than 20 years since the federal health authority transferred oversight of methadone to the provincial level, methadone programming has evolved differently in every province. The landscape of opioid dependence treatment is varied across the country, with generally increasing treatment capacity in all provinces and dramatic increases in some. Each province has an independent methadone program with differing policies, contingency management strategies, laboratory monitoring policies, and delivery methods. Treatment options have increased, with buprenorphine- and heroin-assisted treatment becoming available to limited degrees. Despite this, access remains a challenge in many parts of the country (particularly rural and remote areas) because the demand for treatment has increased even more rapidly than the capacity. Although treatment access remains a priority in many jurisdictions, there is also a need to attend to treatment quality as treatment access expands, including integration with addiction counselling, primary care, and mental health care. As well, coordinated monitoring and reporting of treatment need, quality, and delivery are required; implementing a national policy to promote planning would have tremendous value.