Objective: This study explored the delivery of opioid maintenance treatment (OMT) from a specialist program in rural and remote New South Wales (NSW), focusing on the viability of the model and strategies for its improvement. Design: Program evaluation examining configuration and delivery, client characteristics and trends in demand, using policy documents, service data and stakeholder consultations (n=28). Setting: The Greater Western Area Health Service, a sparsely populated and large geographic area in NSW. Results: There were four service hubs or primary sites. Three sites were co-located with hospitals and one within community health, with all sites providing assessment, prescribing, dispensing and limited case management. Staff were mainly trained nurses, while prescribers were visiting specialists or sessional GPs. There was minimal OMT provision by community prescribers and dispensers. In 2009, there were 638 clients. They were younger on average than those in OMT across Australia. The most common principal drug of concern was heroin (37-85 of clients), while around one-fifth of clients identified prescription opioids (18-23 ). There was a substantial increase in OMT provision between 2006 and 2009 at three program sites. Staff at the sites had limited capacity to engage primary health services and thus reduce their client load. Conclusions: Findings indicate the need to adjust funding to account for increased demand for OMT and to establish a financial incentive for GP prescribers. Dedicated resourcing is needed for a capacity building role to support the uptake of prescribing and dispensing in community services.