Internationally, compliance with program rules and the earning of privileges is common to cultural understandings of treatment for opioid use disorder (OUD). One long standing and striking example of such a culture is methadone maintenance treatment within US opioid treatment programs. This compliance-based model, established by a mix of regulation and culture, has shaped decades of clinical practice and policy within the US-and it is precisely what new federal rules in the US now aim to challenge. The opportunity now is to prioritize programs that expand or embed meaningful participation among people who use opioids in individual, organizational, and policy decisions, and we believe this challenge extends to other healthcare settings. In this commentary, we define meaningful participation by people who use opioids, outline why meaningful participation by people who use opioids is essential, examine barriers to adoption, and propose initial strategies to integrate it effectively into individual healthcare, organizational, and policy decisions. Meaningful participation means that people who use opioids are recognized as the experts in their own lives, needs and preferences, have input in decisions, and this input has impact. Barriers to participation of people who use opioids include gaps in perceptions of participation between people who use opioids and healthcare professionals; cultural inertia; social vulnerability of people who use opioids; assumptions that people who use opioids are not rational decision-makers; imbalances in social standing and power; restrictive institutional policies; and survivorship bias among those who participate. We review examples in Canada, Australia, and the US to illustrate both the promise and challenges to institutionalizing participation of people who use drugs. Strategies to integrate participation by people who use opioids into individual healthcare, organization, and policies decisions are reviewed.