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Background: In response to the dual public health emergencies of COVID-19 and the overdose crisis, the Government of British Columbia (BC) introduced risk mitigation prescribing, or prescribed safer supply. In the context of colonialism and racism, Indigenous people are disproportionately impacted by substance use harms and experience significant barriers to receiving care, particularly those living in rural and remote communities. As part of a larger provincial evaluation, we sought to assess the implementation of risk mitigation prescribing as experienced by Indigenous people who use drugs (IPWUD) in Northern BC., Methods: We used the Consolidated Framework for Implementation Research and the First Nations Perspective on Health and Wellness as conceptual frameworks to guide the study. In partnership with people with lived/living experience, we conducted 20 qualitative interviews with IPWUD. Data were supplemented by four interviews with health planners and analyzed thematically., Results: Participants reported limited implementation of risk mitigation prescribing in Northern BC, with unique regional challenges and innovative facilitators to access. Analysis of supplementary health planner data was consistent with the experiences of IPWUD and together provided a comprehensive picture of implementation in Northern BC. Four themes emerged: 1) Northern socio-politico-cultural barriers to implementation (outer setting), 2) rural and remote healthcare delivery challenges (inner setting), 3) adaptability of risk mitigation prescribing on Northern wellness (intervention characteristics), and 4) Northern ingenuity, relationality and champions facilitating access (implementation process)., Conclusions: Implementation and access to risk mitigation prescribing in Northern BC was limited, with region-specific applicability challenges and a health service delivery model that was not able to sufficiently meet the unique service needs of IPWUD. Demonstrating Northern ingenuity, peer groups, harm reduction community champions, and telehealth services were identified as stopgap measures that promoted access and reduced inequitable implementation within the region., Competing Interests: Declaration of competing interest There are no conflicts to declare., (Copyright © 2024. Published by Elsevier B.V.)