Methadone access doesn’t need to be all or nothing to save lives
In 2024, more than 60,000 people died of an opioid overdose in the United States. While this is a dramatic decline compared to recent years, there is still considerable room for improvement. In particular, better access to methadone—a time-tested treatment for opioid use disorder (OUD)—would prevent many of these deaths. But the medication remains overregulated, and attempts to unshackle it are bogged down by the argument that any reduction in regulation would lead to a dangerous free-for-all. Meanwhile, people continue to die.
There is a better option: We could combine state and federal policy changes to create a system that promotes competition in alignment with President Donald J. Trump’s Feb. 19 Executive Order titled “Ensuring Lawful Governance and Implementing the President’s ‘Department of Government Efficiency’ Deregulatory Initiative,” supports provider autonomy, and fosters consumer choice for people suffering from OUD.
Compared to other opioids like heroin or fentanyl, methadone is slow-acting—meaning that patients find stability rather than a euphoric rush. And because it is long-lasting, it staves off cravings and prevents withdrawals. This enables people taking the medication for OUD to focus on living their lives rather than hustling for their next dose. Methadone treatment cuts illicit drug use and reduces overdose risk by 59 to 80 percent compared to non-medication treatments. People taking methadone for OUD are also less likely to engage in criminal activity. Unfortunately, despite decades of data demonstrating methadone’s lifesaving capacity for the treatment of OUD, the medication is only available at special clinics called opioid treatment programs (OTPs).
Proponents of the OTP-only system say it keeps communities and patients safer by reducing medication misuse and the sale or gifting of diverted doses into the illicit supply. Challengers argue that the regulations do little to protect anybody, noting that diversion is unusual and typically results from inadequate access to appropriate treatment. Furthermore, OTP patients face a number of system-related barriers that hinder their recovery and encourage them to forgo methadone for illicit alternatives. Because this system is the only way to access methadone for OUD, it inherently restricts competition and facilitates regulatory overreach into the patient-provider relationship.
Arguably, the biggest issue is that it is difficult for people with OUD to get take-home methadone doses. Instead, many people must visit their OTP as frequently as six days per week to take their medication under supervision. Lengthy wait times and commutes (80 percent of U.S. counties lack an OTP, and commutes average 45 minutes or more each way) associated with these visits dramatically interfere with many people’s ability to hold a job or participate in important family events—key aspects of life that can promote stability and support recovery. Despite recent federal efforts to reduce barriers to take-home doses, states and clinics still often restrict them, even for individuals who are doing well.
Receiving care from an OTP can also be cost-prohibitive. Although methadone saves tens of thousands of dollars over the lifetime of a single patient, it can be pricey to access. Medicaid is generally the most comprehensive insurance provider for individuals living with OUD, but some state programs still exclude medication-based treatments from coverage. It is common among private insurance providers to refuse to cover methadone through the OTP system, even if other medications like buprenorphine or naltrexone (both of which are less effective for many patients) are covered in an office setting. Out-of-pocket payments vary for individuals who are uninsured or underinsured; however, the average is about $300 to $500 per month. On top of the direct costs of medication, counseling, and urine screenings, many OTP patients must add transportation and child care to their list of treatment-related expenses.
Those individuals who are able to access and afford OTPs may still find the programs dehumanizing and depersonalized. For example, many OTPs mandate counseling on a set schedule rather than according to individual needs or provider recommendations. Some clinics require random and observed urine drug tests, even though these stigmatizing practices are associated with the discontinuation of treatment rather than improved recovery outcomes. In fact, many OTPs actively terminate treatment for any illicit drug use—a practice akin to physicians refusing to prescribe insulin to patients with diabetes who consume unhealthy food.
Although some of these problems occur at the individual clinic level, some are actively mandated or facilitated via policy. A problematic interpretation of federal law limits methadone for OUD to the OTP system, and once there, most states regulate OTPs above and beyond federal guidelines. Some states, for example, make it difficult or impossible for communities to establish new OTPs, tightening the already monopolistic system in which patients have few options. And while the federal government recently reduced some of its barriers to take-home medications, these improvements are meaningless unless states change their laws as well.
Nonetheless, policy conversations often devolve into calls for either maintaining the status quo of overregulation or immediately eliminating OTPs and slashing all legislative and regulatory safeguards on methadone. Meanwhile, every day that lawmakers and advocates battle from these two extremes, approximately 165 Americans lose their lives to an opioid overdose.
A better solution would be to build a system via state and federal policy changes that allow methadone access via OTPs and qualified healthcare providers, such as permitting addiction specialist physicians to prescribe methadone and pharmacies to dispense it. This would “expand availability to an additional 12% of urban, 18% of suburban, and 16% of rural tracts.” And by providing a competitive, expert physician-driven alternative to OTPs, it would align with the Trump administration’s recent efforts at promoting the best readings of underlying statutes and reducing regulations that interfere with competition. It would also lead to more flexibility, more provider autonomy, and more options, thereby ensuring truly patient-centered care.
States should reconfigure their OTP regulations to align with federal guidelines in order to improve competition and quality care within the existing system—the structure of which does benefit some people suffering from OUD.
Despite fears that expanding methadone access would increase diversion and place communities at risk, these outcomes are highly unlikely. Indeed, most patients do not require or benefit from supervised dosing. Nonetheless, there are options for patients who prefer the structure of supervised dosing or whose providers feel it would help. Pharmacy programs allow patients who may struggle to store their medication to visit a local pharmacy to take their dose under supervision. Technological innovations like telehealth, asynchronous video, and electronically locking storage boxes may benefit individuals who are less stable in their recovery.
The overdose crisis in the United States requires realistic, practical solutions—not all-or-nothing rhetoric. Methadone is a proven, lifesaving medication that also benefits society; however, excessive state and federal regulation continues to hinder progress.