Opioid Use Disorder Treatment Options: Buprenorphine, Methadone and Naltrexone

Opioid use disorder (OUD) is treated most effectively with medication: buprenorphine, methadone or extended-release naltrexone, usually alongside counseling and support. Methadone and buprenorphine are associated with large reductions in overdose and all-cause death while people stay in treatment. Since 2023, any clinician with a DEA registration that includes Schedule III can prescribe buprenorphine for OUD where state law allows, while methadone for OUD is still dispensed only through certified opioid treatment programs.

This guide compares the three medications, the newer long-acting injections, what changed in the law, the role of naloxone, and how to find care quickly, including through the federal locator at FindTreatment.gov.

Why medication is the center of OUD treatment

OUD changes how the brain responds to opioids, and withdrawal and craving drive people back to use even when they badly want to stop. Medications for OUD (often called MOUD) work by occupying or blocking the receptors opioids act on, which reduces craving and withdrawal or blocks the high.

The strongest evidence concerns survival. A meta-analysis of cohort studies covering more than 138,000 people found all-cause mortality of 11.3 per 1,000 person-years in methadone treatment versus 36.1 out of treatment, and 4.3 versus 9.5 for buprenorphine. Overdose deaths followed the same pattern. The same analysis identified two high-risk windows: the first weeks of starting methadone, and the period right after leaving treatment with either medication. The authors note that these observational comparisons may be affected by confounding.

That second window is why stopping medication should always be planned with the prescriber. Tolerance falls quickly, and a return to previous doses of opioids can be fatal. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.

The three medications compared

Buprenorphine

Buprenorphine is a partial agonist: it activates opioid receptors less fully than full agonists such as methadone, which is how it eases withdrawal and craving. Most people take it as a daily sublingual film or tablet, often combined with naloxone (as in Suboxone), which is indicated for treatment of opioid dependence as part of a complete plan that includes counseling and psychosocial support.

What changed in 2023

Until 2023, clinicians needed a special federal waiver, often called the X-waiver, to prescribe buprenorphine for OUD, and their patient numbers were capped. Section 1262 of the Consolidated Appropriations Act, 2023 removed the waiver requirement, and SAMHSA states that practitioners with a DEA registration that includes Schedule III authority may now prescribe buprenorphine for OUD if permitted by state law, with no patient caps. SAMHSA notes that the law does not override state laws.

In practice, that means a primary care clinician, psychiatrist or nurse practitioner can prescribe it without separate federal certification, although many still choose not to. If one clinician declines, ask for a referral rather than assuming the medication is unavailable.

Telehealth prescribing

Federal rules on prescribing controlled medications by telemedicine have changed several times. A rule specific to buprenorphine telemedicine prescribing took effect on December 31, 2025, and the DEA and HHS separately extended pandemic-era telemedicine flexibilities through December 31, 2026. Because these rules are still evolving and state law also applies, ask any telehealth prescriber how they handle the first prescription and whether an in-person visit will be required later. The sibling guide on telehealth vs in-person care covers the broader trade-offs.

Methadone and opioid treatment programs

Methadone is a full opioid agonist and one of the longest-established treatments for OUD. SAMHSA states that methadone for OUD can only be dispensed through a SAMHSA-certified opioid treatment program (OTP), and that after a period of stability, patients may be allowed to take doses at home between visits. The methadone label notes that methadone products used to treat opioid addiction may be dispensed only by certified opioid treatment programs under 42 CFR 8.12. SAMHSA revised those federal OTP regulations (42 CFR Part 8) in a final rule that took effect on April 2, 2024, with a compliance date of October 2, 2024, aiming to reduce barriers to care; state rules also shape how each program applies them.

Methadone is often considered for people who have not stabilized on buprenorphine or who want the structure of a clinic, and OTPs bundle counseling and other services on site. The trade-off is structure: frequent clinic visits, particularly early on.

Its label carries boxed warnings, including life-threatening respiratory depression especially during initiation and dose increases, fatal accidental ingestion by children, dangerous interactions with benzodiazepines and other depressants including alcohol, and QT prolongation that can cause serious arrhythmias. SAMHSA advises never using more than prescribed, not drinking alcohol on methadone, and storing it out of reach of children.

Extended-release naltrexone

Vivitrol, a monthly injection of naltrexone, is indicated to prevent relapse to opioid dependence after detoxification, as part of a program with psychosocial support. It blocks opioid receptors rather than activating them, so it does not relieve withdrawal the way buprenorphine and methadone do. The catch is the start: the label recommends at least 7 to 10 days free of opioids beforehand to avoid severe precipitated withdrawal.

In the X:BOT trial, which compared it with buprenorphine-naloxone, only 72% of people assigned to extended-release naltrexone successfully started it, and most of the excess relapse in that group came from those who never got through induction. Among people who did start, relapse rates over 24 weeks were similar between the two medications. The label warns that after treatment, tolerance is reduced and people are vulnerable to potentially fatal overdose at the end of a dosing interval, after a missed dose, or after stopping.

Naltrexone may suit people who have already completed withdrawal, such as after a hospital stay or incarceration, or whose work or preferences rule out an agonist. The same medication also treats alcohol use disorder; see alcohol use disorder medications compared.

Long-acting buprenorphine injections

Two injectable buprenorphine products are approved for moderate to severe OUD in people who have started treatment with a dose of transmucosal buprenorphine or are already on buprenorphine:

Injectables remove daily dosing and the risk of a missed or diverted dose, which some people value highly. Availability depends on whether a clinic or pharmacy is certified in the REMS program, and coverage varies by insurance plan.

Choosing among them

There is no single best medication for everyone. The decision usually turns on a few practical questions, which a prescriber or program works through with you:

Worked example: an adult who has been using illicit opioids daily, works full time and has stable housing might start buprenorphine with an office-based prescriber and later move to a monthly injection to avoid daily dosing. A person who has just completed inpatient withdrawal and does not want an agonist medication might choose extended-release naltrexone before leaving, to avoid the vulnerable window when tolerance has fallen. Someone who has struggled to stay on buprenorphine might do better with the daily contact of a methadone program. These are illustrations, not recommendations.

What the evidence does not show: that one medication suits everyone, or that a fixed treatment length is safe for all. The mortality data come from observational studies, and the strongest comparative trial of naltrexone and buprenorphine shows that getting started is the main hurdle for naltrexone. Switching medications when the first is not working is a normal part of care, not a failure.

Naloxone: keep it on hand

Naloxone reverses opioid overdose. In March 2023, the FDA approved Narcan 4 mg naloxone nasal spray for over-the-counter use, so it can be sold without a prescription in drugstores, grocery stores and other retailers. The labels for both injectable buprenorphine and injectable naltrexone advise clinicians to strongly consider prescribing or recommending an overdose reversal agent.

Anyone in treatment for OUD, and anyone who lives with or cares for them, should know where naloxone is and how to use it. If you suspect an overdose, call 911 as well as giving naloxone.

Counseling, levels of care and special situations

The buprenorphine labels call for counseling and psychosocial support as part of the treatment plan. Counseling helps with triggers, relationships, trauma, work and co-occurring depression or anxiety. It should not be a precondition that delays starting medication.

Most people start MOUD as outpatients. Some need more structure: an intensive outpatient program, a residential program, or hospital-based withdrawal management. The sibling guide to levels of mental health care explains each setting.

• Pregnancy: methadone's label describes neonatal opioid withdrawal syndrome as an expected and treatable outcome of use during pregnancy, to be planned for with the care team. Stopping MOUD abruptly in pregnancy carries its own risks; see psychiatric medications during pregnancy.
• Pain: people on buprenorphine, methadone or naltrexone need a plan for surgery or acute pain. Tell every clinician which medication you take.
• Alcohol and sedatives: combining opioid medications with benzodiazepines or alcohol raises the risk of fatal breathing problems.

How to find treatment now

1. Search FindTreatment.gov, the federal locator, filtering for buprenorphine, methadone or naltrexone.
2. Call the SAMHSA National Helpline at 1-800-662-4357, a free, confidential, 24/7 referral and information service in English and Spanish.
3. Ask your primary care clinician whether they prescribe buprenorphine, or can refer you to someone who does.
4. If someone has overdosed or is in immediate danger, call 911. For other urgent situations, the guide to emergency vs urgent care in New York City explains where to go.
5. If a loved one is not ready, the guide on helping someone who refuses help has practical steps, and naloxone at home is a first one.

Questions to ask a prescriber or program

• Which medications do you offer, and can I switch if the first one does not suit me?
• How will we start: in the office, at home, or after a period without opioids?
• How often are visits and drug tests, and what happens if I have a lapse?
• Do you offer injectable options, and does my insurance cover them?
• Do you provide counseling, or will you coordinate with a therapist?
• Will you prescribe naloxone for me and my household?

Where this practice fits

The site's substance use disorders page and addiction treatment page describe the practice's integrative approach. The practice's ongoing care includes psychiatric evaluation and medication management, psychotherapy including CBT and DBT, and coaching. Its published information does not state whether its prescribers provide buprenorphine, methadone or naltrexone for OUD, so if you need medication for opioid use disorder, ask on the free discovery call and use FindTreatment.gov or the National Helpline so starting treatment is not delayed. The guide on addiction psychiatrist vs general psychiatrist explains when a specialist is the better first step. For more in this series, return to the Choosing Psychiatric Care guide.

Frequently asked questions

Is taking buprenorphine or methadone just replacing one addiction with another?

No. Addiction involves loss of control and harm. Taking a prescribed, steady dose of a long-acting medication under medical care stabilizes brain chemistry, reduces craving and is associated with much lower death rates. Physical dependence on a medication is not the same as addiction.

How long do people stay on medication for opioid use disorder?

There is no set end date. Many people take it for years. Because overdose risk rises after leaving treatment, any decision to taper should be made slowly and with the prescriber.

Do I still need a doctor with an X-waiver to get buprenorphine?

No. The federal waiver requirement was removed by the Consolidated Appropriations Act, 2023. Any practitioner with a DEA registration that includes Schedule III can prescribe buprenorphine for OUD if state law permits.

Can I get methadone from my regular doctor's office?

Not for opioid use disorder. Methadone for OUD is dispensed only through SAMHSA-certified opioid treatment programs, which you can find through FindTreatment.gov.

Do I need a prescription for naloxone?

Not for Narcan 4 mg nasal spray, which the FDA approved for over-the-counter sale in 2023. Other naloxone products may still require a prescription, and many pharmacies and community programs provide it.

Does insurance cover medication for opioid use disorder?

Coverage varies by plan and by medication, and injectable forms often need prior authorization. Ask your insurer which medications and programs are covered before you start, and ask the program or prescriber to help with any authorization.

Sources

1. Waiver Elimination (MAT Act). Substance Abuse and Mental Health Services Administration (SAMHSA), 2023. samhsa.gov
2. Methadone. Substance Abuse and Mental Health Services Administration (SAMHSA), 2025. samhsa.gov
3. Methadone hydrochloride tablets prescribing information. DailyMed, U.S. National Library of Medicine, 2026. dailymed.nlm.nih.gov
4. Suboxone (buprenorphine and naloxone) sublingual film prescribing information. Indivior / DailyMed, U.S. National Library of Medicine, 2025. dailymed.nlm.nih.gov
5. Sublocade (buprenorphine extended-release) injection prescribing information. Indivior / DailyMed, U.S. National Library of Medicine, 2026. dailymed.nlm.nih.gov
6. Brixadi (buprenorphine) extended-release injection prescribing information. Braeburn / DailyMed, U.S. National Library of Medicine, 2025. dailymed.nlm.nih.gov
7. Vivitrol (naltrexone for extended-release injectable suspension) prescribing information. Alkermes / DailyMed, U.S. National Library of Medicine, 2026. dailymed.nlm.nih.gov
8. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 357:j1550 (Sordo L et al.), 2017. pubmed.ncbi.nlm.nih.gov
9. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. The Lancet 391(10118):309-318 (Lee JD et al.), 2018. pubmed.ncbi.nlm.nih.gov
10. FDA Approves First Over-the-Counter Naloxone Nasal Spray. U.S. Food and Drug Administration, 2023. fda.gov
11. SAMHSA's National Helpline. Substance Abuse and Mental Health Services Administration (SAMHSA), 2025. samhsa.gov
12. Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications. Drug Enforcement Administration and HHS, Federal Register, 2025. federalregister.gov
13. 42 CFR Part 8 Final Rule. Substance Abuse and Mental Health Services Administration, 2024. samhsa.gov

Educational information, not medical, tax or legal advice. Decisions about diagnosis, medication and treatment belong with a clinician who knows your history.