Posted on April 18, 2025

Why do many individuals with opioid use disorder (OUD) leave treatment despite knowing the risks? The situation is dire: while medications like methadone and buprenorphine can save lives, dropout rates remain high. Retaining patients in treatment is crucial for their survival, especially given the dangers posed by fentanyl in the illicit drug supply.

Buprenorphine and methadone significantly reduce overdose death risk, with studies showing at least a two-fold reduction in mortality. In treating OUD, it seems misguided to prefer abstinence-only approaches over these effective medications.

Additionally, extended-release naltrexone (Vivitrol) is promoted by some programs, even though evidence of its efficacy in reducing overdose deaths is lacking. Research, including the XBOT trial, raises concerns about its effectiveness compared to methadone and buprenorphine. For lasting recovery, it is essential to prioritize the most effective treatment options.

The Retention Problem

Let's shift our focus back to treatment retention, which is crucial for patient survival. What factors encourage patients to stay in treatment, and what causes them to drop out?

Researchers have investigated various factors that could enhance retention for patients undergoing treatment with buprenorphine and methadone. Surprisingly, interventions such as contingency management and the integration of psychiatric and medical services did not appear to be effective. Even extended-release formulations of buprenorphine, which some may consider more convenient, did not provide better retention rates compared to daily dosing.

A significant study by Noysk et al., published in the Journal of the American Medical Association, further explored this issue. Conducted in British Columbia from 2010 to 2020, the study tracked over 30,000 patients beginning medications for opioid use disorder (OUD). The findings revealed that patients receiving methadone demonstrated significantly better treatment retention than those on buprenorphine/naloxone.

Specifically, 88% of patients on buprenorphine discontinued treatment by 24 months, whereas only 81.5% of those on methadone dropped out. This represents a 37–41% reduction in treatment discontinuation for patients using methadone. Importantly, there was no difference in mortality during treatment between the two groups.

Context Matters: U.S. vs. Canada

Before we rush to conclusions, it's important to consider the context. Canada’s treatment model differs from the U.S. In Canada, both buprenorphine and methadone can be prescribed in office-based settings. In the U.S., only buprenorphine is allowed in these settings, while methadone is still restricted to specialized Opioid Treatment Programs (OTPs).

This difference may skew the comparison. Patients may have better retention when they can access care in less stigmatized, more familiar office settings. If methadone were more widely available in these environments in the U.S., could we see even better outcomes?

Still, the data raises questions. For example, Canadian guidelines currently favor buprenorphine/naloxone as the first-line treatment due to its safety profile. But if it leads to lower retention, should those guidelines be reconsidered?

Methadone: Underused but Effective

Although U.S. guidelines do not officially favor buprenorphine, biases exist in practice. At conferences and within addiction medicine circles, buprenorphine often overshadows methadone. While buprenorphine is recognized as safer and carries a lower risk of overdose, methadone may offer better patient retention, especially in the era of fentanyl use.

One key advantage of methadone is that it does not cause precipitated withdrawal in patients actively using fentanyl, which can be a significant benefit. Inducing a patient too early with buprenorphine can result in severe withdrawal symptoms, which might discourage them from seeking treatment in the future. Methadone avoids this risk.

Both medications, however, are dose-sensitive. In the early 2000s, many Opioid Treatment Programs (OTPs) were hesitant to increase methadone doses above 70mg. We now understand that doses ranging from 80–120mg, and sometimes even higher, are necessary to prevent relapse and enhance retention.

There was also resistance to suggesting buprenorphine doses higher than 16mg; some states, like Tennessee and Virginia, even imposed legal limits on prescriptions. Recent research indicates that doses of 24mg and higher can improve retention outcomes.

Consequently, underdosing—whether due to outdated beliefs, regulatory restrictions, or cost concerns—can undermine treatment success.

Other Barriers to Retention

There are several subtle factors that influence patient retention in treatment programs. One of the most obvious factors is cost: lower out-of-pocket expenses tend to improve retention rates, which is not surprising.

Additionally, withdrawal experiences can vary significantly between different medications. Anecdotal evidence suggests that the withdrawal symptoms from methadone can be much more intense than those from buprenorphine. This intensity may cause patients to be apprehensive about stopping methadone, making them less likely to leave treatment. On the other hand, stopping buprenorphine might be perceived as easier—and it can also be more readily obtained illegally—which may make patients feel that dropping out is less risky.

The COVID-19 pandemic also played a role in treatment retention. During this time, relaxed federal regulations allowed patients to receive more take-home doses of methadone, which led to improved retention rates. While SAMHSA has since revised its rules, not all Opioid Treatment Programs (OTPs) are fully implementing these new policies. Programs that adopt early take-home policies, when safe to do so, may experience an increase in retention rates.

The Human Element

We must recognize the significance of the treatment environment. Patients are more likely to remain in programs where they feel genuinely cared for. A welcoming atmosphere, empathetic counselors, and supportive medical staff all play crucial roles in a patient’s decision to stay in treatment.

While these factors may seem minor, they can be transformative. Data and medication are important, but relationships and respect are equally vital to the treatment process.

So, Where Do We Go From Here?

There is growing evidence that methadone deserves more serious consideration, especially in the era of fentanyl. This does not mean that buprenorphine should be dismissed—far from it. Both medications are essential tools in treating addiction, and both save lives.

We need to challenge outdated assumptions, examine our biases, and advocate for policies that promote access, flexibility, and personalized care. Retention in treatment is crucial. If we genuinely want to save lives, our treatment systems must prioritize keeping patients engaged for the long term.

Perhaps it’s time to openly acknowledge that methadone is effective, and we should be using it more frequently.