Methadone, Buprenorphine, or Naltrexone: Choosing With Your Prescriber

This article supports but does not replace professional care. If you are in immediate danger, call 911. For mental health support in the U.S., dial 988.

The three FDA‑approved options for opioid use disorder

• Methadone is a full opioid agonist provided through certified opioid treatment programs (OTPs).

  
  

• Buprenorphine is a partial agonist available by prescription in office and telehealth settings.

  
  

• Extended‑release naltrexone is a monthly opioid blocker injection given after an opioid‑free period. NYC.gov

  
  

Quick fit guide

• I need strong craving relief and daily structure: methadone at an OTP may fit. It offers supervised dosing with the option to earn take‑home doses. Federal Register

  
  

• I want a pharmacy‑based option I can take at home: buprenorphine is prescribed in clinics or telehealth and filled at pharmacies. The federal X‑waiver is no longer required. SAMHSA

  
  

• I prefer a non‑opioid medication and can be opioid‑free first: extended‑release naltrexone is a monthly shot, started after at least 7 to 10 opioid‑free days. vivitrol.com

  
  

Access and logistics that matter

• Where you start care

  • Methadone is ordered and dispensed at OTPs, not retail pharmacies. The 2024 final rule allows audio‑visual telehealth evaluations for new patients starting methadone at OTPs. It also codifies expanded take‑homes: up to 7 days in the first 14 days, up to 14 from day 15, and up to 28 from day 31, based on clinical judgment. Federal Register

    
    

  • Buprenorphine can be initiated by telehealth; audio‑only is allowed for buprenorphine under the rule. The MAT Act removed the federal waiver and patient caps. State rules still apply. Federal Register+1

    
    

  • Extended‑release naltrexone is administered in clinic monthly. Patients must be opioid‑free before the first dose. vivitrol.com

Evidence snapshot

• Being in treatment with methadone or buprenorphine reduces the risk of overdose and all‑cause mortality versus no medication. Multiple systematic reviews and large cohort studies support this. BMJ+2JAMA Network+2

  
  

• Retention tends to be higher with methadone than with buprenorphine in flexible‑dose real‑world settings. Recent observational work in the fentanyl era shows the same pattern; mortality while on either medication is low. cochranelibrary.com+1

  
  

• Extended‑release naltrexone vs buprenorphine: trials show an induction hurdle for naltrexone because of the opioid‑free requirement. Among people who start either medication, relapse outcomes are similar over 24 weeks. ctnlibrary.org+1

Safety notes to discuss with your prescriber

• Methadone

  • Can prolong the QTc interval in some patients. Clinicians may assess cardiac risk and monitor as needed. NCBI

  • Sedation and respiratory depression risks require careful dose titration, especially early in treatment. The 2024 rule supports patient‑centered dosing with clear documentation. Federal Register

    
    

• Buprenorphine

  • Has a ceiling effect on respiratory depression relative to full agonists. Standard inductions start once withdrawal begins; low‑dose or “micro‑induction” approaches are options in some programs. Follow clinician guidance. Lippincott Journals

  
  

• Extended‑release naltrexone

  • Requires at least 7 to 10 opioid‑free days to avoid precipitated withdrawal. It blocks opioid pain medicines while active, so emergency pain plans should be discussed. vivitrol.com

    
    

Talk through these decision points

• Your goal right now: stabilization, reduced use, or abstinence.

• Access realities: distance to an OTP, pharmacy hours, insurance.

• Medical context: cardiac risk, liver disease, pregnancy, other meds.

• Risk and structure: how much support you want day to day.

• Switching and sequencing: how you would move from one medication to another if needed.

FAQs

Which is “best”?

There is no single best medication for everyone. Methadone often has higher retention; buprenorphine offers pharmacy access and strong safety features; naltrexone is non‑opioid but needs an opioid‑free start. Fit and access drive outcomes. cochranelibrary.com+2JAMA Network+2

Can I switch later?

Yes. People change medications over time based on goals, side effects, access, or life events. Work with your care team on timing and safety.

Can I start buprenorphine without waiting for full withdrawal?

Some clinicians use low‑dose induction strategies when standard induction is difficult. This is individualized and should follow expert guidance. Lippincott Journals

Does methadone still require daily visits?

Early treatment often includes on‑site dosing. Under the 2024 rule, clinicians can grant take‑home doses earlier and in larger amounts when clinically appropriate. Federal Register

What happens if I need surgery while on naltrexone?

Tell your surgical team. Naltrexone blocks opioids, so non‑opioid pain strategies or timing adjustments may be needed. Labeling includes cautions. vivitrol.com

NYC resources

• NYC Health: Medications for Opioid Use Disorder — overview of methadone, buprenorphine, and naltrexone with local links. NYC.gov

• NYC Health + Hospitals Virtual Buprenorphine Clinic — low‑threshold access for buprenorphine. NYC Health + Hospitals

• SAMHSA Buprenorphine Practitioner Locator — find prescribers by ZIP. SAMHSA