Medication for Opioid Use: FAQ

Someone may have told you these medicines are "just another drug," and you are trying to decide whether to start, stay, or quit. Opioid use disorder is a medical condition with medicines that have FDA approval. NIDA names three that help people stop or reduce opioid use: methadone, buprenorphine, and naltrexone. A fourth medicine, lofexidine, treats the immediate misery of opioid withdrawal. NIDA says lofexidine is not long-term treatment of the disorder. The answers below are the questions people ask before they accept, refuse, or quit these medicines. They do not include a dose.

If breathing is slow or the person will not wake, call 911 and use naloxone if you have it. The overdose guide walks through that response. For a mental health crisis, call or text 988.

What each medicine does

NIDA says methadone is an opioid used for this purpose for more than 50 years. It acts on the same receptors as heroin and fentanyl, but more slowly, and it stays in the body longer. In people with opioid use disorder it produces less intense pleasure while reducing withdrawal and craving.

Buprenorphine is also an opioid medicine. NIDA says it activates those receptors less strongly than methadone and can block other opioids from attaching. It comes as films or tablets under the tongue, as a longer-acting injection, and as an implant. Some products combine it with naloxone. NIDA says methadone and buprenorphine can be equally effective at reducing opioid use, that both help people stay in treatment, and that methadone may help some people stay longer.

Naltrexone is not an opioid. NIDA says it only blocks opioid receptors, so opioids cannot produce pleasure, and that evidence suggests it reduces craving. It is also approved for alcohol use disorder. The form used for opioid use disorder is often a monthly injection. Any clinician with prescribing authority can prescribe it. NIDA says that when people stay on it, it can work as well as buprenorphine at preventing a return to use, and that starting it is harder because the person usually has to stop other opioids first.

NIDA says people treated with methadone or buprenorphine are less likely to die or to overdose than people who do not receive those treatments. It also says they are less likely to share injection equipment or to have other behaviors that raise the risk of HIV and hepatitis C. Those are population findings. They are not a promise about one person. NIDA also says fewer than 1 in 5 people with opioid use disorder receive these medicines. Stigma, distance from a methadone clinic, and pharmacies that do not stock buprenorphine are among the reasons it lists.

"Replacing one drug with another"

NIDA takes that sentence on directly. Because methadone and buprenorphine act on opioid receptors, people assume they are a swap. Taken as prescribed by someone with opioid use disorder, NIDA says, they prevent craving and withdrawal without the intense high of other opioids, which makes them less addictive. They do produce dependence. Stopping abruptly can cause withdrawal. NIDA says that withdrawal is milder than withdrawal from other opioids and can be managed by lowering the dose slowly rather than stopping at once. Do not design that taper yourself.

Naltrexone is not addictive. It blocks the receptor instead of activating it.

Both methadone and buprenorphine can be misused if they are injected. NIDA says studies find that most people who misuse buprenorphine do it to control withdrawal from other opioids, not to get high. That fact is not permission to use someone else's medicine. Using it outside a prescription can still be dangerous, especially mixed with alcohol or benzodiazepines. FDA says combining benzodiazepines with opioids can cause severe slowed breathing and death. The same page tells clinicians to use caution when benzodiazepines are combined with medicines for opioid use disorder, and it points to a separate caution against withholding those medicines only because the patient also takes a benzodiazepine. Tell every prescriber about both.

Who is allowed to provide them

Methadone for opioid use disorder is dispensed through approved opioid treatment programs, not through a typical corner pharmacy as a monthly bottle you start on your own. NIDA says new patients usually go to the program every day or almost every day. It also says that since 2020, regulations let many people who have already been in treatment receive up to 28 take-home doses. Whether you qualify is the program's decision under the rules. Travel with take-home doses is covered in the flying guide. Do not skip the clinic and then restart at an old dose after a gap. Tolerance changes. Overdose risk goes up. The relapse guide covers that window.

Buprenorphine does not require a special treatment clinic. NIDA says many physicians, nurse practitioners, and physician assistants can prescribe it, and that telehealth prescribing has made it easier to start and to stay on it. It can also be started in an emergency department after an overdose. The DEA has told registrants that, as of December 29, 2022, a DATA-Waiver, often called an X-waiver, is no longer required to treat opioid use disorder with buprenorphine, that prescriptions use a standard DEA number, and that federal patient caps are gone. The DEA also says the law does not override state rules. A clinician still has to be allowed to prescribe under state law. Training requirements for DEA registration are separate from the old waiver. You still need a prescriber who is allowed to prescribe where you live.

Naltrexone's barrier is clinical, not a clinic license. NIDA says treatment usually starts after the person has completely stopped other opioids, or the medicine may cause withdrawal, and that the wait is often 7 to 10 days. The FDA label for extended-release naltrexone (Vivitrol) says patients should be opioid-free, recommends a minimum of 7 to 10 days after short-acting opioids, and warns that people transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal for as long as two weeks. Precipitated withdrawal can be severe. The label says there is no completely reliable way for a patient to know the wait was long enough, and that a clinician should be ready to manage it. NIDA notes that research has tested faster starts under medical supervision. Faster does not mean unsupervised. Do not take a first dose alone to "see what happens."

Pregnancy, housing, and the first days of treatment

NIDA says methadone and buprenorphine are recommended in pregnancy and are safe in breastfeeding, with only minimal amounts in breast milk. CDC says quickly stopping opioids during pregnancy is not recommended. The pregnancy guide quotes those sources at length, including the limited evidence on naltrexone in pregnancy. A positive pregnancy test is a reason to call the prescriber, not a reason to flush the medicine.

SAMHSA tells recovery homes not to bar prescribed buprenorphine, methadone, or naltrexone. If a house requires you to stop in order to move in, that request conflicts with SAMHSA's recovery-housing guidance. The sober living guide explains the levels of housing and that point.

During the first days of a residential stay, ask whether the medicine will be continued. Stopping it for the sake of a program rule can trigger withdrawal and, later, a higher overdose risk. The 72-hour guide covers evaluation and stabilization. The comparison guide covers refusing a program that cannot explain its medication policy.

What to do with a missed dose or a bad day

Call the prescriber or the opioid treatment program. Do not double a dose because a friend did. Do not add alcohol or benzodiazepines to "get through" the gap. If you used illicit opioids again, say so. The clinician needs that fact before changing the medicine. Naloxone should be in the home of anyone at risk of opioid overdose. It does not treat withdrawal, and it does not replace the daily or monthly medicine.

FindTreatment.gov can locate opioid treatment programs and other facilities. SAMHSA's National Helpline is 1-800-662-HELP (4357). SmarterRecovery is not a prescriber. Call or text (800) 653-9376 if you need help finding a program that continues medication.

Additional Resources

Sources cited on this page:

• NIDA: Medications for Opioid Use Disorder
• DEA: Elimination of the DATA-Waiver requirement
• FDA label: Vivitrol (extended-release naltrexone), opioid-free interval
• FDA: Boxed warning on benzodiazepines, including combined use with opioids
• CDC: Treatment of opioid use disorder before, during, and after pregnancy
• SAMHSA: Best Practices for Recovery Housing (medication access)
• SAMHSA FindTreatment.gov
• SAMHSA National Helpline
• 988 Suicide & Crisis Lifeline

Common Questions