Three medications are FDA-approved to treat opioid use disorder: buprenorphine (often sold as Suboxone), methadone, and extended-release naltrexone (Vivitrol). All three can be part of what is often called medication-assisted treatment, or MAT, now commonly called medications for opioid use disorder (MOUD). They work in very different ways, and each has real strengths and real drawbacks. Choosing among them is one of the most important decisions in opioid recovery. This guide compares the pros and cons of each, summarizes what head-to-head research shows, and covers recent federal rule changes that affect access. If you want a basic introduction first, see our overview of medication-assisted treatment.
| Buprenorphine (Suboxone and others) | Methadone | Extended-Release Naltrexone (Vivitrol) |
|---|
| How it works | Partial opioid agonist: activates receptors enough to prevent withdrawal and cravings, with a ceiling on effects | Full opioid agonist: long-acting, fully activates receptors | Opioid antagonist: blocks receptors so opioids have little effect |
| Where it is given | Prescribed by clinicians in offices, clinics, or by telehealth; filled at pharmacies | Only through certified opioid treatment programs (OTPs) | Monthly injection in a clinic or office |
| Starting requirements | Must be in some withdrawal to avoid precipitated withdrawal, or use a low-dose start | Can be started without withdrawal | Must be fully off opioids, usually 7 to 10 days |
| Forms | Daily film or tablet; weekly or monthly injections | Daily liquid or tablet | Monthly injection |
| Overdose risk reduction | Strong evidence | Strong evidence | Less established in population studies |
| Misuse and diversion potential | Low to moderate | Moderate; controlled through OTP dosing | None |
- Office-based access. Can be prescribed by many clinicians and filled at a regular pharmacy. Since January 2023, federal law no longer requires a special "X-waiver" to prescribe it, which has broadened the pool of prescribers.
- Ceiling effect. As a partial agonist, it has a lower risk of respiratory depression than full opioids when taken alone.
- Strong mortality evidence. Large observational studies have linked buprenorphine treatment to substantially lower risk of overdose death.
- Flexible formulations. Daily films and tablets, plus weekly and monthly injectable forms that reduce the burden of daily dosing and the risk of diversion.
- Telehealth options. It can be started and managed through telehealth under current federal rules.
- Precipitated withdrawal. Starting buprenorphine too soon after full opioids can trigger sudden, severe withdrawal. With fentanyl, timing can be harder, though low-dose initiation approaches can help.
- May not be strong enough for some. People with very high tolerance, common in the fentanyl era, may find buprenorphine does not fully control cravings.
- Some diversion risk. Films and tablets can be sold or shared, though diverted buprenorphine is often used to self-treat withdrawal.
- Pharmacy barriers. Some pharmacies still stock limited supplies or are reluctant to fill prescriptions.
- Longest track record. Methadone has been used to treat opioid addiction since the 1960s and has decades of evidence behind it.
- Effective for high tolerance. As a full agonist, it can control withdrawal and cravings in people for whom buprenorphine is not enough.
- No withdrawal needed to start. It can be started without waiting, which avoids the induction challenges of the other two medications.
- Strong retention and mortality benefits. Methadone has strong evidence for keeping people in treatment and reducing overdose deaths.
- Built-in structure. Opioid treatment programs provide counseling and regular contact, which helps some people.
- Clinic visits. Methadone for opioid use disorder can only be dispensed through certified opioid treatment programs, often requiring frequent, sometimes daily, visits early in treatment. This can be hard for people who work, lack transportation, or live far away.
- Overdose risk during the first weeks. Methadone builds up slowly in the body, so doses must be increased carefully. Combining it with alcohol or benzodiazepines is dangerous.
- Heart rhythm effects. At higher doses, methadone can affect heart rhythm, so some patients need monitoring.
- Drug interactions and stigma. Many medications interact with methadone, and clinic-based treatment can carry social stigma.
SAMHSA's 2024 update to the federal rules governing opioid treatment programs, 42 CFR Part 8, expanded flexibility. Changes include allowing more take-home doses earlier in treatment, permitting telehealth for certain parts of care, and removing the requirement of a one-year history of addiction before admission. The full rule is published in the Federal Register. How quickly individual clinics adopt these flexibilities varies.
Extended-Release Naltrexone (Vivitrol): Pros and Cons
- Not an opioid. It has no misuse potential and does not cause physical dependence, which appeals to people and programs that prefer an opioid-free approach.
- Monthly dosing. One injection lasts about a month, eliminating daily decisions about medication.
- Fewer regulatory hurdles. Any licensed prescriber can administer it, and it is often used in criminal justice settings and by professionals in monitoring programs.
- Also treats alcohol use disorder. Helpful for people with both opioid and alcohol problems.
- Hard to start. A person must be fully detoxed from opioids, usually for 7 to 10 days, before the first injection. Many people return to use during that waiting period.
- Overdose risk after stopping. Because naltrexone reduces tolerance, a person who stops the injection and returns to opioids faces a high overdose risk. Attempting to overpower the blockade with large doses is also dangerous.
- Less population-level evidence for reducing deaths. Studies of real-world treatment have shown stronger mortality reductions for buprenorphine and methadone than for naltrexone.
- Injection-site reactions and cost can be barriers.
A major National Institute on Drug Abuse Clinical Trials Network study, known as X:BOT and summarized in a review of the network's opioid use disorder trials published on the NIH's PubMed Central, compared extended-release naltrexone with buprenorphine-naloxone in 570 adults starting treatment. Published in The Lancet in 2018, the trial found that many more participants failed to start naltrexone because of the need for full detox. In the overall group, relapse was more common among those assigned to naltrexone. However, among people who successfully started their assigned medication, outcomes were similar.
The lesson is practical: naltrexone can work as well as buprenorphine for people who get through induction, but induction is a major hurdle.
Observational studies have also compared real-world outcomes. One large study of overdose survivors in Massachusetts, published in Annals of Internal Medicine in 2018, found that treatment with methadone or buprenorphine was associated with significantly lower risk of death in the following year, while naltrexone was not associated with a significant reduction, though fewer people received it.
No. Addiction involves compulsive use, loss of control, and continued use despite harm. People stable on prescribed buprenorphine or methadone take a measured dose that prevents withdrawal and cravings without producing a high, allowing them to work, parent, and rebuild their lives. Physical dependence on a medication is not the same as addiction, much like dependence on insulin or blood pressure medication.
There is no fixed endpoint. Research generally shows better outcomes with longer treatment, and stopping too early is linked to higher relapse and overdose risk. Decisions about tapering should be made with a clinician when a person is stable. Our article on detox vs. medication treatment for opioid use disorder explains why detox alone carries risk.
Methadone and buprenorphine are recommended treatments for opioid use disorder during pregnancy because they reduce the risks associated with ongoing opioid use and withdrawal. Evidence for naltrexone during pregnancy is more limited. Our guide to substance use treatment during pregnancy covers this in detail.
Coverage for all three medications has expanded considerably. Medicaid programs in every state cover medications for opioid use disorder, and Medicare covers opioid treatment program services, including methadone. Most commercial plans cover buprenorphine and naltrexone, though prior authorization or pharmacy restrictions sometimes apply. Monthly injectable forms of buprenorphine and naltrexone are more expensive than daily medications, which can affect coverage decisions. Before starting, ask your insurer which medications and formulations are covered and whether prior authorization is needed. Our guide to verifying insurance benefits for treatment explains which questions to ask.
- Buprenorphine often suits people who want office-based or telehealth care, have moderate tolerance, and value flexibility.
- Methadone often suits people with very high tolerance, those who did not respond to buprenorphine, or those who benefit from daily structure.
- Naltrexone often suits people who are already detoxed, strongly prefer a non-opioid option, or are in settings where agonist treatment is not available.
The best medication is the one a person can start, stay on, and benefit from. Switching is possible if the first choice does not work. Medication works best combined with counseling and support. You can find programs on our medication-assisted treatment page, through SAMHSA's FindTreatment.gov, or by calling the SAMHSA National Helpline at 1-800-662-4357.
Buprenorphine offers flexible, office-based treatment with strong evidence for reducing overdose deaths but can be tricky to start with fentanyl. Methadone is the most powerful option and has the longest track record, but requires opioid treatment program visits, though 2024 federal rule changes expanded take-home flexibility. Naltrexone avoids opioids entirely and is given monthly, but requires full detox first and has less evidence for preventing deaths. The NIDA X:BOT trial showed naltrexone and buprenorphine perform similarly once started, but starting naltrexone is much harder. Each option can save lives, and the right choice depends on the person.
Frequently asked questions
Suboxone (buprenorphine) can be prescribed in offices or by telehealth, has a ceiling effect that lowers overdose risk, and is linked to fewer overdose deaths. Drawbacks include precipitated withdrawal if started too early, possible inadequate control for very high tolerance, and some diversion risk.
Methadone is highly effective, has decades of evidence, works for high tolerance, and can be started without withdrawal. Drawbacks include required visits to an opioid treatment program, overdose risk during early dose increases, heart rhythm effects, and drug interactions.
Vivitrol (extended-release naltrexone) is a non-opioid monthly injection with no misuse potential. Drawbacks include needing 7 to 10 days fully off opioids before starting, high overdose risk if stopped, and less real-world evidence for reducing overdose deaths.
In the NIDA X:BOT trial, people who successfully started either medication had similar outcomes, but far more people failed to start Vivitrol because of the detox requirement. The better choice depends on whether a person can complete detox and their treatment preferences.
No. Addiction involves compulsive use and loss of control. People stable on prescribed buprenorphine or methadone take a measured dose that prevents withdrawal and cravings without a high, allowing them to function. Physical dependence on a medication is not addiction.
Yes. SAMHSA's 2024 update to 42 CFR Part 8 expanded take-home dose flexibility, allowed telehealth for certain parts of care, and removed the requirement of a one-year history of addiction before admission to an opioid treatment program.
This article was reviewed by the RehabsNearMe Editorial Team for accuracy, clarity, and relevance. Information may be sourced from publicly available treatment resources, government agencies, and healthcare references where applicable.
Last reviewed: October 2026
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