Somebody has probably told you that medication is available. Somebody else has probably told you it is just swapping one drug for another. Both of those people may care about you a great deal, and only one of them is describing what the research actually shows.
This guide is about the medications used to treat opioid use disorder and alcohol use disorder: what each one does inside the body, what the evidence says about who lives and who does not, where each one can legally be prescribed, and what the medication cannot do on its own. It is written for the person deciding and for the family sitting alongside them.
What Is Medication-Assisted Treatment (MAT)?
Medication-assisted treatment, or MAT, is a broad term historically used for FDA-approved medications combined with counseling and behavioral therapies in substance use disorder care [1]. For opioid use disorder, current federal guidance increasingly uses medications for opioid use disorder, or MOUD, because methadone, buprenorphine, and naltrexone are treatments in their own right rather than medications that merely “assist” counseling [2]. Medication can be used alongside therapy and recovery supports, but access to OUD medication should not depend on whether a person agrees to counseling.
Medication can reduce withdrawal, craving, or the rewarding effects of substance use, depending on the medication, and that can make it easier to engage in the rest of life and treatment. People can still participate in counseling during withdrawal or early stabilization, but severe withdrawal may make concentration and participation harder. The medication and the behavioral supports are parts of one individualized treatment plan, not a hierarchy in which one is the “real” treatment.
The federal body that sets the standards here is the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services, and most of what follows comes from its guidance.
Why You May See It Called MOUD Instead
You will increasingly see the term medications for opioid use disorder, or MOUD. It is related to MAT but not synonymous with it. MOUD refers specifically to the medications used to treat opioid use disorder [2].
SAMHSA now explicitly distinguishes the terms. MAT has traditionally described medication combined with counseling or behavioral interventions, while MOUD refers specifically to the FDA-approved medication categories for opioid use disorder [2]. The change in language matters because medication is a core treatment for OUD, not merely an “assistant” to counseling. MAT is also broader in common use because it may refer to medications used for alcohol use disorder, whereas MOUD is opioid-specific.
You will also meet older vocabulary that has not gone away. Terms like drug abuse and substance abuse survive in the names of institutions, in insurance codes, and in the phrase substance abuse treatment, even though clinical language has moved to opioid use disorder (OUD) and alcohol use disorder. None of this signals a different condition. It signals when the document was written.
What MAT Treatment Is Not
- It is not the same as detox. Methadone or buprenorphine treatment can begin without completing an opioid-free detox, while naltrexone requires an opioid-free interval before initiation.
- It does not require counseling as a condition of receiving OUD medication. Counseling and other behavioral services should be available and can be helpful, but current federal OTP rules say MOUD access is not contingent on participation in counseling [2].
- It is not simply “replacing one addiction with another.” Methadone and buprenorphine can produce physical dependence, but dependence is not the same as the compulsive, harmful pattern that defines opioid use disorder.
- It is not limited to opioids. Alcohol use disorder also has FDA-approved medications, often called medications for alcohol use disorder or MAUD.
The FDA-Approved Medications for Opioid Use Disorder
Three medications are FDA-approved for opioid use disorder: methadone, buprenorphine, and naltrexone [1]. They work differently. Methadone is a full opioid agonist, buprenorphine is a partial agonist, and naltrexone is an antagonist. The best fit depends on clinical history, treatment goals, access, prior response, and other medical factors.
Methadone, a Full Opioid Agonist
Methadone is a long-acting full opioid agonist. At an appropriately individualized maintenance dose, it can prevent withdrawal, reduce craving, and blunt the effects of other opioids. It can also cause sedation, respiratory depression, and physical dependence, particularly during dose changes or when combined with other central nervous system depressants, so it should not be described as producing “no high” or no opioid effects in every circumstance.
Methadone has the longest history of use for OUD and an extensive evidence base. Maintenance treatment can continue as long as it remains beneficial, and it reduces illicit opioid use and mortality. Its access is more tightly regulated than buprenorphine because methadone for OUD is dispensed through federally certified opioid treatment programs.
Buprenorphine, a Partial Opioid Agonist
Buprenorphine is a partial opioid agonist. It activates the mu opioid receptor but has a ceiling on some opioid effects, especially respiratory depression, which contributes to a lower overdose risk than full agonists such as methadone or heroin. The ceiling is not a rule that every opioid effect stops increasing after one specific dose, and buprenorphine still requires careful prescribing and monitoring.
Buprenorphine is available in several formulations. Suboxone combines buprenorphine with naloxone, which has little effect when taken as directed under the tongue but can deter some forms of injection misuse. Extended-release injectable buprenorphine products can reduce the need for daily dosing. When used as prescribed for OUD, buprenorphine reduces withdrawal and cravings and has a lower respiratory-depression risk than full opioid agonists, although it can still cause opioid effects and can be dangerous when combined with other sedating drugs.
Naltrexone, an Opioid Antagonist
Naltrexone is an opioid antagonist. It blocks opioid receptors rather than activating them and can prevent or blunt the euphoric and other opioid effects while enough medication is active. Because it is not an opioid agonist, it does not produce opioid physical dependence.
Timing matters. Naltrexone should not be started while a person is physically dependent on opioids or in acute opioid withdrawal because it can precipitate severe withdrawal. It is generally started only after an adequate opioid-free interval, which is why medical detox or another supervised transition may be needed first. Unlike methadone and buprenorphine, naltrexone does not produce opioid physical dependence.
Medications for Alcohol Use Disorder
The alcohol half of addiction medicine gets far less attention than it should. Three medications are approved for alcohol use disorder: naltrexone, acamprosate, and disulfiram [1].
Naltrexone and Vivitrol
Naltrexone is an opioid-receptor antagonist in both OUD and AUD treatment. In alcohol use disorder, it can reduce craving and the rewarding effects of drinking for some people [1]. Vivitrol is the extended-release monthly injectable form of naltrexone, which can reduce the burden of remembering a daily pill. A clinician still needs to screen for contraindications and current opioid exposure before starting it.
Acamprosate and Disulfiram
Acamprosate is used to help maintain abstinence after alcohol withdrawal and may reduce some of the negative symptoms associated with prolonged abstinence. It is not a treatment for acute alcohol withdrawal. Disulfiram interferes with alcohol metabolism and can cause an unpleasant reaction if alcohol is consumed, so its usefulness depends heavily on adherence and whether that approach fits the person [1].
These medications work through different mechanisms, so they should not be described as doing the same job by a single pathway. Naltrexone reduces alcohol’s rewarding effects for some people, acamprosate supports maintenance of abstinence, and disulfiram creates an aversive reaction if alcohol is consumed [1]. Medication choice depends on treatment goals, medical history, contraindications, and patient preference.
What the Evidence Says About OUD Treatment and Survival
The Mortality Finding
A 2017 systematic review and meta-analysis in the BMJ pooled cohort studies covering 122,885 people on methadone and 15,831 on buprenorphine, and compared death rates during treatment against death rates out of it [2].
The numbers, per 1,000 person-years:
- Methadone, all-cause mortality: about 6 deaths in treatment against 14 out of treatment
- Methadone, overdose mortality: 3 deaths in treatment against 13 out of treatment
- Buprenorphine, all-cause mortality: about 4 deaths in treatment against 11 out of treatment
The pooled analysis found substantially lower mortality during methadone and buprenorphine treatment than after treatment stopped [3]. For methadone, overdose mortality averaged about 2.6 deaths per 1,000 person-years in treatment versus 12.7 out of treatment. The first four weeks after stopping either methadone or buprenorphine were particularly high-risk periods for all-cause mortality, at roughly 32 deaths per 1,000 person-years in the cohorts with time-specific data [3]. That supports careful continuity and discontinuation planning rather than an arbitrary stop date.
What the Study Cannot Tell You
Two limits matter. The review pooled observational cohorts, so the mortality differences are associations rather than randomized proof of causation. The authors also noted that 96 percent of deaths and 98 percent of person-years in the included data came from Australian studies [3], so the absolute rates should not be treated as Iowa-specific estimates.
The direction of the finding is consistent and clinically important, but the precise rates are population estimates rather than a prediction for any individual.
Does MAT Substitute One Addiction for Another?
This concern is understandable because two of the medications used for OUD are opioids themselves. The key distinction is between physical dependence on a prescribed medication and the compulsive, harmful pattern that defines opioid use disorder.
Methadone and buprenorphine can produce physical dependence, so stopping them abruptly can cause opioid withdrawal. That is a pharmacologic effect, not proof that treatment has created a new addiction. Naltrexone does not create opioid dependence.
Physical dependence and addiction are not the same thing. Physical dependence means the body has adapted to a medication and withdrawal can occur if it is stopped abruptly. Opioid use disorder involves a broader pattern of impaired control, craving, continued use despite harm, and other functional consequences. A person taking a stable prescribed dose of methadone or buprenorphine may be able to function normally without the repeated intoxication and withdrawal cycle of untreated OUD. Side effects and impairment can still occur, especially during treatment changes or when other sedating substances are involved, so medication should be used exactly as prescribed.
The useful question is not whether the body has adapted to a medication. It is whether the person’s life is getting bigger or smaller. The chapter on suboxone side effects works through this in full, because it is the single most searched objection in this whole subject.
Medication and Behavioral Health Care
Medication is treatment in its own right, especially for opioid use disorder. Counseling and other behavioral services can add support, but current federal guidance does not make counseling a prerequisite for receiving MOUD [2]. The more accurate point is that many people benefit from combining medication with behavioral health and recovery supports, not that a prescription without therapy is automatically “half a service.”
Medication treats important parts of the disorder, including withdrawal, craving, opioid effects, or alcohol-related reinforcement, depending on the medication. It does not by itself solve every problem that may surround substance use, such as housing instability, trauma, relationship conflict, or another mental health condition.
For opioid use disorder, medication should not be withheld simply because a person declines counseling or counseling is unavailable. SAMHSA’s revised federal OTP rule explicitly says medication access is no longer contingent on receiving counseling and that a patient’s refusal of counseling does not preclude MOUD [2]. Counseling should be available and tailored to the person’s needs and goals.
Behavioral health care can still be valuable. Individual therapy, group work, peer support, case management, relapse-prevention planning, housing or employment support, and treatment for co-occurring mental health conditions may address needs that medication does not. Where depression, anxiety, trauma-related symptoms, or another condition co-occurs, dual diagnosis treatment can be part of the same plan. The mix and intensity of services should be individualized rather than treated as a condition for receiving medication.
Where Each Medication Can Legally Be Prescribed
This is the most practically useful section on the page, and it is the part most articles skip. The three medications are not equally available, and the reason is regulatory.
Methadone and Opioid Treatment Programs
Federal rules still restrict methadone for opioid use disorder to certified opioid treatment programs. SAMHSA’s current 42 CFR Part 8 guidance says the revised rule does not allow methadone to be prescribed outside an OTP for OUD, although OTP medication units can operate in settings such as pharmacies where permitted [2].
Access can still be harder when the nearest OTP is far away, but the old rule that new patients had to make a supervised trip every day before earning take-home medication is outdated. Under the revised federal rules, an OTP practitioner may authorize take-home methadone from the first week when it is clinically appropriate. The federal limits allow up to 7 take-home doses during the first 14 days, up to 14 from day 15, and up to 28 from day 31, with the actual amount based on clinical judgment and patient safety [2].
Radix Recovery’s current opioid addiction treatment page describes its medication program as using Suboxone and naltrexone or Vivitrol and states that medication-assisted treatment is offered rather than required. Methadone for OUD is obtained through a federally certified opioid treatment program rather than through an ordinary residential or outpatient prescription.
Buprenorphine in Family Medicine and Office Settings
Buprenorphine can be prescribed in office-based settings, including primary care and family medicine, rather than only through opioid treatment programs. That access expanded substantially after the federal X-waiver requirement was eliminated at the end of 2022.
That requirement is gone. Congress eliminated the DATA 2000 or X-waiver requirement in the Consolidated Appropriations Act, 2023, so clinicians no longer submit a special Notice of Intent solely to prescribe buprenorphine for opioid use disorder [4].
The federal X-waiver and its special patient caps are gone. SAMHSA says licensed practitioners, except veterinarians, who hold a DEA registration with Schedule II through V authority may prescribe buprenorphine for OUD where state law allows, and the former federal patient limits were eliminated [4]. A separate federal training requirement now applies when many practitioners obtain or renew a DEA registration, but it is not a return of the old buprenorphine waiver.
How Long Does MAT Treatment Last?
There is no single duration that fits everyone. Buprenorphine treatment is individualized and can continue for months, years, or in some cases indefinitely, while methadone may also be used long term. Continuing medication is not a treatment failure, and stopping simply because an arbitrary deadline has been reached can increase risk. Duration should be decided with the prescriber based on benefit, safety, preferences, and recovery stability.
The BMJ analysis found particularly high mortality in the first four weeks after people left methadone or buprenorphine treatment [3]. That finding supports careful planning around discontinuation, but it does not mean every medication requires a taper. Methadone and buprenorphine can produce physical dependence and are generally reduced gradually when discontinuation is appropriate; naltrexone does not produce opioid dependence and does not require the same kind of taper. The chapter on Suboxone withdrawal symptoms covers buprenorphine tapering in more detail.
The useful question is not how quickly medication can be stopped. It is whether continuing, changing, or discontinuing it best supports the person’s safety, recovery goals, and clinical stability.
Starting Medication-Assisted Treatment and Behavioral Health Care in Iowa
Treatment usually begins with an assessment of the substance use disorder, current use, withdrawal risk, medical and psychiatric conditions, previous treatment, medications, and the person’s goals. Withdrawal management may be needed for some people, but opioid use disorder medication does not always require completing detox first: methadone and buprenorphine can be initiated as treatment, while naltrexone requires an opioid-free interval before it can be started safely.
Four things worth asking any program before you commit:
- Which medications do you actually offer on site, and which would mean a referral elsewhere?
- Does the assessment cover withdrawal risk, and does treatment start with medical detox if it is high?
- What psychosocial treatment comes with the medication, in hours per week?
- What happens if the first medication does not suit me?
If drinking is the problem rather than opioids, ask specifically whether the program evaluates and prescribes medications for alcohol use disorder rather than assuming that every substance use program does. An alcohol rehab program may include a medication discussion, but prescribing capacity and addiction-medicine expertise vary by setting.
Your Life Iowa is a free, confidential statewide resource for substance use, mental health, gambling, and related concerns. It is staffed 24/7/365, with calls at (855) 581-8111, texts at (855) 895-8398, and live chat, and it is a service of the Division of Behavioral Health at the Iowa Department of Health and Human Services [5]. Family members and friends can also contact the service, and system navigators can help connect people with appropriate treatment resources.
The Five Chapters in This Guide
Each of these goes considerably deeper than this page does.
- Suboxone side effects and what to expect in the first few weeks, which is the question most people have on day three.
- Suboxone vs methadone, including where Sublocade fits as the long-acting option.
- Suboxone withdrawal symptoms and how a taper is actually sequenced.
- How does naltrexone work for alcohol, covering Vivitrol, acamprosate, and disulfiram.
- Does Suboxone help with kratom withdrawal, and with 7-OH, which is a newer question than the others.
Two related pages sit outside this guide and are worth reading alongside it: 7-OH withdrawal warning signs for anyone whose opioid exposure came through kratom derivatives rather than through prescription pain relievers or heroin.
One closing thought. Medications for opioid and alcohol use disorders are evidence-based treatments, not a lesser form of recovery. For methadone and buprenorphine, the mortality evidence is especially important: remaining in treatment is associated with substantially lower all-cause and overdose mortality than being out of treatment [3]. The right medication and duration are individual clinical decisions, but taking an effective medication as prescribed does not make a person’s recovery less legitimate.
Sources
- Substance Abuse and Mental Health Services Administration. Treatment Options for Substance Use Disorder. https://www.samhsa.gov/substance-use/treatment/options
- Substance Abuse and Mental Health Services Administration. 42 CFR Part 8 Final Rule: Frequently Asked Questions. https://www.samhsa.gov/substance-use/treatment/opioid-treatment-program/42-cfr-part-8/faqs
- Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, Ferri M, Pastor-Barriuso R. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550. https://doi.org/10.1136/bmj.j1550
- Substance Abuse and Mental Health Services Administration. Training Requirements (MATE Act) Resources. https://www.samhsa.gov/substance-use/treatment/resources/mat-act/training-requirements
- Your Life Iowa, Division of Behavioral Health, Iowa Department of Health and Human Services. https://yourlifeiowa.org/
