MAT Options for Opioid Use Disorder
Six medications treat opioid use disorder, in three drug classes, across two delivery formats. The decision between them is not abstract. It depends on whether you are still using, what your insurance is, where you live, what your daily routine looks like, and what you have already tried.
| Medication | Class | Frequency | Where | Best fit |
|---|---|---|---|---|
| Methadone | Full agonist | Daily | OTP only (federally certified) | Severe, long-term OUD; pregnancy |
| Suboxone (sublingual buprenorphine) | Partial agonist | Daily | Any prescriber | Most active OUD patients in office-based care |
| Sublocade (extended-release buprenorphine) | Partial agonist | Monthly | Any prescriber (REMS) | Patients stable on Suboxone wanting easier adherence |
| Brixadi (extended-release buprenorphine) | Partial agonist | Weekly or monthly | Any prescriber (REMS) | Patients needing dosing flexibility or easier induction |
| Oral naltrexone | Antagonist | Daily | Any prescriber | Detoxed patients with strong adherence support |
| Vivitrol (extended-release naltrexone) | Antagonist | Monthly | Any prescriber | Detoxed patients wanting non-opioid maintenance |
The three drug classes
All MOUD falls into one of three pharmacological buckets. Full agonists, partial agonists, and antagonists.
- Full agonists. Methadone is the only one approved for OUD. It activates the opioid receptor fully, just slowly enough that patients do not get high at maintenance doses. Strongest withdrawal control, strongest craving suppression, most retention in treatment.
- Partial agonists. Buprenorphine in all its forms. Activates the receptor partially. Has a ceiling on respiratory depression that makes it much safer than methadone or full opioids. Treats withdrawal and cravings effectively.
- Antagonists. Naltrexone in oral or Vivitrol form. Blocks the receptor entirely. Does not treat withdrawal or cravings directly. Works by preventing relapse from being rewarding.
The treatment ladder, when it makes sense
Most patients with active OUD start on Suboxone or methadone. Suboxone if they can be stabilized in office-based care, methadone if they need the structure or have failed buprenorphine. After 6 to 12 months of stability, some patients transition to longer-acting options. Sublocade or Brixadi for those who want to stay on buprenorphine but reduce daily medication. Vivitrol for those who want to come off opioid medication entirely.
This is not a required sequence. Many patients start directly on Vivitrol if they have already detoxed (post-jail, post-residential, post-medical detox) and want a non-opioid option. Some patients stay on Suboxone indefinitely. There is no "right" length of treatment. The data supports continued maintenance for as long as the patient benefits.
Pregnancy
Methadone has the strongest evidence base in pregnancy and is the standard of care. Buprenorphine (Subutex, the buprenorphine-only form, not Suboxone) is the alternative when methadone is not available or appropriate. Vivitrol is generally avoided in pregnancy due to limited safety data.
The cost reality
Methadone is the cheapest medication, $80 to $200 per week in cash for clinic visits and dosing, but it is restricted to OTPs which limits geographic access. Suboxone is $100 to $300 per month for generic. The injectables run $1,200 to $1,600 per shot. All are covered by every state Medicaid program. Patient out-of-pocket cost on Medicaid is typically $0 to $5 for any of these medications.
What does not work
Detox alone, without medication maintenance, has a relapse rate above 90% within 12 months. "Just go to AA" is not a treatment plan for moderate-to-severe OUD. Tapering off MOUD too quickly because of stigma or social pressure is the most common reason patients return to use.