Methadone Remains Superior to Buprenorphine for Opioid Use Disorder Treatment Retention, Even as Fentanyl Dominates the Drug Supply

Compared with buprenorphine, methadone is associated with superior treatment retention among people with opioid use disorder (OUD). Historically, studies involved populations with heroin or prescription opioid use. Today, high potency opioids, including illicitly manufactured fentanyl and its analogues, pervade the drug supply. This retrospective observational study used nine linked population-level administrative databases in British Columbia, Canada to assess the risk of treatment discontinuation and mortality among people with OUD initiating buprenorphine or methadone during a time when fentanyl became dominant in the illicit drug supply (2010–2020).

• The study examined 30,891 individuals initiating methadone or buprenorphine for OUD treatment.
• The risk of treatment discontinuation within 24 months was greater among recipients of buprenorphine versus methadone (89 percent versus 82 percent; adjusted hazard ratio [aHR], 1.58).
• The risk of mortality was low with both buprenorphine and methadone (0.08 percent versus 0.13 percent, respectively; aHR, 0.57).

Comments: Receipt of methadone continues to be associated with greater OUD treatment retention than buprenorphine, even as illicitly manufactured fentanyl has become widespread in the drug supply. It is notable that in Canada, both methadone and buprenorphine are available in office-based settings. In contrast, methadone for OUD treatment can only be obtained in the US in an opioid treatment program, which may limit the generalizability of these findings to populations with less restrictive access to methadone.

Susan L. Calcaterra, MD, MPH, MS

Reference: Nosyk B, Min JE, Homayra F, et al. Buprenorphine/naloxone vs methadone for the treatment of opioid use disorder. JAMA. 2024;332(21):1822–1831.