A large new analysis published in JAMA Network Open adds useful detail for one specific group: people who recently survived an overdose. In this study methadone was linked to better survival.
2 Minute Medicine reported on the study and rated it as Level 2 evidence. That means the evidence is good but not definitive.
What the Study Measured
Researchers used linked health data from Ontario, Canada to compare people who started methadone with similar people who started sublingual buprenorphine naloxone.
Everyone in the study was at least 15 years old. Each person had visited an emergency department for an opioid overdose within the previous year and started opioid agonist treatment between 2017 and 2023.
Researchers matched participants one to one using propensity scores, sex and treatment start date. The final group included 5,882 people with 2,941 in each treatment group. The researchers looked primarily at whether participants died from any cause within one year.
Methadone and Survival
During the year of follow up, 165 people who started methadone died. The buprenorphine naloxone group had 210 deaths. That equals 5.6% of the methadone group compared with 7.1% of the buprenorphine naloxone group. Researchers reported a hazard ratio of 0.78 with a 95% confidence interval of 0.63 to 0.95.
People who started methadone also stayed in treatment longer. They had a lower risk of discontinuing treatment.
Their median treatment duration was 25 days compared with 16 days for people taking buprenorphine naloxone. The overdose findings were more complicated.
Researchers found no significant difference between the groups in the time to another opioid overdose across the full follow up period.
But when they looked only at periods when participants actively took their assigned medication, methadone showed a higher overdose hazard of 1.52 with a confidence interval of 1.19 to 1.93.
What the Findings Mean
The per protocol analysis provides an important piece of the story. When researchers looked only at time spent actively taking treatment, the mortality difference between the medications disappeared.
The hazard ratio was 0.84 and the confidence interval was wide enough to include no effect. The study authors saw this as a possible sign that treatment engagement matters as much as the medication itself.
Their conclusion was that staying connected to effective opioid agonist treatment may matter more than which medication someone starts.
Methadone’s survival advantage may largely reflect the fact that people in the study stayed on it longer.
The researchers also identified several limitations. They didn’t randomly assign people to treatment. Participants had substantial differences in their treatment histories before matching.
The study couldn’t capture overdoses that never led to an emergency department visit. Researchers also didn’t model medication changes in their primary analysis.
Methadone vs Buprenorphine
Methadone is a full opioid agonist. Licensed opioid treatment programs dispense it and typically require daily in person visits early in treatment.
Buprenorphine naloxone is a partial opioid agonist. Clinicians can prescribe it through office based settings and patients can take it at home. That can make treatment easier to access but it can also make it easier to stop.
Both medications have FDA approval for opioid use disorder. Both also have substantial evidence supporting their use. Most rehab centers that offer medication assisted treatment work with one or both medications.
What This Means for You
If you’re choosing addiction treatment after an overdose, this study highlights one factor that deserves serious attention: which program can you realistically stick with?
The medication with better survival numbers in this study was also the medication that participants stayed on longer.
The other side matters too. Daily dosing can make methadone harder to manage if you have a job, childcare responsibilities or limited transportation.
A buprenorphine program that you can attend for a year may serve you better than a methadone program that you leave after three weeks.
Comparing Rehab Programs
When you compare programs ask which medications they offer and whether you take the medication on site or at home. Ask what happens if you miss an appointment.
It’s also worth asking how the program handles the first month. That’s when many people in this study stopped treatment.
Check your insurance coverage before you commit. Methadone programs and office based buprenorphine prescribers may bill differently. You should also verify the facility’s licensing and accreditation before choosing a program.
Finding a Treatment Center
Rehab.com’s directory lets you compare treatment centers by medication offered, level of care, location and insurance accepted.
I’d focus on those details rather than choosing based on the medication name alone. The program you can realistically stay with may matter just as much as the medication you start. Call
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