The midterm results are behind us, yet the 119th Congress still has an opportunity to shape a more enduring record. Before leaving Washington, lawmakers can overhaul a portion of a regulatory framework that currently prevents one of the most effective treatments for opioid use disorder from reaching many people in need.
The bipartisan Modernizing Opioid Treatment Access Act 2.0 (MOTAA 2.0) would authorize certain addiction specialists to prescribe methadone for opioid use disorder and dependence and would permit community pharmacies to dispense it.
Methadone and buprenorphine stand as the two most potent options for treating opioid use disorder. A 2020 comparative-effectiveness study tracked 40,885 individuals across six treatment paths. Only those treated with methadone or buprenorphine showed a meaningful reduction in overdoses and serious opioid-related acute care compared with those who received no treatment. Those treated with either methadone or buprenorphine had a 76 percent lower overdose risk at three months and a 59 percent lower risk at 12 months. Detoxification, residential treatment, intensive behavioral interventions, and naltrexone did not significantly cut overdoses during either window.
Both medications alleviate withdrawal symptoms and cravings, but they act differently. Methadone fully activates the brain’s opioid receptors, whereas buprenorphine activates them only partially and has a ceiling effect. That ceiling lowers buprenorphine’s risk of respiratory depression and overdose. Yet the full-agonist property of methadone may better suppress withdrawal and cravings in individuals who have developed high opioid tolerance from regular exposure to potent illicit fentanyl. Buprenorphine can also trigger withdrawal if started too soon after fentanyl or another full opioid agonist.
These distinctions may help explain why methadone often sustains patients in treatment longer. A 2024 population-based study found that people who began methadone stayed in treatment for a median of 66 days, compared with 30 days for those who started buprenorphine. After adjustment, buprenorphine recipients faced a 58 percent greater risk of dropping out. A comprehensive 2023 systematic review and meta-analysis similarly identified better retention with methadone after the first month, including at six months in both randomized trials and observational studies. More recently, a 2025 JAMA Network Open analysis concluded that buprenorphine’s lower mortality risk during treatment did not offset its higher rate of discontinuation. The authors urged that treatment guidelines should not automatically privilege buprenorphine over methadone and that clinicians should tailor choices to each patient’s tolerance, prior treatment history, preferences, and ability to remain engaged in care.
Yet federal law generally ties methadone treatment for opioid use disorder to government-certified opioid treatment programs, or OTPs—commonly referred to as methadone clinics. Physicians may prescribe methadone for pain, and pharmacies may fill those prescriptions. But if the same clinician uses methadone to treat addiction, criminal penalties can be imposed. Patients must instead obtain methadone through an OTP, often requiring in-person visits for observed dosing.
That bifurcated system leaves millions without access to effective therapy. The 2025 National Survey on Drug Use and Health found that roughly 4 million Americans aged 12 and older had opioid use disorder in the prior year. Only about 15.7 percent—around 623,000 people—reported receiving medication for it.
The United States operates only 2,110 federally certified opioid treatment programs, versus roughly 60,000 retail pharmacies. Approximately 80 percent of U.S. counties lack an OTP.
Distance is only part of the burden. Daily or near-daily clinic visits disrupt work, child care, schooling, and family responsibilities. Public transportation can stretch a manageable distance into hours of travel. Researchers found that patients living more than 10 miles from an OTP were 29 percent more likely to miss a dose than those living within five miles. A five-state study with high opioid-overdose mortality rates showed rural residents faced an average 49-minute drive to the nearest methadone clinic, compared with 17 minutes to a federally qualified health center.
MOTAA 2.0 would open another access route. It would authorize physicians who are board-certified in addiction medicine or addiction psychiatry to obtain a separate Drug Enforcement Administration (DEA) registration to prescribe methadone for opioid use disorder. Patients could fill these prescriptions at community pharmacies. The Department of Health and Human Services could later authorize additional prescribers who meet the agency’s standards.
The bill’s sponsors revised the original MOTAA to address concerns raised by law enforcement and treatment providers. The earlier MOTAA, approved by the Senate Health, Education, Labor, and Pensions Committee in December 2023, permitted pharmacy-dispensed methadone for unsupervised use and generally limited prescriptions to a 30-day supply.
MOTAA 2.0 would allow either supervised or unsupervised dosing at pharmacies, depending on clinical judgment. It restricts pharmacy-dispensed methadone for opioid use disorder to liquid or dispersible tablet forms, excluding the traditional solid tablets tied to much of the earlier era of pain prescribing deaths. It preserves federal and state authority to limit dispensing quantities, requires electronic prescriptions, preserves state licensing frameworks, and permits states to stop the program within their borders. It also requires annual DEA reports on participating prescribers, disciplinary actions, state opt-outs, and pharmacies ordering eligible methadone formulations. The law would take effect 180 days after enactment.
Not everyone is satisfied. The group Advocates for Opioid Addiction Treatment labels MOTAA dangerous and warns it could escalate diversion and recreate the “pill mill” dynamics of the early 2000s. The American Association for the Treatment of Opioid Dependence and the National Association for Behavioral Healthcare oppose it as well. Law-enforcement opponents include the National Sheriffs’ Association, Major County Sheriffs of America, the National Police Association, and the National Alliance of State Drug Enforcement Agencies.
Methadone can cause respiratory depression and fatalities, particularly at initiation or when combined with other depressants. Concerns about induction, accidental ingestion, and diversion deserve careful attention. But opponents frequently cast MOTAA 2.0 as permitting unrestricted prescribing by clinicians lacking addiction training. That is not what the bill does.
The diversion data are less alarming than opponents claim. When the COVID-19 pandemic began, the Substance Abuse and Mental Health Services Administration allowed clinically stable OTP patients to take home up to a 28-day methadone supply, with less stable patients capped at 14 days.
If broader take‑home access were a major driver of diversion and deaths, one would expect to see a spike in methadone-related mortality. That did not occur. A study conducted by the National Institute on Drug Abuse and the Centers for Disease Control and Prevention found that monthly methadone-involved overdose deaths remained steady after the reform, even as overdoses from other substances continued to rise. Methadone’s share of overdose deaths declined. A subsequent state comparison also found that expanded take-home privileges did not increase methadone-involved mortality.
SAMHSA concluded that diversion remained at a level sufficient to consider the reforms permanent in 2024. The agency notes that misuse and diversion are more likely when methadone is prescribed for pain than when programs dispense it for opioid use disorder.
That distinction matters because critics repeatedly point to the methadone-associated deaths surge in the early 2000s. A Government Accountability Office investigation linked much of that rise to a rapid expansion of methadone prescribing for pain. The report shows pain-related prescriptions increasing from about 531,000 in 1998 to 4.1 million in 2006—about sevenfold. Yet that history is not directly comparable to MOTAA 2.0, which does not duplicate the pain-prescribing surge of that era. It offers carefully monitored treatment for a diagnosed opioid use disorder under a separate DEA registration.
Research also challenges the assumption that diverted methadone is primarily used for recreation. The National Institute on Drug Abuse notes that diversion is chiefly linked to methadone prescribed for pain, rather than methadone dispensed to treat opioid use disorder. Among people who obtained methadone illicitly, the most commonly reported reason was missing a scheduled medication pickup. In another survey, 80 percent of those who diverted methadone did so to assist others who used drugs.
A Baltimore study found that diverted methadone and buprenorphine were mostly used to self-treat withdrawal and attempt detoxification rather than to get high. Participants described diverted medication as a bridge into treatment, after leaving treatment, or when clinic rules and waiting lists limited access to formal treatment. A 2026 review of 29 studies from seven countries similarly reported that people most often diverted methadone to help friends or partners in withdrawal, while recipients generally used it to prevent withdrawal or to avoid illicit opioids. The review found no support for the claim that systems relying exclusively on specialty clinics necessarily yield less diversion or fewer overdoses.
Expanding lawful access to treatment may more effectively shrink the illicit methadone market than forcing patients to travel farther and endure onerous clinic rules.
OTP operators also have a clear financial incentive to preserve their dominant role. Advocates for Opioid Addiction Treatment describe themselves as a coalition representing more than 700 OTP and office-based treatment facilities. The American Association for the Treatment of Opioid Dependence asserts it represents more than 1,400 OTPs. Their policy arguments deserve a fair hearing, but Congress should recognize that MOTAA would provide patients with alternatives to the facilities those groups represent.
MOTAA 2.0 still stops short of a complete revolution. As of 2024, roughly 4,600 physicians are certified in addiction medicine and 1,500 in addiction psychiatry. Even if every single one pursued the new registration and accepted new patients, they could not adequately meet the needs of the 4 million people with opioid use disorder. A substantial share practice in the same large metro areas that already host OTPs.
The ideal vision would be that any properly licensed clinician who wishes to treat opioid use disorder could prescribe methadone, just as clinicians can prescribe buprenorphine today without the former X-waiver. Before the federal rules took effect in 1972, American doctors treated patients with methadone in standard medical offices. Clinicians in Canada, Britain, and Australia have prescribed methadone in community settings, working with pharmacists, for decades.
MOTAA 2.0 leaves too much influence with the DEA, depends on a small cadre of specialists, and offers little relief for states that block reform. Yet it would dismantle the federal OTP monopoly and begin treating opioid use disorder more like other medical conditions.
The Senate version, S. 4941, sits with the Senate HELP Committee. Its House counterpart, H.R. 9790, is before the Energy and Commerce and Judiciary committees. No hearings or markups have taken place on the current bill.
Senate HELP Chairman Bill Cassidy (R–LA), House Energy and Commerce Chairman Brett Guthrie (R–Ky.), and House Judiciary Chairman Jim Jordan (R–OH) still have latitude to advance it. Congress could also attach MOTAA to a suitable year-end package, as urged by the American Society of Addiction Medicine and nearly 150 supporting organizations.
The midterm elections delivered a pointed rebuke to Republicans, giving Democrats control of both chambers after two years of unified Republican leadership. The outgoing majorities now face a brief window to demonstrate that they can remove a harmful government barrier and accomplish something meaningful.
