Safer Solutions: What does competition have to do with methadone access?
Note: This is our final Safer Solutions entry for 2025. We’ll be back Jan. 7, 2026.
Today, talk of curbing the supply of illicit drugs, particularly opioids like fentanyl, is commonplace. Methadone addresses the other side of the equation—demand—by helping people get into and stay in recovery. It’s one of the most effective treatment methods for opioid addiction, considered the “gold standard” by doctors and researchers. But methadone for opioid addiction is hard to access because it is uniquely regulated among Food and Drug Administration (FDA)-approved medicines in the United States, where it can only be accessed via specialty clinics called opioid treatment programs (OTPs).
OTPs play an important role in methadone treatment, but many Americans face barriers that prevent them from accessing these clinics. An estimated 77.5 million Americans live in counties without an OTP, which are “extremely scarce” in rural areas. That distance prevents some from making the daily commute to an OTP. While the average travel time to an OTP is about 45 minutes each way, a commute time of even 10 minutes can cut treatment retention by 33 percent. Federal and state regulatory barriers to opening new OTPs exacerbate this scarcity.
Incremental improvements to OTPs
Some recent innovations can help OTPs better reach and serve patients. Mobile medication units allow OTPs to visit underserved areas, and recent regulatory changes allow OTPs to offer “take-home” doses to some patients, decreasing the number of trips they must make to the OTP and making treatment less disruptive to other responsibilities like work and family. But variations in state and OTP policies dictate whether and how many take-homes are offered—and when they are rescinded. Some patients quit methadone treatment altogether because of “limited access to take-home doses and consequent need for daily or near daily clinic attendance.”
Competition concerns
Despite incremental improvements, the OTP-only system leaves many people with (at most) a single access point to methadone for opioid addiction. This lack of healthcare competition provides little market incentive for OTPs to improve patient experience. Some patients express frustration with their experience at OTPs, reporting “limited hours of operation … long lines, a lack of communication, and on-the-spot changes in patient requirements,” which make it difficult to meet the work and family obligations that are so important to recovery.
Consolidation concerns
Increased OTP ownership consolidation is adding to concerns about competition. A 2023 analysis of healthcare providers noted that “[c]onsolidation has the potential to increase efficiency and help some struggling providers to keep their doors open in relatively underserved areas, but it can also reduce market competition and ease pressure on providers to … invest in quality improvements.”
From 2011 through 2022, private equity firms “appeared to capture large shares of the OTP market, often by acquiring multiple facilities in the same county.” Researchers noted that overly burdensome regulations and community stigma make it hard to open new OTPs, allowing a small number of owners to increasingly dominate the market, which “might reduce incentives to compete on quality or improve service offerings that benefit patients.”
Lawmakers have long expressed concerns about consolidation in healthcare more broadly. As Sen. Bill Cassidy (R-La.), a physician himself, wrote in 2018, “[m]onopolies by large health systems have been particularly devastating to patients in rural areas.” In 2024, Rep. Jodey Arrington (R-Texas) talked about “one of the key issues plaguing our broken healthcare system … increased consolidation in healthcare markets.” Regarding methadone, in 2024 a bipartisan group of senators wrote, “We are concerned that there is incompatibility manifesting itself in private-equity-backed OTPs seeking to maintain their monopoly on methadone access, not because it is good for the patient, but because it is good for the bottom line.”
New avenues to access
The scale of the overdose crisis demands more access to evidence-based treatment, not less. Market competition can incentivize providers to improve patient access and experience, which can improve treatment uptake and adherence in turn. Competition can also drive down costs.
Removing unnecessary barriers to opening and operating OTPs would help. We can increase competition through surgical deregulation—by decreasing restrictions on where OTPs can open, minimizing the steps required to open them, and removing onerous regulations on existing providers.
Policymakers should also open up new avenues for methadone access. R Street has endorsed the federal Modernizing Opioid Treatment Access Act, which would expand methadone provision beyond OTPs by allowing addiction physicians to prescribe methadone for opioid addiction and pharmacies to dispense it—thereby creating new access points and meeting unmet demand.
R Street has also encouraged federal regulatory reform to achieve a similar outcome. In a recent letter, R Street and partner organizations asked the federal government to consider how the current regulation of methadone “materially harms competition in health care delivery,” stating that “[c]ontinuing to separate … methadone from other medical care has … created significant access barriers to this lifesaving medication…”
As economist and author Thomas Sowell once wrote, “[c]ompetition does a much more effective job than government at protecting consumers.” Regarding methadone access, the fact that its consumers are grappling with opioid addiction does not change this reality. Barriers to access can literally be a matter of life and death, and robust competition can better protect these consumers by increasing both access and patient choice. Individuals, families, communities, and taxpayers would all benefit from a healthy combination of deregulation and increased competition for this lifesaving medication.