More than 44,000 people died from opioid overdoses in the United States in 2025. Despite recent declines in overdose deaths, the country remains in crisis. Paradoxically, only a tiny fraction of people trying to access treatment for opioid use disorder (OUD) have access to methadone, the gold standard medication approved to treat addiction. Decades of research have shown that methadone is safe and effective, reducing risk of death from opioid overdose by more than half in some studies. Yet millions of Americans who might benefit from methadone are denied access due to byzantine and punitive rules that limit dispensing to specialized clinics, called opioid treatment programs (OTPs).
In Liquid Handcuffs: Policing and Punishment in Methadone Clinics and the Future of Opioid Addiction Treatment, author Helen Redmond, a licensed clinical social worker, journalist, and advocate, provides a meticulous yet eminently readable history of the regulation of methadone treatment for OUD and its consequences. Redmond’s book highlights how methadone ended up in this dystopian regulatory state and how the restrictive policies undermine efforts to beat the opioid crisis.
Alongside this important background, Redmond recounts the experiences and grievances of the people who attempt to navigate the regulatory complexities of the OTP system. Redmond explains how, in practice, these regulations subject patients to onerous and often degrading requirements that dissuade most from seeking treatment.
Approved for opioid addiction by the Food and Drug Administration (FDA) in 1972, methadone is designated as a controlled substance, making it subject to the same FDA rules on efficacy and safety applied to all drugs, as well as Drug Enforcement Administration (DEA) limits on production and dispensing for controlled substances. That designation, along with law enforcement concerns that it might enter the street drug supply, spawned the restrictive system aimed at avoiding such “diversion.” But ironically, simply by making clinic access so impractical, patients often seek methadone outside of the regulated clinic system or turn to street drugs. Redmond argues that policymakers seeking to ease the opioid crisis and curb overdoses should allow methadone to be more widely accessible without undue access barriers.
Some of the barriers Redmond most strongly decries are the requirements that patients must take their doses under staff observation, requiring them to travel to clinics, sometimes daily. Clinics are often far—partially due to state and local regulations limiting clinic numbers and locations—sometimes up to two hours away.
Patients are also subject to urine screenings under observation and sometimes inappropriate demands that have nothing to do with their treatment needs. In a particularly egregious example, one clinic imposed the completely arbitrary requirement that people show they were doing “something positive during the day” to continue to receive treatment.
Redmond provides readers with valuable research about methadone, such as a report by the National Academy of Sciences Institute of Medicine (IoM) from 1995 that concluded, “The effectiveness of methadone treatment of opiate addicts has been established in many studies conducted over three decades. … Consumption of all illicit drugs, especially heroin, declines. Crime is reduced, fewer individuals become HIV positive, and individual functioning is improved.”
Even so, Redmond details stories of patients who liken their experience on methadone to being on probation or parole. One woman was five months pregnant when a flood inundated the city of Boulder, Colo., and her methadone clinic closed. She was told to go to a clinic in Denver, but there was no public transportation running. Another woman lost her job and her access to her methadone because she had some wine during a toast at her grandson’s high-school graduation.
Patients using methadone to manage pain, as well as those taking other opioid medications, do not face the same hurdles or humiliation faced by those using methadone for OUD. Buprenorphine (often known by a brand called Suboxone) was approved in 2000 and is considered less effective but less risky than methadone. Thus, Buprenorphine can be prescribed by medical prescribers for at-home use, and millions of people have used it to discreetly treat opioid dependence while maintaining their professional and personal lives.
Forced inconvenience is rooted in the myth of diversion
A key reason patients don’t take or stay on methadone is the requirement to use it in a clinic. While “take-home” doses alleviate the inconvenience of showing up every day, that privilege is at the discretion of clinic staff. For decades, federal regulations have required near-daily supervised use for at least the first three months of treatment, with the potential to earn increasing numbers of take-home doses depending on length of stable treatment. Even when patients are allowed take-home doses, visiting family out-of-state, traveling for work, or even going on vacation are practically impossible because at any time a patient can be called to appear in person at the clinic within hours with all the take-home bottles they have been issued to make sure they have not been sold or otherwise misused.
The fear of misuse or sale of clinical-dispensed methadone is, again, the primary justification advanced for imposing such strict rules on methadone access. But Redmond argues these fears are overblown and rooted in moralistic misperceptions that methadone treatment is merely substituting one addiction for another, because methadone is technically an opiate. Redmond points out that methadone does not get users “high,” and long-term use is recommended to allow people to be productive members of their communities, as part of their recovery.
Redmond’s book digs into this myth with the question, “Who is buying diverted methadone and why?” She posits that it is “not the opioid-naive general public looking to experiment with a narcotic. It is overwhelmingly people who are dependent on an opioid and are not in treatment. One study showed that 34% of people who used diverted methadone were trying to stop using heroin, 10% to reduce a drug habit, 10% because no other narcotics were available, and 9% to avoid withdrawal.” In other words, many of those using illicit, diverted methadone might wish to access it legitimately through the clinic system, but cannot because they find the clinic strictures too prohibitive.
Hope for change?
A bill in Congress offers a small improvement to the methadone system. The Modernizing Opioid Treatment Access Act 2.0 (MOTAA 2.0), introduced by Sens. Edward J. Markey (D-Mass.) and Rand Paul (R-Ky.), would authorize physicians board-certified in addiction treatment to prescribe, and pharmacies to dispense, methadone for OUD treatment directly to patients. There are currently around 6,400 physicians that meet these qualifications, so the legislation would allow some people to get much more effective and convenient treatment. While the bill would do nothing to dismantle the dysfunctional clinic system, it could help demonstrate that expanding the number of medical professionals legally able to dispense methadone is safe.
During the pandemic, the Substance Abuse and Mental Health Services Administration issued guidance allowing clinics to offer stable methadone patients up to 28 days per month as take-home doses if state regulations allow it. That rule was made permanent before it was due to expire, but not all states have opted to implement it.
Studies conducted following the new guidance have concluded that take-home dosing didn’t increase overdose deaths or diversion, the two reasons always given to limit or deny them. The latest, an August 2026 academic study funded by Pew Charitable Trusts, confirms the lack of harmful outcomes and articulates the many benefits gained from people taking advantage of the relaxed rules.
Redmond’s Liquid Handcuffs offers a rare window on the absurdity of many of the methadone restrictions. As she puts it, “In any other field of medicine, deliberately denying someone their life-saving medication as a punishment would be grounds for a lawsuit, disciplinary action, or license suspension.”
It seems counterproductive to impose any complicating restrictions on people trying to access opioid addiction treatment. MOTAA 2.0 is far from comprehensive, but its policies are a step in the right direction.