Where I live, for example, the one methadone clinic often has a waiting list and it takes 1-2 years to get in the clinic!

Sometimes a person can’t make it to a methadone clinic for daily dosing, so the option is closed to them.

Sometimes an opiate dependent person has mental health issues or other life issues that make it unrealistic for them to comply with the rigid rules, structure and rigorous demands of most methadone clinics.

Sometimes a person rules out methadone treatment because of misinformation, or they can’t get past the stigma.

Although I agree with everything you said in your comment, I often see situations where people end up in one treatment instead of the other for a variety of reasons.

Ideally, both medications would be available in a range of settings so that both the medication and the delivery structure would match the needs of the patient!

Patients who need in excess of 60mgs of methadone to stabilize are unlikely to do well on buprenorphine, due to it’s ceiling effect. And, the usual dose of methadone required by most clinic patients is 80-120mgs. Therefore, methadone is targeted at the patient with a more severe opiate addiction, i.e., someone with a longstanding history or very heavy use pattern of either heroin or Rx opiates. Bupe, on the other hand, is targeted at those with a lighter use history–for example, someone who was using 10-20 vicodin a day for 6 months. This would be the main consideration in choosing between the two treatments, because obviously, the advantages of bupe are many (less “red tape”, the ability to Rx a month’s worth at a time right away, getting your treatment from a regular doctor’s office, and so on) and would be wanted by ALL patients. However, bupe is simply unlikely to work well for those with serious, heavy or long term habits.