Treating Opioid Use Disorder With Methadone in Pharmacies

Importance Methadone, a medication for opioid use disorder, is underused in the US response to the opioid overdose crisis. Under federal law, methadone can be offered in pharmacies via medication units, although a change to federal statutes or regulations could allow more options for pharmacists to dispense methadone. Objective To analyze innovative return on investment (ROI) for 2 pharmacy-based models: (1) pharmacy-based medication unit and (2) pharmacist-dispensed methadone. Design, Setting, and Participants This cross-sectional economic evaluation, conducted from March 13, 2024, to August 22, 2025, created 2 models for pharmacy-based methadone dispensed at community-based pharmacies in the US to people who are stable on methadone maintenance treatment and who were referred by the opioid treatment program (OTP) or who recently initiated treatment due to the new option for pharmacy dispensing: (1) an OTP and a pharmacy partner to operate a medication unit in the pharmacy wherein OTP clinicians prescribe and pharmacists dispense methadone and (2) regulatory changes that allow medical professionals to prescribe methadone and pharmacists to dispense the medication. Each model included startup costs plus 3 years of operational costs and revenue. Input data were extracted from key informant interviews, a time-motion study, and the literature. Data were analyzed from June 2024 to July 2025. Exposures Models addressed clinical services, anticipated consumers, potential competitors, key differentiators, and critical success factors. Input data were combined with microcosting methodology and enumerated minimum, best, and maximum values (PertBeta distributions) for 121 key inputs. A total of 10 000 Monte Carlo simulations were conducted to obtain 95% uncertainty intervals (UIs). Values are presented in 2024 US dollars. Main Outcomes and Measures The primary study outcomes were ROI ratios and net profits after 3 years in operation. Results The medication unit model (model 1) assumed a total of 3429 (95% UI, 1385-6244) client visits over the 3 years, indicating a mean (SD) of 95 (36) visits per month. For the pharmacist-dispensed model (model 2), the total number of client visits was estimated as 793 (95% UI, 531-1167), indicating a mean (SD) of 22 (5) visits per month. For model 1, over 3 years, a pharmacy would net 3. 53 (95% UI, 1. 14-6. 99) for every 1. 00 spent, yielding a profit of 96 904 (95% UI, 5365-267 451), including a 93. 8% likelihood of netting 15 000 by year 3. For model 2, over 3 years, a pharmacy would net 2. 64 (95% UI, 2. 04-3. 41) for every 1. 00, yielding a profit of 23 844 (95% UI, 15 045-36 546), including a 97. 6% likelihood of netting 15 000 or more by year 3. Conclusions and Relevance In this economic evaluation of 2 pharmacy-based methadone business models, both models demonstrated positive ROI over 3 years. This finding suggests that increased access to methadone—a key step in reducing overdose deaths—can be profitable for community pharmacies. Changes to federal statutes or regulations may be needed, depending on the preferred model.