ArticleHarm reduction journal2026
'It wasn't to get high; it was just to get by': experiences of patients who use fentanyl during methadone treatment and opportunities for improving care in Vermont and New Hampshire.
Article in Harm reduction journal, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundIn March 2020, federal regulations were updated to improve access to methadone for people with opioid use disorder (OUD) during COVID-19, and in February 2024, these COVID-19 flexibilities were further updated and made permanent. During the same time, high rates of fentanyl use and opioid overdose persisted in Vermont and New Hampshire. It was not well known how opioid treatment programs (OTPs) were meeting the needs of patients who continued to use fentanyl while on methadone. This study explored the experiences of patients who used fentanyl while on methadone for OUD and their suggestions to improve care.
methodsSemi-structured one-hour interviews and a brief survey were conducted with 30 patients who continued to use fentanyl while on methadone from 5 OTPs within 3 healthcare facilities in Vermont (n = 14) and New Hampshire (n = 16) from March 2023 to November 2024. Interviews focused on patient experiences with medication induction, dosing, fentanyl use, access to harm reduction materials, and recommendations to improve care. Interviews were audio recorded, transcribed, and analyzed using general thematic analysis.
resultsMost participants identified as White (90%; n = 27), male (53%; n = 16), and were unemployed (73%; n = 22). Patients' current daily methadone dose ranged from 35 to 220 mg, with commuting times from 10 to over 60 min. Six major themes were identified. Patients reported continuing fentanyl until reaching a sufficient methadone dose, after which fentanyl use decreased or stopped. Discomfort or withdrawal during induction was common, often triggering continued fentanyl use. Access to take-home doses was restricted and varied by state and OTP. Split dosing helped some manage cravings and reduce over-sedation for others. Naloxone and fentanyl test strips were highly accessible. Participants suggested structural changes to lower barriers to care, such as extending OTP hours and dosing windows. Three sub-theme patient recommendations to improve care also emerged including: (1) implementing a faster induction process, (2) increased access to take-home doses, and (3) expanded split dosing in OTPs.
conclusionsThis study highlights the importance of leveraging the expertise of patients who use fentanyl while on methadone to co-produce methadone treatment delivery. Findings may help inform the development of interventions to reduce barriers to treatment access and success within rural areas which may be slow to implement policy change.
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