“Tethered to this ball and chain”: Women’s perspectives on bodily agency within Opioid Treatment Programs

Abstract

Background

Methadone Maintenance Treatment (MMT) reduces the risks associated with opioid use disorder (OUD), including overdose mortality and HIV/HCV transmission, and promotes patient well-being. Nonetheless, MMT is highly underutilized in the United States, with less than 10% of those with OUD receiving MMT. This study examines how women’s feelings of bodily agency while receiving MMT through Opioid Treatment Programs (OTPs) can impact treatment retention.

Methods

In-depth interviews were conducted with 20 women in Pennsylvania with a lifetime history of criminal legal involvement and use of medications for opioid use disorder (MOUD), and 12 substance use disorder (SUD) treatment professionals who work with criminal-legal involved women using MOUD. A thematic analysis was conducted using iterative rounds of inductive coding.

Results

While women attested to the profound benefits which methadone treatment can provide, they also described how both formal and informal policies in the OTP system can taper these benefits by diminishing their feelings of bodily agency. Women reported a lost sense of bodily agency due to being unable to provide input in the dosing process, navigating strict requirements that tied medication receipt to compliance, and facing mistreatment or threats of punishment when committing perceived transgressions. Women responded through actions that reclaimed bodily agency, by either leaving treatment or using illicit drugs while in treatment; both of these actions can end women’s engagement with treatment. Finally, evidence suggests that these feelings of lost agency may be particularly prevalent among female patients due to gendered judgments about women’s histories and capabilities.

Conclusion

Findings suggest the need for MMT programs to shift toward patient-centered, trauma-informed care informed by harm-reductionist principles. Concrete policy recommendations include reducing measures of surveillance, prohibiting administrative discharge due to the use of other substances, and expanding access to methadone beyond OTPs.

1. Background

In 2021, over 100,000 people in the United States died of an overdose (Spencer et al., 2022) compared to around 17,500 in 2000 (Planalp & Lahr, 2018)—a nearly 7-fold increase. Seventy five percent of these deaths were opioid-related, and around 60 percent involved synthetic opioids, particularly non-prescribed fentanyl (Spencer et al., 2022). The long dominance of the abstinence-only model of treatment in the U.S., such as that employed in 12-step programs, may have contributed to these elevated overdose rates (SAMHSA, 2022a). One study found that abstinence-based treatment programs increased the risk of fatal opioid-related overdose by 77 percent when compared to no treatment at all; comparatively, non-abstinence-based programs that utilized methadone reduced the risk of fatal overdose by 38 percent (Heimer et al., 2024). Approved in 1972 by the U.S. Food and Drug Administration, methadone is far from new (Institute of Medicine Committee on Federal Regulation of Methadone Treatment, 1995). However, with mounting evidence proving its effectiveness at reducing the risk of overdose, overdose death, and transmission of infectious diseases (Karki et al., 2016; Larochelle et al., 2018; Mattick et al., 2003; Schwartz et al., 2013; Sordo et al., 2017), U.S. activists, policymakers, researchers, and drug users alike are increasingly calling for the use of methadone to address the ongoing overdose crisis (Simon et al., 2022).

Despite the proven effectiveness of methadone, there remain steep institutional barriers to its use in the U.S. While other medications for opioid use disorder (MOUDs) like buprenorphine can be prescribed in office-based settings and dispensed at pharmacies, methadone can only be provided for opioid use disorder (OUD) by federally certified Opioid Treatment Programs (OTPs) (SAMHSA, 2015). OTPs are subject to a complex and uneven regulatory landscape: the Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Agency (DEA) issue regulations, guidelines, and recommendations at the federal level, state governments can employ additional restrictions, and OTP directors can add further restrictions at their programs (SAMHSA, 2015). As more than half of OTPs are for-profit organizations, OTP practices are also influenced by private sector incentives (Sharma et al., 2017).

OTPs operate under a biomedical framework that follows the chronic, brain-disease model of addiction: those diagnosed with OUD are provided a daily dose of methadone under medical supervision to reduce opioid cravings, reduce withdrawal symptoms, and block or blunt the reinforcing effects of other opioids (WHO, 2009). Yet, unlike with other medications in the U.S., patients beginning methadone maintenance treatment (MMT) must visit OTPs daily for supervised dose administration, submit to random drug testing, and, depending on state and OTP regulations, attend mandatory counseling sessions (Izquierdo et al., 2022b; SAMHSA, 2015). Patients who do not meet these requirements may be discharged against their will (Izquierdo et al., 2022b; SAMHSA, 2015).

Thus, despite MMT’s biomedical framing as a therapeutic intervention, OTPs function more like institutions of social control (Bourgois, 2000). This contradiction can be unpacked through Foucault’s theories of biopower and disciplinary power–where biopower is a mechanism of power that regulates and manages populations’ biological processes, like life, death, or illness, and disciplinary power is a mechanism of power that trains individual’s behaviors and thoughts (2000). OTPs utilize various forms of “regulatory technologies” to exercise these forms of power over patients at a micro-institutional level, regulating their behaviors, managing their biological processes, and restricting their own agency over their bodies (Keane, 2009; Nettleton et al., 2012). Such technologies are directed at bodies and behaviors deemed deviant–where deviance is not an inherent quality of said bodies or behaviors, but rather determined by dominating social groups that create rules and subjectively label those who break them as outsiders (Becker, 1963) These technologies thus aim to transform “deviant drug users” into productive and obedient citizens, as defined by dominant gender, race, and class structures (Bourgois, 2000; Friedman & Alicea, 2001; Keane, 2009; Nettleton et al., 2012).

As one concrete example of how OTPs enact biopower and disciplinary power to do this, Fraser (2006) describes how OTPs’ strict structuring of time aims to teach patients self-discipline, timeliness, and responsibility. Patients must arrive to the clinic on time, often daily, and at early and limited hours, and must wait for long periods of time to receive their dose; not abiding by these time expectations can result in missing one’s dose (Fraser, 2006). Through these such practices, OTPs coerce patients into policing themselves in accordance with the dominant standards and ideals they impose. Patients must mitigate their own “risky behaviors” by submitting to the discourse, rules, and structures presented to them. Thus, these technologies limit patients’ ability to make their own decisions about what they do with and for their bodies; in other words, these technologies limit patients’ bodily agency (Friedman & Alicea, 2001; Keane, 2009; Nettleton et al., 2012; Mayock & Butler, 2021).

If patients do not effectively self-police and submit to clinic rules, they may face punishment. Such punishment is often directly inflicted on patients’ bodies, serving as a key tenant to operations of biopower within the clinic (Bourgois, 2000; Fraser & Valentine, 2008; Smith, 2011; Harris & McElrath, 2012). As punishment for missing dosing times, missing counseling sessions, or failing urine screenings, OTPs can take away take-home doses, enforce dose reductions, or discharge a patient from treatment as punishment, leading to withdrawal (Fraser, 1997; Bourgois, 2000; Friedman & Alicea, 2001; Fraser & Valentine 2008; Smith, 2011; Harris & McElrath, 2012). But punishment can also appear in more elusive ways. The rigid scheduling and significant time commitments required by OTPs can prevent patients from maintaining employment, seeking additional healthcare and social services, and fulfilling other personal and familial responsibilities, stripping them of agency over where they can go and what they can do with their bodies at any given time (Smith, 2011; Rance et al., 2012). Punishment within the OTP apparatus not only coerces compliance but also attempts to dismantle drug-using culture, assimilate drug-using peoples, and eradicate resistive subjectivities (Brookfield et al., 2021).

Female patients must also navigate the gendered effects and logics that operate through OTPs. Fraser (1997) and Friedman & Alicea (2001) report a lack of overall gender-sensitive care present at OTPs, including childcare services, all-women treatment or counseling spaces, and trauma-informed care that addresses experiences with domestic and sexual abuse. Both note how incorporating these services would improve women’s retention in and satisfaction with MMT. But beyond these tangible spaces and services, Fraser (1997) and Friedman & Alicea (2001) also point to more intangible gendered power dynamics and expectations that operate within OTPs. While men are also subject to regulatory technologies like supervised urine screenings, supervised dosing, and strict attendance rules, there are key differences in how these practices are experienced. Because OTPs exist within a broader patriarchal system, their biopolitical and disciplinary logics reinforce patriarchal control and domination over women’s bodies, leading women to feel an overall lack of bodily agency within MMT (Fraser, 1997; Friedman & Alicea, 2001).

Despite the various ways OTPs use disciplinary and biopolitical power to regulate patients’ behaviors and bodies, especially those of women, patients are embodied actors with potential for exerting alternative, resistive subjectivities (Dennis, 2016, 2020). Resisting OTPs’ operations of control, surveillance, and regulation allows women to reclaim agency over their bodies. Scholars have found that women resist in many ways, for example by negotiating treatment terms with staff to have more time for personal, familial, and work responsibilities, or by manipulating urine screenings and using other substances outside of treatment (Friedman & Alecia, 2001; Fraser, 2006; Smith, 2011; Schlosser, 2018; Mayock & Butler, 2021).

While nearly 5.6 million U.S. residents over age 12 had an OUD diagnosis in 2021 (SAMHSA, 2022b), only 475,000 people accessed MMT that same year (NASADAD, 2022). Thus, despite its proven effectiveness, MMT is clearly underutilized in the U.S. Significant research has aimed to outline barriers to MMT initiation and retention, with the goal of informing interventions to increase MMT use (Hutchison et al., 2023). Nonetheless, both research and policy initiatives continue to focus primarily on instrumental barriers to MMT engagement—gender non-specific factors like transportation, clinic hours, and insurance, and women-specific factors like childcare (Letourneau et al., 2013; Pasman et al., 2022).

Certainly, addressing these very tangible issues could increase access to MMT. However, this study returns to the rich history of critical social research on OTPs outlined earlier to examine patients’ continued experiences with the power exerted by OTPs. Drawing on the accounts of 20 women currently or previously enrolled in MOUD treatment programs in Pennsylvania and 12 SUD treatment professionals who work with women using MOUD, this manuscript examines how women’s feelings of agency over their bodies in OTPs impact their engagement in MMT. We outline how women experience a loss of bodily agency in MMT, demonstrate how this loss motivates women to leave treatment or take actions that can lead to discharge, and suggest how women’s histories of gender-based trauma make them uniquely susceptible to experiencing loss of agency as a trigger. Ultimately, we extend these findings to suggest policy and practice recommendations that could improve the quality and effectiveness of MMT, particularly for women, as a key treatment model and harm reduction strategy in the U.S.

2. Methods

This manuscript derives from a study examining barriers and facilitators to MOUD treatment initiation, retention, and completion among criminal-legal involved women with OUD. The study, approved by the Pennsylvania State University Institutional Review Board (STUDY00018974), leveraged interviews with women who have a history of MOUD use and criminal legal involvement, SUD treatment professionals, and criminal legal professionals who work with women with OUD. The present manuscript draws only on those interviews conducted with SUD treatment professionals and the women with lived experience, as criminal legal professionals did not speak to the specific topics discussed in this manuscript. The authors of this manuscript include the PI of the study, two team members who participated in data analysis, and one team member who provided guidance throughout all stages of the study.

The study team used three strategies to recruit women with lived experience for interviews. First, flyers with information about the study were sent to OTPs across Pennsylvania to be hung in clinic waiting rooms. OTPs and their addresses were identified using the SAMHSA Opioid Treatment Program Directory. Additionally, the study team posted social media advertisements with information about the study, and participants were encouraged to share information with others through snowball sampling. Potential participants were screened for eligibility using a REDCap survey. Eligible participants needed to 1) have a lifetime history of MOUD use, 2) have a lifetime history of criminal legal involvement, 3) live in Pennsylvania, and 4) be at least 18 years of age. Twenty eligible women were recruited for participation, meeting recent recommendations for achieving theoretical saturation in bounded qualitative research (Hennink and Kaiser, 2022).

Similarly, three strategies were used to recruit SUD treatment professionals who work with women using MOUD. In addition to sending flyers to the OTPs to recruit female patients, the study team also called the 113 OTPs to share information about the study and recruit staff members. Phone numbers for the OTPs were again obtained using the SAMHSA directory. In addition to calling OTPs, the study team posted social media advertisements, and participants were again encouraged to share information with other potential participants. Potential participants for this subsample were also screened for eligibility using a REDCap survey. Eligible participants needed to 1) practice in Pennsylvania, 2) work with female patients or clients, 3) be at least 18 years of age, and 4) either a) prescribe MOUD, or b) provide accompanying counseling, case management services, or other care for women participating in an MOUD treatment program. Twelve eligible SUD treatment professionals were recruited for participation, again meeting recommendations for achieving theoretical saturation (Hennink and Kaiser, 2022).

Participants from both groups were contacted by the study team to schedule interviews, which took place over the phone between May and August 2022. At the time of the interviews, interviewers first explained the study purpose (i.e., to assess barriers and facilitators to MOUD treatment initiation, retention, and completion among criminal-legal involved women) and asked participants to provide verbal consent. After the consent process, interviewers proceeded with a roughly 60-minute interview. Women’s interviews focused on their personal experiences with MOUD treatment and the criminal legal system, while the professionals’ interviews focused on their work with criminal-legal involved women in their MOUD treatment programs. Interviewers used a semi-structured interview guide which included a limited number of main questions to be asked to all participants, along with suggestions for optional probes. Main questions were open-ended, such as “What was the most helpful when you were in treatment?” and “What was the least helpful when you were in treatment?” Optional probes included suggestions to get participants talking, like “How did relationships with treatment providers, staff, and counselors influence your treatment experience?” Interviewers also could ask probes or follow-up questions of their own based on participants’ answers. All participants were compensated with a $50 gift card at the conclusion of their interviews.

Interviews were transcribed, and all identifying information was removed from the transcripts. The study team then analyzed transcripts through a thematic analysis (Braun and Clarke, 2006). First, three study team members devised a coding scheme inductively. These team members read transcripts independently, generating a list of primary codes that encompassed all major subjects in the transcripts. Each continued to read additional transcripts until no new codes were added with subsequent reading. The team members compared lists, and discrepancies were discussed and resolved. Once this list of primary codes was finalized, the three team members repeated this process to generate secondary codes—themes arising within each of the major subjects. Using the resulting codebook, four study team members then coded the transcripts. Three of these team members each served as the “primary coder” for one-third of the transcripts. The fourth team member (the PI) double-checked all coded transcripts for consistency in data interpretation across the three primary coders. Any discrepancies between the PI’s interpretation and the primary coder’s interpretation on a single transcript were discussed between the PI and primary coder and resolved. Any discrepancies between primary coders’ interpretation across transcripts were identified by the PI, discussed as a group, and resolved. Discrepancies of both kinds were minimal, providing credence that interpretation was largely consistent across coders.

3. Results

3.1. Participant demographics

Among the women with a history of MOUD use and criminal legal involvement, participants ranged in age from 24 to 54 years, with an average age of 37. Most (70%) identified as white and non-Hispanic, one identified as African American, one as biracial, and four did not specify. Over half (60%) were single, one was married, six (30%) were engaged or in a relationship, and one did not specify. Roughly two-thirds (65%) had children under the age of 18, ranging from 1 to 4 total children; and of those with children, roughly two-thirds currently had custody. Regarding educational attainment, approximately half (55%) had a high school diploma or GED as their highest degree, four (20%) had obtained a bachelor’s degree, one had obtained an associate’s degree, two (10%) had a post-HS certificate, one had less than a high school degree, and one did not specify. Over half (65%) were employed either part-time or full-time, while the remainder (35%) were not employed.

Among the SUD treatment professionals, participants ranged in age from 38 to 54 years, with an average age of 48. Most (83%) identified as female, while two (17%) identified as male, and two-thirds (66%) identified as white and non-Hispanic, two (17%) identified as African American, and two did not specify. The sample included nurses (n = 3), counselors (n = 3), case managers (n = 3), recovery/treatment program directors (n = 2), and a research assistant overseeing case managers (n = 1).

For the purposes of this manuscript, it is also important to note how many of the women specifically used methadone, rather than other MOUDs, and of these women, how many experienced a disruption in their methadone treatment, for example due to voluntary departure or discharge. Most (75%) of the women reported using methadone at some point. Of these, 20 percent did not report experiencing a disruption in methadone treatment, 33 percent had experienced a disruption and were not using methadone again at the time of the interview, and 47 percent had experienced a disruption but were using methadone again at the time of the interview. Importantly, these numbers could be undercounts. Some women who did not report using methadone ever may have used it at some point but just did not mention it in the interview. Additionally, some of the women who did not report experiencing a disruption may have actually done so but again did not mention it.

3.2. Findings overview

In their interviews, women detailed the profound benefits which methadone treatment had brought to their lives. However, these benefits were often tapered by negative experiences with the methadone treatment system. More specifically, women described how both formal and informal policies and practices used by OTPs diminished their feelings of bodily agency—both concerning what they put in their bodies (i.e., agency over their bodily well-being) and what they do with their bodies (i.e., agency over their bodily routines). Through a thematic analysis, we found that women feel a loss of bodily agency due to 1) being unable to provide input in the dosing process; 2) navigating strict requirements that tie medication receipt to compliance; and 3) facing mistreatment or threat of punishment when committing perceived transgressions. Women responded to these experiences in ways that reclaimed lost bodily agency, such as by 1) leaving treatment or 2) using illicit drugs while in treatment. Since OTPs often respond to illicit substance use punitively through discharge, both actions of reclamation could end women’s treatment engagement. Finally, evidence in both women’s and SUD treatment professionals’ interviews suggest why these feelings of lost bodily agency may be particularly prevalent among female methadone patients: gendered judgments about women’s histories and capabilities may especially encourage providers to apply and enforce these agency-diminishing policies and practices on female patients. In the Discussion, we also suggest why this perceived loss of bodily agency may have a particularly strong impact on women.

3.3. Loss of bodily agency in the clinic

Participants asserted that accessing methadone had benefited them in a variety of ways. This was especially true for those subject to a lesser degree of surveillance and control by the clinic—receiving take homes, being treated well by staff, having little or no experience losing take homes, and/or never facing involuntary discharge. For these participants, having access to a safe and regulated supply of methadone brought a sense of normalcy. They could worry less about navigating the unregulated, illicit opioid supply or facing withdrawal if they were unable to access an opioid at all. One participant (#35) even told us that, because she could consistently take methadone orally, she felt more confident in her body: “I was able to wear short-sleeve shirts, and I wore sun dresses, shorts, and skirts for that whole summer, because I was happy to be able to show my arms and stuff.”

Some participants also mentioned that certain accountability measures were useful for them. One participant (#23) who had been in MMT for approximately six months told us that she appreciated daily-dosing. She said, “I like how the methadone’s controlled every day. If I need that structure in my life, then I need that structure in my life.” Another participant (#28) told us that she benefited from the counseling she received at her OTP, although she recognized that some clinics execute this more effectively than others: “If I have a problem, I can call my counselor... They’re there to help me through whatever I’m struggling with... If you’re at a good clinic [laughs], they’ll do these groups for you that are actually useful.”

However, even when finding benefit in methadone use, many participants detailed ways that the OTP model negatively impacted them. After beginning MMT, some participants explained that the power clinics exert over their treatment created a sense of lost bodily agency. In this section, we illustrate three categories of policies and practices that engender these feelings.

3.3.1. Lack of patient input in dosing decisions

First, some participants reported feeling uninformed about dosing decisions or feeling excluded from the decision-making process. The inability to get information or provide input resulted in a lack of agency over decisions about what one puts in their body. For example, some reported that the dosages they were given, both during induction and stabilization, led to undesired bodily sensations; yet when voicing these concerns, they were ignored. One participant (#27) told us she felt uncomfortable by how often her dose had been increased:

Someone suggested the methadone clinic. I went… and, in my mind, I didn’t like it because I had to go there every day, and they’re telling me that I should be increasing this methadone. I didn’t like the way the methadone affected me and made me very tired, and I couldn’t function and all this stuff, but they kept wanting me to increase it.

Even when she informed staff that she felt drowsy and unable to function with a dose that felt too high, staff kept increasing the dose. Although increases during induction and stabilization are necessary to achieve a therapeutic dose, staff could have addressed her concerns through education about the dosing process or by stretching out her increases to alleviate symptoms. This lack of communication and regard made her feel she had no voice in how her body was being treated; her bodily well-being was out of her control.

Conversely, some participants felt they were given too low of a dose during induction, leading to unpleasant withdrawal symptoms. One participant (#34) told us that when she first arrived at the clinic, amid withdrawal, staff only gave her five milligrams of methadone, which she expressed was too low to alleviate her withdrawal symptoms. Recalling her poor interaction with staff, she told us:

I was like, ‘Dude, I literally didn’t do stuff for two days because I had to wait to get in.’ I felt like that was rude of them because I was sitting there dying. I was like, ‘Anything you can do. I’ll sit here and wait for two hours just so I know I’m not going to die off of this.’ They let other people do it, but they wouldn’t let me.

Like the earlier participant, she found that staff ignored her negative bodily experiences. Despite her requests, they did not attempt to alter her induction process in any way to alleviate her withdrawal symptoms. Together, these narratives illustrate how the clinic’s power over the dosage-setting process reduces patients’ abilities to exert agency over their bodily well-being.

3.3.2. Strict clinic requirements

Participants also revealed that strict clinic requirements—particularly regarding dosing and counseling—made them feel “tethered” to the clinic. This tethering further restricted bodily agency by impacting where patients could go and what they could do, disrupting and altering their bodily routines. To access methadone, participants spent a great deal of time getting to and waiting at clinics. At the start of treatment, OTP patients must dose daily, and this may continue for months or even years. OTPs also often require patients to attend weekly or monthly counseling sessions. Some participants reported that these were strenuous commitments. One individual (#39) told us that methadone saved her life, but she had to restart MMT several times before finding stability. She explained that she had visited clinics with strict attendance requirements that did not align with her obligations and routines:

You can’t even live any normal life and have a job if you have to do all that. They say your recovery is supposed to be the most important thing. Well, you’ve got to pay bills and stuff… If you’re older and you’ve got children, it’s hard to go to clinics like that.

This participant felt daily dosing and counseling requirements reduced her ability to fulfill other aspects of her life like work and parenting. Recall participant #23 who appreciated daily dosing; her experience diverged from #39 because she did not yet have a job and had few other responsibilities. She was able to make daily dosing work because she had not yet rebuilt a “normal life.”

Earlier we also introduced participant #28, who appreciated counseling sessions at her current clinic. However, she had not always benefitted from strict OTP rules. In a previous experience with MMT, she was frustrated by that clinic’s daily dosing requirements. She described:

I was frustrated with the whole having to go every day, and it really feels like you’re tethered to this ball and chain because they make it hard. They do make it hard. Because the restrictions from the state are hard… And these places don’t give you the option of getting bottles.

As this participant alludes to, some patients can get take-home doses (“bottles”), lowering the amount of time spent travelling to and waiting at the clinic. Take-home doses are typically granted to patients who have been enrolled for longer periods of time, have no recent history of positive drug tests, and attend supervised dosing periods and counseling sessions regularly and on time. Take-home doses allowed participants like #28 and #39 to have greater agency over what they could do and where they could go. Participant #39, for example, explained:

If you do the right thing, you get take-homes. You don’t have to go to the clinic every day and you don’t have to go to all those groups and do all those one-on-ones and do all that. You can live a normal life.

Finding a clinic which did not require her to come every day and attend a lot of counseling sessions gave her greater agency to go and do what she pleased, living a “normal life”. Ultimately it was through this clinic that she found longer-term success in MMT.

But participant #28 explained that some clinics do not give take-home doses, while at others, “You need to do a lot of work to get bottles.” She also felt that decisions to give take-homes could be arbitrary and that staff did not always recognize how crucial take-homes were for people to have freedom over their own lives. She explained:

I wish that they [the staff] were more considerate. I don’t think that they think of people as an individual. I think that they just think of it as like a job, and they just want to get it done sometimes.

The lack of person-centered concern in these decisions was corroborated by some SUD treatment professionals in our sample. For example, participant #2 relayed how one of her patients, who was recently diagnosed with cancer, “couldn’t get her take-homes anymore” due to “some kind of medication that showed up in her system.” As a result, “Now she has to come to the clinic every day and go through chemo and this and that.” Participant #28 also envisioned that pharmacy dispensing could give her greater agency over her bodily routines:

It would be great if they, instead of making us drive to the clinic every day to dose, if they would say the pharmacies instead. I know that technicians can measure out medications and stuff. Why can’t we just go to the closest pharmacy and get our dose from a pharmacist? Why do we have to go 30 minutes in any direction to go to a clinic?

While pharmacy dispensing currently is not a possibility in the United States, we return to this participant’s suggestion in the Discussion.

3.3.3. Perceived mistreatment from staff and the threat of punishment

Finally, participants explained that perceived mistreatment from staff and staff’s ability to invoke punishment contributed to feelings of lost bodily agency—both in terms of their bodily well-being and routines. One participant (#30) dreaded getting her dose at the clinic every day, knowing that if she were late, the staff’s no-exception commitment to their dosing schedules would leave her subject to withdrawal:

I didn’t want that to be my life—running on in there every morning, waiting in the long line. Maybe there’s 20 people deep, it doesn’t matter. You get there two minutes late, doors locked, you’re sick, you don’t get your dose that day.

This participant felt like MMT involved a life-long venture of arriving and waiting, and this was compounded by her constant worry over being late; if she were late, the clinic could deny her access to methadone that day, leading to withdrawal. She felt like her bodily well-being was in the hands of clinic staff, who had the power to provide a late dose or turn her away. Other participants reported that staff’s decisions on late dosing could feel arbitrary. Participant #28 reported:

[At] the clinic we’re at now, there’s a bus that comes, and it comes right when they close. Now, because the bus comes sometimes 10 minutes after, they’ll stay over for that bus. [But] if you come 10 minutes after, they won’t let you dose, but they’ll let the bus dose. [laughs] How does that make sense? You’re like, “You’re here dosing anyway, why can’t you just dose me?” They’re like, “Well you should have been here at 11:00.” You’re like, “Well the bus—” It just doesn’t make sense.

This arbitrariness or uncertainty about staff reactions could heighten feelings of one’s own lost bodily agency.

Other participants reported facing punishment, or threat of punishment, for reasons unrelated to clinics’ formal requirements. One participant (#26) told us that, despite dosing at the same time every day, a nurse would sometimes report that she arrived late, putting her at risk of being removed from the clinic. She told us, “I just felt like she was against me, and come to find out, she had a family member that looked like me and did drugs, and she took it out on me.” Another participant (#35) relayed that one nurse had been displeased with the noisiness in the clinic lobby one day and threatened to shut down the dosing window early:

[She told us,] ‘Shut it. If you guys don’t quiet it down, we’re closing the windows, and you can just sit.’ Then 10 minutes later, she was like, ‘If you don’t shut up now, you’re going to be screwed the rest of the day. We’re just going to shut down the building.’

General behavioral transgressions, like being “loud”, are not formalized clinic rules. Nonetheless, this nurse used the threat of shutting down dosing to pressure patients into submitting to informal behavioral expectations. Threats like these compounded women’s feelings of a lack of agency over their bodies. Not only did they have to get to the clinic daily, but they also had to be extra cautious about arriving on time, following clinic rules, and pleasing clinic staff, knowing they could lose access to methadone for not doing so.

3.4. Regaining bodily agency in the clinic

In the section above, several participants explained how practices which restore some sense of agency over their bodies—such as receiving take-home doses—could help them find stability and success in methadone treatment. Conversely, others explained how a perceived loss of bodily agency—and the absence of any kind of restorative practices—could motivate them to take actions that reclaim such agency but ultimately end their treatment engagement. In this section, we illustrate how perceived loss of bodily agency motivates participants to leave treatment or commit acts of resistance that result in discharge.

3.4.1. Leaving the clinic

First, in recounting the experiences we outlined in the earlier section, participants sometimes explained how that perceived loss of bodily agency motivated them to leave treatment voluntarily. Recall participant #27, who felt frustrated that staff continued to increase her dose during the induction process, despite her concerns about how that dose made her feel. She continued her story, explaining that, eventually, the lack of concern from staff and lack of agency she had over her body during the dosing process motivated her to leave. She told us, “I quit taking the methadone… I left the methadone clinic and used heroin for about a month.” At that time, she decided to try inpatient treatment and checked herself in: “I was like, “Well, I’ll try treatment one more time.” To be honest, I just said, “If it doesn’t work, I’ll kill myself.” That’s where I was at when I went to treatment.” At this inpatient facility, she felt that she had “a really good counselor” who formulated a “five-minute, five-day, five months, five years from now goal” plan with her input. She left this facility after four months, in 2020, and was still in recovery when we interviewed her in 2022.

Participant #27 left methadone treatment due to the loss of bodily agency she felt during the induction and stabilization process. Others left due to the loss of agency over their bodily routines or bodily well-being that resulted from strict clinic requirements and staff mistreatment. Recall participant #28, for example, who felt “tethered” to the clinic due to daily dosing requirements. After explaining to us her “frustration” with “having to go every day” and not having “the option of getting bottles,” she said, “Those have been some reasons why I’ve personally left [methadone treatment].” At other clinics, this participant had also experienced mistreatment from staff. She told us that feeling like staff held total power over her bodily well-being had led her to leave as well:

Another reason was, I’ve left because I’ve gone to clinics and [the] nurses or anything like that, we just don’t get along. I’ve had issues with the staffing, and it’s been to the point where they just make you want to give up, where you start to think, ‘Well, it might just be easier to go use than deal with them.’

Participant #30, who also was frustrated with daily dosing requirements and worried that staff would turn her away if she arrived just a few minutes after closing, similarly chose to leave rather than remain subject to the power exerted by the clinic. After recounting the frustrations that we quoted earlier, she continued, “Who wants that to be your life, the rest of your life? I didn’t.”

SUD treatment professionals also saw patients leave for the reasons these women described. Participant #11 told us she had worked in methadone treatment for 25 years, working in positions ranging from clinic supervisor to counselor. When asked why women exit treatment, she said the main reason was:

They don’t progress to a level of freedom that they had hoped that they would be at, at a certain point, meaning to be able to receive six-day take homes and not have to go to the clinic every day, and that takes longer than they wanted.

This participant explained that patients left the clinics she has worked at because they desire greater “freedom.” But, she further noted that the power exerted by the clinic over her bodily routines could create issues with satisfying court requirements. Clinics’ strict requirements could even prevent patients from being able to comply with probation. She continued:

Or, it becomes too much of a time constraint between the requirements of probation, having to be compliant with the probation requirements so that they don’t get revoked… If I was not able to function successfully, and I was told I needed to see probation or I’d go to jail or I’d just get discharged from a treatment program, I’d be going to probation. I’d want to stay out of jail.

This quote suggests that patients are not even afforded the agency over their bodily routines to successfully navigate both probation and methadone treatment. This participant acknowledges that she would even leave the clinic in order to succeed in her probation requirements.

3.4.2. Resisting the clinic

Second, rather than leaving the clinic, other participants explained how they took actions that resisted the clinic’s power and reclaimed bodily agency. One such action of resistance involves the continued use of illicit substances. OTP patients are forbidden from using non-prescribed, DEA-scheduled substances. To prevent patients from doing so, OTP staff utilize various surveillance measures, like supervised urine screenings. If these tests are positive, staff can reduce patients’ take-home doses or discharge them. But some participants we spoke with used other substances alongside methadone anyway. These participants did not believe this practice had negative impacts on their treatment; rather, they concertedly used these other substances to regain agency over their bodily well-being. Recall participant #34 who felt ignored when she expressed concerns of being given too low of a starting dose. This participant found that she had a much easier time in treatment while she was using heroin alongside methadone:

[It] helped me more whenever I was also using [heroin] with it, but I was only doing like three bags when I first started. And then I went down to two bags within three months. Then I went down to one bag another three months, and then if I felt like I needed, I would extend the time before I’d go down. Now I’m down to like basically almost half a bag at this point, but I feel like that worked better for me.

Since this participant felt her needs and desires were not acknowledged by the clinic, she instead reclaimed agency over her bodily well-being by continuing to use heroin. Indeed, she felt that this decision was beneficial for her treatment process.

However, if caught, actions such as these could result in discharge from the clinic, which similarly to voluntarily leaving, would end a patient’s engagement with methadone treatment. Recall participant #39, who had told us that receiving methadone at a “good clinic” saved her life. This instance had not been her first attempt at MMT; she had previously been discharged from a different clinic. She told us that, for years, staff at that clinic had turned a blind eye to her cocaine positive urine tests. Yet, one day, upon receiving this positive test, they ordered her to attend an intensive outpatient (IOP) program and return to the clinic with a negative cocaine urine test in 30 days. Without attending IOP and testing negative for other substances, she would be discharged:

All of a sudden, they changed the rules in the clinic… They let me get away with all these dirty urines for three years. Now, I’m put in IOP. I’ve got 30 days to get a clean urine. If I don’t, I’m thrown off the clinic. That’s what happened. After three years of giving dirty urines, they say you got 30 days. Boom or you’re out.

She was unable to complete IOP, and, after 30 days, she did not test negative. Subsequently, she was put into a rapid seven-day dose taper from methadone and discharged from the clinic:

They threw me off. That is really the worst thing you can do to somebody. You’re sick as a dog… After the third or fourth day when that stuff just starts leaving your body, holy shit. Look out. You’ll do anything to make yourself feel better.

This participant told us that she was left to experience methadone withdrawal without support. Even trying to seek treatment with buprenorphine, another MOUD, was not an option because of the potential severe precipitative withdrawal she would experience with methadone still in her system. She recalled, “The only thing you can do is you try hard to get methadone on the streets. You used to be able to get pills here and there, but it’s very hard. Then, what do you do? Go back to dope.” She told us that forced seven-day dose tapers should be eliminated:

Many people have died from getting thrown out of clinics. That’s the worst thing you can do to somebody... You’re taking somebody from 90 mg down to nothing. Some people are [at] like 150... You take them down to nothing in seven days. You haven’t used in so long so what happens? They overdose.

She added that the unregulated drug supply, where heroin is increasingly mixed with fentanyl and xylazine, has raised this risk of overdose even further.

As this participant explained, patients who are discharged are left with few options or lines of support, aside from an unregulated drug supply that can lead to unintended overdose. Some OTPs legitimize themselves by claiming to return the “illicit” opioid user to a life of “normalcy;” yet contrary to their own logic, they force some of their patients, often those most in need of accessing methadone, back to the illicit market. Another participant (#28) pointed out this contradiction: “I’ve seen people go in and get kicked out for hot urines, for stuff that—Yes… they were using. But isn’t that why they’re there?” When we interviewed her in 2022, participant #30 had found recovery (not through methadone treatment, but through long-term inpatient treatment) and was working as a counselor in a clinic herself. She explained that she has to discharge patients for missing too many required counseling sessions, but she expressed discontent toward this practice:

I feel bad when I have to discharge somebody because they’ve missed too many appointments, and that’s the reality, that’s how it works. You miss these appointments, I’m sorry, but I’m canceling your doctor appointment, and you’re discharged. That’s my job. Then what? What happens to that person then? Now they’re in withdrawals. What are they doing now?... You just keep on doing heroin until you die.

This participant recognized the potential harm this practice could create, but she felt that she had to uphold the policy of the clinic.

3.5. How gender shapes the loss of bodily agency

The experience of losing bodily agency in the clinic is certainly not limited to female patients. In fact, one participant (#28) recounted a story of her boyfriend being required to attend inpatient treatment after testing positive for Gabapentin, which he had been taking for a shoulder injury; when he did not successfully complete inpatient, he was tapered off methadone, discharged by his clinic, and handed Narcan on the way out. Yet, by focusing on gender differences in treatment experiences, our interviews enable us to consider why feelings of lost bodily agency might be particularly prevalent among women.

Interviews with SUD treatment professionals suggest that there are certain judgments about patients’ histories and capabilities that are applied unequally to women. In another manuscript from this study, we demonstrated how treatment professionals believe that women have more difficulty in MOUD treatment than men because they have deeper trauma histories (Redacted, 2024). The participants we quoted explained that, as a result of these histories, female patients are more “broken” than men, with low self-esteem and self-worth. But what’s more, some treatment professionals also connected these perceptions of women’s pasts with ideas of what women require in treatment. One participant who works as a nurse at a methadone clinic told us:

I think a lot of women, when they’re out there in their active addiction, they don’t hold themselves accountable because of their lack of self-worth. I think accountability is majorly important to help with getting over the trauma and to help with self-esteem. I think anybody who needs to build self-esteem needs to hold themselves accountable.

Thus, this judgment—that women’s histories of trauma limit their ability to hold themselves accountable—may encourage providers to apply and enforce bodily agency-diminishing policies and practices on female patients.

Elsewhere, we have also demonstrated how factors related to women’s roles as mothers can pose particular challenges to engaging with MOUD treatment (Redacted, 2024). However, some treatment professionals downplayed these logistical barriers that women faced that could make it look like they do not “hold themselves accountable”. For example, when asked what women’s biggest barriers to treatment success are, one SUD treatment professional, a counselor, said:

I think it’s the barriers that make it unaccessible in their minds. “I have to work, I have to take care of the kids.” You know what I mean? Those kind of things—the excuses that they come up with. I think that’s a big issue.

This participant suggests that logistical barriers imposed by navigating employment and childrearing are not true barriers but are rather excuses that women who do not want to hold themselves accountable lean on. Participant #12 similarly referred to issues such as transportation or childcare as “baby barriers,” saying that “those people who are really dedicated tend to find ways to address those obstacles.” Downplaying these logistical barriers could further encourage providers to impose institutional accountability measures on female patients that limit their bodily agency.

Some women corroborated that they felt they were given less agency over their bodies than men in treatment settings. Recall participant #34, who explained that she felt unable to provide input in the dosing and stabilization process when she started methadone treatment. She provided other stories of times when she felt that counselors did not listen to her as well. In another instance, she reported asking for help with withdrawal side effects and feeling unheard:

They were like, “Oh, well, headaches aren’t usually a part of withdrawal, so I don’t believe that all of your symptoms are withdrawal.” I’m just like, “No, a lot of people I know get headaches and that’s mainly because of the dehydration you go through so technically you should put that in your textbook as one of the things.” We had a whole argument about it. It’s like they just don’t ever listen, you know?... I honestly feel they listen to a lot of the guys more than the girls, honestly.

This participant continued to explain that she saw men in her clinic “game” the system more often than women—for example, using illicit drugs in the days immediately following a urine screening and then stopping when they believed another screening was coming. Nonetheless, she felt that she was provided less of a voice in decisions about her body than men.

4. Discussion

4.1. Key findings

In sum, this manuscript demonstrates that women may feel a loss of bodily agency—including agency over what they put in their bodies (i.e., their bodily well-being) and what they do with their bodies (i.e., their bodily routines)—when seeking MMT at OTPs. This loss of bodily agency stems from both formal policies and informal practices at OTPs including 1) being unable to provide input in the induction, stabilization, and tapering processes; 2) navigating strict requirements that tie medication receipt to compliance; and 3) facing mistreatment from staff or threats of punishment when committing perceived transgressions. This manuscript further shows that this loss of bodily agency can motivate some women to reclaim control over their bodies by leaving treatment, and that it can motivate others to reclaim bodily agency in other ways—such as by using illicit drugs— that can result in involuntary discharge. In other words, this loss of bodily agency can reduce sustained treatment engagement, which is ultimately associated with increased risk of overdose death (Krawczyk et al., 2020).

These findings build on a rich body of literature that draws on Foucault’s theories of biopower and disciplinary power to demonstrate how OTPs enact power over patients through regulatory technologies—such as strict structuring of time (Fraser, 2006)—to decrease deviance and mold them into productive and obedient citizens (Bourgois, 2000; Friedman & Alicea, 2001; Keane, 2009; Nettleton et al., 2012). In light of recent policy shifts that are encouraging and prioritizing the use of MOUDs like methadone, increasing attention has been afforded to barriers people with OUD face in seeking and staying in MOUD treatment programs (Hutchison et al., 2023). Nonetheless, such research tends to point to the individual-level factors which inhibit MOUD use (Letourneau et al., 2013; Pasman et al., 2022), rather than the institutional-level policies and practices used by OTPs which could discourage or limit engagement. This manuscript adds to the recent literature on MOUD engagement barriers by turning to the latter and drawing on notions of power in OTPs that have been documented for decades. Simultaneously, it adds to the critical social research on MMT by enumerating the informal and formal OTP practices which engender a sense of bodily agency loss and showcasing how related reclamations of bodily agency lead to exits from treatment.

This manuscript also adds a gendered analysis to this literature by considering the reasons that women, specifically, may experience a loss of bodily agency in OTPs. Research has shown that women must navigate gendered power dynamics and expectations in OTPs, which can diminish their satisfaction with treatment experiences (Fraser, 1997; Friedman & Alicea, 2001). Women with OUD are also subject to unique dimensions of stigma that can impose a further barrier to treatment engagement (Huhn & Dunn, 2020). For example, while having an OUD, in general, is a stigmatized trait (Goffman, 1966; Taylor et al., 2021), mothers with OUD face additional stigma because they are presumed to be failing in their roles as parents, while fathers do not (Bakos-Block et al., 2022). This divergence stems from gendered judgments of parenthood, such as the relative importance of mothers and fathers’ presence in children’s lives (Bakos-Block et al., 2022).

This manuscript extends this work; our findings suggest that specific gendered judgments about women’s histories and capabilities may encourage providers to apply and enforce policies and practices on female patients that decrease their sense of bodily agency. Yet simultaneously, due to the high prevalence of trauma histories among women with OUD—which has both been shown extensively in the literature (Santo Jr. et al., 2021) and was evident among the participants in this study (Redacted, 2024)—female patients may be especially vulnerable to the negative impacts of a sense of lost bodily agency. Butler et al. (2011) explain that providers can retraumatize or trigger trauma survivors when “he or she recapitulates aspects of the betrayal, boundary violation, objectification, powerlessness, vulnerability, and lack of agency experienced during the original trauma” (181). They further suggest that such experiences can “slow patient progress, reduce openness to treatment, or derail therapy altogether” (180). Thus, in the context of MMT, provider actions which reduce patient’s bodily agency may be especially likely to trigger negative responses among patients who have experienced past traumas—which includes a vast majority of female patients.

4.2. Implications

Given these key findings, we suggest that enacting policies and practices which restore MMT patients’ bodily agency or remove the punishment associated with reclaiming bodily agency could promote treatment retention, particularly for women. In the United States, this could be accomplished by relaxing certain OTP regulations and guidelines that this manuscript shows can reduce women’s agency over their bodily well-being. Specifically, OTPs could move away from the use of administrative discharge for missed doses or services, as studies show that continuing treatment with methadone is safer than rapid discharge in these circumstances (CSAT, 2005; NASEM, 2019). OTPs could also move away from responding to continued substance use with discharge or the threat of discharge, as research shows this can similarly restrict a program’s ability to prioritize the health and wellbeing of its patients (Frank, 2020). Finally, OTPs could shift away from a culture of bodily surveillance by removing urine screening requirements, or using oral fluid for screening if removing screening requirements is unfeasible, and removing supervised dosing requirements.

This culture could be further lessened by greater adoption of more flexible take-home medication policies that restore patient agency over bodily routines. During the COVID-19 pandemic, several countries, including the U.S. and the United Kingdom, allowed greater flexibility for take-home medication. In the UK, research found that, after take-home policies were relaxed in early 2020, methadone-related deaths increased among individuals not in methadone treatment but not among individuals in treatment, raising concerns about diversion (Aldabergenov et al., 2022). However, in the U.S. context, research has shown that relaxed take-home guidelines increased treatment engagement, improved patient satisfaction, and did not lead to increases in methadone diversion, methadone-related overdoses, or overdose deaths (Adams et al., 2023; Amram et al. 2021; Brothers et al., 2021; Figgatt, et al., 2021; Levander et al., 2021). Following this evidence, SAMHSA made the updated regulations increasing take-home flexibility permanent (HHS, 2024). Nonetheless, individual states and OTP leadership maintain authority to decide whether, and to what extent, they wish to implement changes to their take-home policies, and thus not all methadone patients benefit from these new guidelines (Levander et al., 2022). Future research demonstrating positive patient experiences and outcomes under relaxed guidelines could motivate further uptake.

OTPs could also restore patients’ bodily agency by moving toward trauma-informed, patient-centered care informed by harm-reductionist principles. In such a model, providers could work with patients to develop a treatment plan that aligns with their unique needs and life history. Such a treatment plan could include accountability measures, such as a counseling requirement, if the patient desired. Research shows that when patient-centered care is even just partially implemented within MMT, it can improve feelings of empowerment and lead to increased retention rates, decreased fatal overdose rates, and improved outcomes (Joseph et al. 2021; Marshall et al., 2021). This model could be especially beneficial for women with complex trauma histories, as it would encourage providers to avoid potentially retraumatizing practices and behaviors (e.g., supervised urine screenings, disregard of needs vocalized by the patient, authoritative decision-making about the patient’s body without their input), ultimately reducing triggers experienced by patients and improving patient satisfaction (Butler et al., 2011).

Nonetheless, Marshall et al. (2021) has questioned whether full implementation of patient-centered care is even possible within the OTP model. Looking to the global landscape of methadone treatment models, many other countries allow for more flexible approaches to methadone access which may better align with patients’ needs. In Switzerland, for example, at the Arud Center for Addiction Medicine, patients are not subject to urine screenings, punished for using illicit substances, or given counseling requirements (Facher, 2024). Patients at Arud can access weeks’ worth of take-home medication from the onset of treatment, allowing for much greater patient freedom over their bodily routines, spending much less time traveling to and being at the clinic (Facher, 2024). Similarly, in France, patients can start working toward receiving 28 days of take-homes from community pharmacies after one to two weeks of methadone treatment and do not have required counseling or urine screenings (Englander et al., 2024). Whereas methadone and other forms of MOUD are heavily underutilized in the U.S. (Jones et al., 2023; NASADAD, 2022; SAMHSA, 2022a), 87% of people in France with OUD receive methadone or buprenorphine (Englander et al., 2024).

There are also several other countries that allow methadone to be prescribed through primary care and administered and dispensed in pharmacies. Whereas the OTP model siloes methadone treatment from other healthcare and social services, this model integrates methadone treatment into national health care systems. Office-based prescribing and pharmacy dispensing are associated with higher patient satisfaction and quality of life (McCarty et al., 2021) while also being safe, effective, and more accessible than the OTP model (Tuchman et al., 2006; Wu et al., 2023). In Australia, for example, most methadone patients receive prescriptions through general practitioners and pick up their medication from pharmacies (Izquierdo et al., 2023). Evidence suggests that Australia’s pharmacy-based model, particularly that in New South Wales, significantly reduced overdose and mortality rates between 2001 and 2020 (Challion et al., 2022). Overall, the aforementioned countries—Switzerland, France, and Australia—all have much lower rates of overdose deaths compared to the U.S. (Baumgartner et al., 2022), and this can likely be, at least in part, attributed to their MOUD delivery models that are much more progressive, accessible, expansive, and better integrated with primary healthcare (Englander et al. 2024; Facher 2024; Izquierdo et al., 2023).

Following these countries’ lead, the Modernizing Opioid Treatment Access Act (MOTAA), introduced to the U.S. House of Representatives in March 2023, would allow board-certified addiction doctors and psychiatrists outside of OTPs to prescribe methadone for OUD and permit pharmacy dispensing. However, as this bill prohibits primary care physicians or advanced practice providers from being able to prescribe methadone for OUD, methadone treatment would still largely occur within the OTP system and otherwise be limited to only 3,808 addiction medicine and 1,398 addiction psychiatry physicians nationwide (ABMS, 2023). This would continue to leave many suburban and rural communities with limited to no access to methadone treatment (Joudrey et al., 2023). To more equitably expand methadone access, MOTAA would need to be amended to include all primary care physicians or advanced practice providers. Ultimately, this could allow all methadone patients to choose what setting of methadone provision works best for them. But particularly for women, this choice would allow those with complex and complicating trauma histories to choose settings where they feel safest or that employ principles of trauma-informed care; ultimately, women would have a better chance at identifying providers who are attune to the gendered components that have traditionally been at play in MMT.

Considering the efficacy of the aforementioned international methadone treatment models that do not utilize urine screenings, do not impose punishments for illicit substance use, and do not impose counseling requirements on all patients, MOTAA could also be amended to include these stipulations, giving methadone patients even greater agency over their bodily well-being and routines. Doing so could increase overall patient satisfaction, increase retention rates, and, ideally, draw in the 5.1 million U.S. citizens who currently do not or cannot access methadone (NASADAD, 2022; SAMHSA, 2022b).

4.3. Limitations

We conclude by contextualizing the findings and implications presented here within the study’s limitations. First, we note that this is a relatively small-scale qualitative study. The interviews were in-depth and encouraged participants to share their narratives as they see fit; this dataset allows for us to identify common themes and provide rich, descriptive accounts of those themes. However, our dataset—both due to sample size and open-ended interview style— does not allow us to assess prevalence of these themes or track patterns of which women do and do not have these experiences and why. Second, the study design did not entail collecting certain details about treatment experiences in survey-like fashion. For example, we cannot say exactly how many participants received take-home doses, and we cannot say exactly how many times each participant left MMT or how long each participant was in MMT before leaving. The themes we present in this manuscript arose when asking very general questions about participants’ experiences in MMT. Future research could utilize interview tools that more specifically delve into the themes we uncover here, which would allow for more systematic analysis of prevalence and patterns. Future research could also consider experiences of both male and female patients, allowing for direct comparisons of the prevalence and impact of feelings of bodily agency loss.

Third, our sample of women had diverse educational and employment experiences, but they were relatively homogenous in terms of race/ethnicity. Patients’ experiences with power and agency in MMT could be impacted by intersectional identities, and we cannot assess this variability in this study. Finally, our study was also geographically bounded, as all participants lived in Pennsylvania. Pennsylvania has several coded laws that specifically restrict access to methadone; for example, state law allows for the administrative discharge of patients for continued drug use, missed doses, and nonparticipation in ancillary services like counseling sessions (Izquierdo et al., 2022a). These are not coded in federal law, and thus methadone patients in some states may face less stringent policies in their clinics. Nonetheless, patients in other states with more restrictive state laws could face even greater demonstrations of power by their clinics and experience greater losses of bodily agency. While we suspect that the themes we report here are experienced broadly across the U.S., there may be some level of variation in degree across different states and clinics. Thus, future research should also consider experiences with power and bodily agency in OTPs across more diverse contexts and for more diverse samples of participants.

Highlights.

• Informal and formal practices and policies at Opioid Treatment Programs (OTPs) reduce patient bodily agency, particularly among women

• Some patients voluntarily leave OTPs to regain a sense of bodily agency

• Others break OTP rules to regain bodily agency, leading to administrative discharge

• Both voluntary departure and discharge heighten risk of overdose and related harms

• Restoring patients’ bodily agency within methadone maintenance treatment (MMT) could improve retention and benefit well-being