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Despite decades of evidence supporting methadone as a life-saving treatment for opioid use disorder, its delivery in the US has been stymied by stigmatizing dispensation policies that are neither evidence-based nor person-centered. Implementation failures and regulatory challenges have resulted in a significant treatment gap in the US and less than 30% of people with OUD enter and remain in treatment. In this article, we provide a historical overview of the methadone treatment (MT) system in the US and outline why it requires de-implementation. We present the COVID-19 public health emergency as a naturalistic experiment in de-implementation, outline evidence from this period on how COVID-19 related flexibilities influenced treatment outcomes and patient experiences and present a de-implementation framework to contextualize these changes while imagining further expansion of de-implementation efforts to support sustained change. We highlight how patient advocacy can shape further de-implementation while noting current threats to progress.