AbstractThis article reviews some of the issues and dilemmas faced by methadone maintenance treatment (MMT) programs counselors. The context in which MMT occurs sets the tone and constraints within which clinicians must find ways to be effective; negative attitudes and tensions with regulatory agencies have a strong impact Coexisting disorders, particularly depression and thought disorders, are discussed and special medication considerations are noted. Counselor collaboration on medical issues, and dosing policies and practices are explored, as well as the clinical approach to tapering off methadone. The article examines helpful clinical strategies when clients continue to use heroin or other drugs, and explores psychological issues that frequently occur, women's issues, and problems that may arise when patients have human immunodeficiency virus-spectrum disease. It also reconsiders the role of family therapy. Several innovative and promising psychoeducational approaches are described and the potential integration of MMT with 12-Step programs is addressed. Recommendations are offered for training and supervision.