Treating opioid addiction shouldn’t leave physicians, patients feeling criminal

Office-based opioid agonist treatment is a viable modality for primary care physicians to consider.


Our patient sat in the waiting chair, nervous and clammy. His golf shirt began to stain with sweat as he fidgeted and played with his wedding ring. Heart pounding, nerves racing, his stomach twisted in knots.

He wasn’t in withdrawal. He was five years clean and planning to be out of town for more than four weeks. He was here for his Suboxone refill and he needed an extension beyond the 30-day mandate for narcotics.

For years, this man came religiously every month for treatment, with no missed appointments and clean urine tests. During his last work trip, he had to produce his airline tickets and hotel reservation before the pharmacy would take a second look at his refill.

The years of shooting up, stealing, and addiction were long behind him, but stigma never left. He had the initiative to start treatment. He was successful in a new job, with a stable livelihood. Yet he felt almost criminal trying to get the medication that helped him stay sober.

Anna Augustin, OMS IV

Feeling criminal about opioid treatment is a feeling shared by physicians.

The biggest problem to battling opioid addiction is that the treatments themselves involve narcotics. Understandably, most physicians decline to treat opioid addiction based solely on this fact.
Additionally, the debate of “choice” versus “disease” is unfortunately still prevalent among health care

Opioid dependence is a disease. To successfully treat this epidemic, we must manage it like any other type of disease. Treating diabetes does not involve temporary insulin. The condition is always there and some type of treatment will always help.

People who have been or are currently addicted to opioids will always be addicts.

Office-based opioid agonist treatment

Depending on the severity of the disease, opioid treatment can range from lifestyle modification to inpatient rehab. The middle ground is office-based opioid agonist treatment (OBOT).

OBOT therapy is a reasonable alternative to treatment in a methadone clinic. Instead of waiting outside of a clinic each day, patients receive a once-a-month prescription of buprenorphine (Suboxone) from a physician.

Coupled with naloxone, the three forms of Suboxone treatment result in sudden withdrawal when injected or snorted. If taken as prescribed, the naloxone effects are negated and patients feel relief without concomitant symptoms. This safeguard against potential abuse also makes it easier for a primary care physician to manage.

OBOT therapy is relatively new and some practitioners are unaware of this treatment modality. Additionally, federal guidelines require an eight-hour course for primary care physicians to be certified in Suboxone treatment. The process is tedious. In the first year after certification, the physician can see a maximum of 30 patients for Suboxone treatment.

Why would any physician want to go through all of these steps? The answer is simple. The opioid epidemic has come to the point that physicians need to stand up and say, “I am here to help.”

Who are we helping? I’ve seen middle-aged mothers in for treatment, embarrassed about their pill habits. Their families, spouses, and children are unaware of their addiction.

I see many hard-working men who struggled for decades against addiction because of one back injury. I’ve seen an elderly woman in tears because she got hooked on Percocet. “My doctor,” she said, “She kept pushing the prescription up. And I’m hooked. I’m a grandmother and I’m a drug addict. This was never supposed to be me.”

We are no longer treating a small minority of the population. We are treating our neighbors, our children, our elderly and our friends. Office-based opioid agonist treatment is an ideal place for many primary care physicians to start.


  1. JoHN E Rauch

    Is anyone looking at the literature pointing to the findings of Kenneth Blum PHD who has changed the definition of alcoholism and addiction from an incurable, relapsing disease (AMA 1953) to a chemical imbalance of the neurotransmitters of the brain reward centers?Who also, in studying both “addictive” and “normal” brains found in the addictive brain to have what he has titled the RDS Syndrome. He being a pharmacologist decided to attempt to balance the chemical problem of the neurotransmitters using the amino acid precursors which the body metabolizes to restore them. Using double blind studies, after only 30 days, the group taking the amino acid supplements noted a marked reduction in their CRAVINGS, as well as a marked reduction in there anxiety and depression. Why aen’t we using this holistic, Osteopathic approach , which is treating the cause rather than just the symptoms, along with the drugs mentioned in the article above? All the drugs mentioned in the article above are useful but when they are stopped the Cravings return. If one is able to balance the neurotransmitters the cravings will disappear.

    1. Victoria Thieme

      Hi I am a physician and a mother of four. My second child was diagnosed at age 12 w RDS in Maine! I was just thinking about this point yesterday and agree that we should continue this research and practice exploration further. My daughter is now 21 and still struggles w her behaviors daily. She had been put on Wellbutrin to help her behaviors. I do not think it is the right way to help a child though. In principle it makes sense but at that age I think intensive skills building would have been healthier.

  2. Michael D. Lockwood, DO

    I would rather have heard as to how Osteopathic treatments mitigate pain and subsequent pain behaviors thus decreasing the likelihood of initiating opioids. Literature exists that show pain and cognition are linked (see JAOA September 2018 p 617-621). After addiction, what role do we as Osteopathic Physicians have and what are our goals for Osteopathic care? Less pain afferent activity? Improved cognition?

  3. DrB3

    Good article and critical at this time. However, one clarification: it is NOT the naloxone in Suboxone or other buprenorphine/naloxone combo-products that precipitates withdrawal if the product is used inappropriately (i.e.shooting it, snorting it or using it in conjunction with other opioids), it is the buprenorphine itself. The myth that the naloxone is the primary ‘opioid blocker’ in Suboxone is shared by many, physicians included.

    Taking any buprenorphine (with or without naloxone) in any fashion before sufficient time has passed (~18-24 hrs) since last using an opioid like heroin, hydro/oxycodone, etc will precipitate withdrawal that can last all day. Naloxone has a half-life of 30 minutes; buprenorphine’s is ~24-36 hours. If it were the naloxone that precipitated the withdrawal, it would pass in ~2 hours. It isn’t.

    I’ve been waivered for 15 years; I’ve seen every shenanigan with Suboxone etc one could consider. Most other countries don’t even use the combination product. I personally think the naloxone was a gimmick to get it past our FDA. Addition of naloxone doesn’t do what Indivior said it would do. But with the right motivation and use, it’s a medication that saves lives and provides sufficient dopamine to get on course without the negative consequences of addiction or being altered.

  4. Lily Bridgers

    It’s amazing to hear that if used as directed, the effects of naloxone are neutralized and patients get relief without concurrent symptoms, reducing the risk of misuse and making it simpler for a primary care physician to administer. I want to share that piece of information with my aunt who’s been worried sick about one of his sons who’s currently in rehab due to opioid addiction. I really wish they’d consider putting him on suboxone, especially if prescribed by a center near us.

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