Buprenorphine

Buprenorphine is a medication used to treat opioid-use disorder by reducing cravings and preventing withdrawal, and it is central to the book’s account of both the possibilities and the obstacles of medication-assisted treatment. Its effects depend not only on the drug itself but on whether patients can obtain sustained care: the narrative follows people for whom treatment was interrupted, costly, or socially contested, even as clinicians describe maintenance therapy as safer than returning to illicit opioids.

Treatment and Pharmacological Role

Buprenorphine blunts opioid cravings and, in excess, is less dangerous than methadone. That relative safety helped regulators permit physicians to prescribe it in office-based settings, rather than requiring patients to attend near-daily clinics. It is a partial opioid agonist: treatment can prevent Dopesickness and reduce cravings, theoretically without producing a high. The book presents it as a practical treatment that can help patients regain stability before slowly tapering, if tapering is appropriate.

Among public-health officials, buprenorphine is described as a leading treatment for opioid-use disorder. It reduces the risk of overdose death by half compared with behavioral therapy alone. Researchers disagree about how long maintenance should continue: one recommendation is to remain on medication for at least twice as long as the addiction lasted, while others consider discontinuation too risky for people with long histories of opioid use. The evidence described in the book also cautions against treating short-term detoxification as equivalent to maintenance. A study found that half of patients relapsed within a month of being weaned, with better outcomes among those tapered from lower doses; another, following patients over five years, found that roughly a third were drug-free after eighteen months, a third remained on medication-assisted treatment, and most of the remainder had returned to heroin or illicit opioids.

Treatment Interrupted and Unequally Accessible

Jesse Bolstridge’s treatment history illustrates how a prescription can be part of care without securing continuity. In January 2013, his mother, Kristi Fernandez, sent him to a ten-week rehabilitation program in Jacksonville, where he received intensive counseling and medical detoxification and briefly took buprenorphine, commonly known by the brand name Suboxone. He was weaned off the medication after three weeks, a practice the book identifies as common and increasingly controversial. Fernandez still owed $25,000 for the program, despite insurance coverage and payments of $25 a week automatically deducted from Jesse’s checking account. National Institute on Drug Abuse director Nora Volkow argued for long-term maintenance alongside behavioral treatment and recovery support, rather than brief detoxification programs aimed at abstinence.

Tess Henry’s care shows how pregnancy, insurance, and location shaped access. Nearly seven months pregnant when released from jail in June 2015, she first stayed with her mother, Patricia Mehrmann, then entered the Life Center of Galax for the final month of her pregnancy. It was among the few Virginia facilities willing to accept patients receiving medication-assisted treatment. Tess took Subutex, a buprenorphine formulation without naloxone that was then recommended for some pregnant patients because it was considered safer for the baby, though more liable to misuse by the mother. Private insurance covered most of the $20,000 treatment bill; her father paid the $6,500 deductible from the remainder of Tess’s college-savings fund. After using heroin during the first half of pregnancy and Subutex during the second, Tess worried that her baby might experience neonatal abstinence syndrome, which can require an extended hospital stay and, in some cases, neonatal intensive care and methadone treatment.

Later, buprenorphine helped Tess feel normal, and insurance covered 80 percent of the medication’s cost. The clinical visits remained cash-only: $700 up front, then $90 to $100 per follow-up, as many as four appointments each month. For Tess and Patricia, the medication itself was therefore only one step in a costly care pathway. Waiting lists, limits on the number of patients a certified physician could treat, and the shortage of nearby providers further narrowed access. Federal rules then capped certified physicians at 100 patients, a limit raised to 275 later in 2016. Access in Virginia expanded in 2017 in part through the work of addiction specialist Hughes Melton, who helped lead the state’s opioid response, advocated broader Medicaid reimbursement, and pushed for coverage of required counseling and care coordination. His weekly flights between his Highpower clinic in Lebanon and his Richmond office linked local practice to statewide policy work, but greater formal capacity did not quickly reach every community.

Stigma, Misuse, and Treatment Disputes

Buprenorphine’s status as an opioid-based treatment made it controversial among people who opposed treating addiction with another drug. Tess had attended Alcoholics Anonymous and Narcotics Anonymous meetings but felt stigmatized for taking the medication. Although Narcotics Anonymous formally accepted medication-assisted treatment, members asked to sponsor or mentor her declined. The book presents this rejection as a social barrier distinct from the clinical question of whether the medication works: patients could be offered treatment by a physician yet remain unwelcome in recovery settings that equated medication with being unclean or substituting one opioid for another.

The drug also circulated outside clinical care. Black-market sales, particularly of Subutex, were widespread; buprenorphine could produce a high if injected or snorted, or when taken with benzodiazepines, a combination that could be fatal. The account distinguishes this misuse from responsible treatment. Art Van Zee reported patients who had tapered from 16 milligrams of Suboxone to as little as half a milligram daily, while hesitating to discontinue it entirely because he had seen tapering lead to relapse. Volkow likewise warned that patients buying Suboxone on the black market were often trying to avoid withdrawal, a practice she considered safer than returning to heroin. A Roanoke psychiatrist described one patient who concealed Suboxone strips before a two-week jail term because local jails did not permit medication-assisted treatment. The episode illustrates how institutional rules could interrupt treatment and drive patients to extraordinary lengths to preserve it.

Evidence, Policy, and the Book’s Argument

The book traces the caution surrounding buprenorphine to a longer history of distrust toward treating opioid addiction with another opioid. Researchers developed buprenorphine partly because it blunts cravings and is less dangerous than methadone in excess, but the legacy of earlier medical enthusiasm for heroin kept clinicians and criminal-justice officials wary of maintenance drugs. Office-based prescribing made buprenorphine more accessible in principle, while also creating new problems of oversight and uneven practice. Some rural clinics failed to drug-test patients or require counseling, and some co-prescribed benzodiazepines, practices the book contrasts with the work of better-regarded clinics run by Van Zee and Melton.

The narrative’s central contrast is between evidence for continuing treatment and the systems that make it difficult to continue. Early weaning can contribute to relapse, which in turn may be misread as proof that medication-assisted treatment is ineffective. Van Zee described patients who had rebuilt their lives, earned advanced degrees, found work, and regained custody of their children; he argued that opponents failed to distinguish these patients from people misusing the medication. Research cited by the book also found superior outcomes when patients received maintenance medications such as buprenorphine or methadone. The argument is not that every prescription guarantees recovery, but that short treatment, interrupted access, punitive rules, and stigma can turn a potentially protective medication into an incomplete intervention.

That gap remained visible in the later response to overdose. Warren Bickel received a $1 million grant to test faster transfers from emergency departments to outpatient buprenorphine treatment, including use of the newly approved once-monthly injection Sublocade. He had recently lost a family friend whose Suboxone dose was reduced after a follow-up test found additional opioid use; Bickel argued that the patient needed a higher, not lower, dose. The Roanoke Community Services Board had added treatment for twenty-one patients, but only after they engaged in counseling, while Carilion Clinic still had a three-week wait for outpatient medication-assisted treatment. In this account, buprenorphine stands both for an evidence-supported means of reducing overdose risk and for the distance between recognizing an effective treatment and making it reliably available.