Medications for Opioid Use Disorder

Wonder drugs” for opioid use disorder look different on the streets than in medical journals.

Key points

• Medications for opioid use disorder have downsides that don't appear in most of the medical literature.

• Fentanyl use is up even though overdose deaths are down.

• Full-abstinence recovery is both possible and beneficial for many patients.

Nearly all Americans are aware of the U.S. opioid crisis. Overdose deaths increased sixfold between 2003 and 2023, from 12,940 to 79,358. Yearly increases have been especially steep since 2013, when fentanyl hit the streets. COVID-19 further exacerbated the crisis until a marked decline in overdoses in 2024.

The recent drop in overdose deaths is credited by public health officials primarily to medications for opioid use disorder (MOUDs), particularly naloxone (Narcan) and Suboxone/Subutex. Naloxone reverses active overdoses almost immediately by “kicking” opioids out of receptors in the brain and body and blocking their return. Nasally administered Narcan, when given quickly, can literally bring overdosed users “back from the dead.”

The second drug, Suboxone, is used to prevent overdoses in the first place. Suboxone combines naloxone with buprenorphine, a powerful opioid itself. Buprenorphine spares patients from withdrawal, while low-dose naloxone limits the euphoria and risk of overdose that buprenorphine alone carries. Although patients maintain a low-level “high” and remain physically addicted to buprenorphine, low-dose naloxone prevents intense intoxication and overdoses by partially blocking opioid receptors.

Both naloxone and Suboxone have been available for more than two decades. Those who credit them with the recent downturn in overdoses point to broader distribution and availability following intensive promotion in medical journals, by healthcare systems, and by the National Institutes of Health.

Yet post-COVID-19 reductions in several causes of death have been reported. Alcohol-related deaths, cocaine overdose deaths, and suicides all trended down in 2024. This suggests an additional common cause that isn’t explained by MOUDs.

The Downsides of MOUDs

I’m not suggesting Narcan and Suboxone aren’t essential parts of treatment. Rather, I argue that the current public health narrative minimizes their drawbacks.

Opponents of Narcan have long held that it enables opioid usena worry many public health officials flatly reject. Many of us who work on the streets, however, have heard our opioid-addicted clients describe hoarding Narcan so they can get “higher” and be revived if needed. As Reuters reported in "Fentanyl Express," their Pulitzer Prize-winning investigation of the opioid crisis, fentanyl use has increased even though overdoses have declined. This is almost surely attributable to Narcan.

Suboxone treatment also comes with costs, particularly diminished quality of life for those who are treated long-term. Memory problems, constant sedation, fatigue, and low motivation are common side effects that can easily be overlooked in primary care settings because they’re less intense than the symptoms of heavier opioid use they replace. Over time, however, these side effects can erode well-being and may undermine patients’ agency in their extended recovery. Employment instability, social disengagement, oral infections, and tooth loss are also common with long-term Suboxone treatment, and overdose risk, though far lower than for heroin or fentanyl, isn’t trivial.

None of these findings should be surprising given similar long-term effects of methadone, another long-acting opioid that was commonly used to treat opioid addiction before Suboxone was available. The American Society of Addiction Medicine doesn't mention these long-term effects in its National Practice Guideline, which encourages indefinite Suboxone treatment.

In addition, buprenorphine like all long-acting opioids carries a very long withdrawal period, extending up to a month beyond the few days of heroin and fentanyl withdrawal. Patients who eventually seek full abstinence therefore face a more difficult road to get there. Many aren’t informed of this when Suboxone is prescribed.

Some promotional materials distributed to prescribing physicians misleadingly claim that opioid detox is ineffective. Here again, those of us who work on the streets see many people choose detox and fully recover especially when that detox is paired with inpatient treatment. At the Hope Resource Center in Columbus, where I contract part-time, all eight peer support specialists were once addicted to fentanyl and have a year or more of full-abstinence recovery. Several of them were homeless before they first detoxed and entered treatment.

These people’s stories show us that opioid use disorder can be overcome without indefinite buprenorphine treatment and maintained opioid addiction. Ashley Arick, a former peer support specialist at the Hope Resource Center who is now its outreach director, shares her story of repeated relapses while treated with Suboxone, and how her decision to choose full abstinence changed her life. (Readers can hear Ashley’s story on the Get a Grip Podcast.)

My point in writing this post isn’t to deride MOUDs, which are essential tools in our treatment armament and are needed to save lives. Even long-term Suboxone treatment is necessary for some patients.

Yet transparency about these medications is also essential given their effects on quality of life. These effects should not be swept under the rug, despite the well-meaning intentions of public health officials. Whether one is a prescribing physician, a person fighting opioid addiction, or a family member, we deserve to know the downsides of medications to make informed treatment decisions.

Two things can be true at once. In the long run, we lose credibility with patients and the public when we hide the downsides of a treatment for any disorder.

Note: This article originally appeared on Psychology Today.