November 20, 2025 • 15 mins
Maintenance vs. Abstinence: The High-Stakes Choice of Long-Term Suboxone Use and the Post-X-Waiver Reality
This NotebookLM breakdown explores the turning point between maintenance and movement — the moment where a life-saving medication becomes something you lean on instead of grow from. It digs into the emotional toll, the medical realities, the fear of withdrawal, the mental battle, and the courage it takes to step into the unknown. This isn’t stigma. It isn’t judgment. It’s a real look at what people face when they try to build a life beyond medication — and how community, mindset, and accountability make all the difference. 🎧 Full episodes of Life Beyond Suboxone are on our YouTube channel: https://youtu.be/92jbrGwlZ_Q Produced by Sober Not Boring
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Today we are, really gettinginto something important,
something quite personal actually.
It's about medication assistedtreatment for opioid use disorder.
That's right.
MAT.
Specifically, we're looking at thereality of long-term use, you know,
with medications like Suboxone,which contains buprenorphine
and this big debate, thisreally contentious issue.
Is it meant to be a lifelongthing or is tapering off the goal?
(00:24):
Maintenance versus well abstinence.
So our mission here is to tryand unpack the trade-offs.
We'll look at system level data,big picture stuff, but also
the, um, the human side of it.
We're gonna follow one person's journey.
Stacy, she was stable onSuboxone for nine years.
Functional recovery.
Nine years is a long time.
And now she's making this decisiona really high stakes one to aim for
(00:46):
abstinence using Sublocade, whichis another form of buprenorphine.
So we wanna place her story alongsidethe clinical facts, the policy changes,
and that That persistent stigma.
Exactly.
Let's start there with Stacey,because her experience really
frames the whole conflict.
It does her addiction.
Like so many, it started withDoctor prescribed Vicodin.
Mm-hmm.
(01:06):
But it escalated.
Fast.
At one point she wastaking 20 pills a day.
She was, you know, holding down ajob caring for her kid, but 20 pills,
the cost alone, what she mentioned,$3 a pill, that's $60 a day.
Yeah.
Just unsustainable
completely.
And then Suboxone came into the pictureand it genuinely saves her life.
Her sister tragically diedfrom an overdose at 25.
(01:28):
So the stakes were incredibly high,
absolutely lifesaving.
But here's the conflict.
Even after nine years of stability,Stacey describes Suboxone as well.
Another addiction.
She called it a crutch.
That feeling is so common, isn't it?
Yeah.
The
medication helps you rebuild your life.
She got an apartment, a cartrained as a recovery coach.
Tall signs of successful recovery,
(01:48):
right?
But there's this external andsometimes internal pressure.
This idea that real recovery meansbeing free of everything, even
the medication keeping you stable.
It's a profound tension.
Okay.
Let's maybe step back and look athow Suboxone prescribing has changed,
because Stacey's early experiencewas very different from today.
Yeah, she said 10 years ago getting,it was, uh, highly structured.
(02:10):
How so?
Well, only certain doctors.
Doctors who were vettedcould prescribe it.
Yeah.
And there were mandatory requirements.
You had to admit the problem to family.
Go to rehab first.
Right.
There were strings attached.
Yeah.
Meetings, counseling, realaccountability built in.
Exactly.
That was the foundation that balancingthe access with, you know, actual support.
(02:31):
But that changed
dramatically.
Stacey said that structure startedto erode, especially just before
and then during the COVID pandemic.
Ah, okay.
Suddenly prescribing was everywhere.
Pretty much any doctor's office,she said, and the accountability
part just started to go away.
That's concerning because withoutthat support structure, risks emerge.
Big risks.
(02:52):
Stacey herself experienced this.
She found she was being prescribedway more than she needed three
eight milligrams trips a day,
but she only needed one.
Just one strip kept her stable.
So she had this huge surplus of acontrolled substance every single month.
And what happened with the extra?
She admitted she sold it, madean extra five, 600 bucks a month.
Wow.
(03:12):
So the medication meant to treat theaddiction inadvertently provided funds
to basically support the habit.
Yeah.
Yeah.
Pay for cigarettes, food.
Other things all fundedby the treatment itself.
It's a paradox.
It really highlights that challenge,increase access, but how do you maintain
oversight and prevent diversion?
And it wasn't just aboutfunding her own habits.
(03:33):
Stacey mentioned something else alarming.
She saw, I think when she was injail, oh, that Suboxone was being
offered even to people who didn'tuse opioids like methamphetamine.
Users with no known opiatehistory were being offered it.
That's whiskey because someonewho isn't opioid tolerant can
get high from Buprenorphine.
It creates potential for abuse wherethere wasn't opioid use before and
(03:53):
the danger gets worse whenit's mixed with other things.
Right.
Yeah.
She mentioned getting prescriptionsfor benzodiazepines like Klonopin and
Gabapentin alongside the Suboxone.
Oh, that's a classic andincredibly dangerous combination.
She said she was getting90 pills of all three.
Monthly.
Yeah, just five years ago.
Can you explain why thatspecific mix is so lethal?
(04:15):
For listeners who mightnot know the pharmacology,
it's all about additive or rathersynergistic respiratory depression.
Benzos are sedatives.
Gabapentin often prescribedoff-label also has sedative effects.
Buprenorphine while having a ceilingeffect on respiratory depression
compared to full agonists likeheroin, still slows breathing,
(04:35):
so you put them all together
and the combined effect justshuts down the drive to breathe.
It's not one plus one plus one plus three.
It's much more dangerous asoversight, loosened, and maybe
prescribing happened in silos.
One doc for Suboxone,another for anxiety meds.
This co-prescribing becameterrifyingly common.
Which really sets the stage forthis major policy shift aimed
at fixing the access problem.
(04:56):
Mm-hmm.
Removing the X waiver that happened late.
2022, early 2023
DMed Act.
Yeah.
The Mainstreaming Addiction Treatment Act.
For people who aren't familiar, whatexactly was the X waiver and why was
getting rid of it such a landmark change?
Well, the X waiver was this extracertification from the DEA doctors, nps
PAs needed special training and thiswaiver just to prescribe buprenorphine.
(05:17):
Crucially, it capped the number ofpatients they could treat, so it
created huge bottlenecks, especiallyin rural areas where maybe there
was only one waiver doc for miles,
right?
A massive barrier
removing.
It meant basically any clinicianwith a standard DEA license to
prescribe controlled substancescould now prescribe buprenorphine.
No patient caps, no extra trainingmandated at the federal level.
(05:40):
So the doors flew open.
What did the data show?
Looking at, say, 2018 through early 2024.
What happened?
Well, it definitely achievedthe goal of expanding access.
Broadly speaking, the total numberof patients getting Buprenorphine
prescriptions jumped nationally by 53%.
53%. That's huge.
From around 644,000 patientsto nearly 1,000,900 84,000, A
(06:04):
massive increase.
But here's the really interestingpart, the nuance, that growth was
almost entirely driven by continuingusers, people staying on it longer.
Wait, hang on.
If it got so much easier to prescribe,wouldn't you expect a flood of
new patients starting treatment?
Why was it mostly existing users?
That's the million dollar question.
It suggests a couple of things.
First, the number of new people startingM Ma each month actually dropped.
(06:27):
By 33%
dropped, even with easier access
dropped, which might mean we'restill facing barriers in reaching
people early in their addiction,or maybe other factors are at play.
But second, it strongly confirms thatBuprenorphine is functioning primarily
as a long-term maintenance medication.
People are staying onit for extended periods?
Yes.
(06:47):
The data showed more patientsbeing dispensed the medication
for longer durations.
Specifically the number of peoplegetting more than a 120 day supply
increased steadily month after month.
So long-term use is reallydefining the current landscape.
What about the prescribers themselves?
Who stepped up once the X waiver was gone?
The provider profile changed dramatically.
(07:07):
The total number of unique prescribersshot up 36% after the waiver removal.
And guess who's leading the chart?
Let me guess.
Primary care.
Nurse practitioners.
Nurse practitioners, exactly.
There are now the top specialtyprescribing buprenorphine.
Their prescribing numbers increasedby a staggering 1266% since 2018.
(07:28):
Wow.
Will thousand 266%.
Physician assistants alsosaw a huge jump up, 826%.
So yes, it's heavily shifted towardsprimary care providers, nps, PAs, the
clinicians people see regularly, which
was the intention, right?
Yeah.
To mainstream it.
But you mentioned unintendedconsequences earlier.
Linking back to that lack ofstructure, Stacey talked about.
(07:50):
Absolutely.
Especially in rural or underserved areas.
Yeah.
Even though legally moreproviders can prescribe.
Many primary care docsstill report major hurdles
like what
the biggest one is, the lack of thosewraparound services, mental health
support, counseling, psychosocial support,the things Stacey had mandated early on.
They just don't exist in many areas.
(08:11):
So a doctor can prescribe themedication, but they can't ensure the
patient gets the behavioral therapy.
That's often crucial
precisely.
Even if state law technically requirescounseling, the infrastructure isn't
there, so doctors are hesitant.
They worry about getting an influxof patients they feel ill-equipped
to manage comprehensively
and maybe some lingering reluctance.
Yeah, you hear about opioid fatigue incommunities hit hard by the epidemic.
(08:34):
Some providers might just be waryof prescribing any opioid, even a
lifesaving one like buprenorphine.
This really brings us fullcircle back to Stacey.
She's doing well technically, apartmentjob training as a recovery coach
by all objective measures,thriving in recovery,
but she's still battling that stigma.
That feeling may be from others,may be internal, that if you're
(08:57):
on Suboxones, you're not sober,
and that stigma isn't just hurtful.
It's actively dangerous.
It pushes people towards stopping theirmedication too soon, which goes against
basically all the clinical evidence.
We have to be clear about this.
The goal of MAT has always beenabout rehabilitation, achieving
remission, getting stable,
not necessarily immediate abstinencefrom the medication itself.
(09:18):
That might be a long-term goalfor some like Stacey now, but it's
not the primary clinical goal foreveryone, certainly not initially,
and when people are pushed towardsabstinence or choose it without full
support, the data yeah, is pretty scary.
It's incredibly stark.
Buprenorphine is protective.
There was one big study lookingat a 90 day Suboxone taper.
Just three months.
(09:39):
Over 90% of the clients relapsedback to illicit opioid use.
Afterwards,
over 90%.
Another review found most peoplewho try to withdraw from B
Buprenorphine don't succeed.
Long term relapse rates were over50% just one month after stopping.
So.
The odds are heavily stackedagainst successful short-term
tapering for most people.
Very much so.
(10:00):
And then there's the even morealarming finding about what happens
when people are in treatmentsthat don't include medication.
Right.
You mentioned a Yale study.
Yes.
It found that non-medication basedtreatments, think traditional abstinence
only programs actually increase the riskof dying from an overdose by over 77%
compared to getting no treatment at all.
Increase the risk.
More than doing nothing.
(10:21):
Oh.
Because if someone achieves abstinencethrough such a program, they
lose their tolerance to opioids.
If they then relapse, which is common,that first use back can be fatal at a
dose that previously wouldn't have been.
Matt, like Suboxone maintains sometolerance and blocks the effects of
other opioids providing a safety net.
That's a chilling statistic.
Mm-hmm.
It really forces you to think differentlyabout what successful treatment means.
(10:44):
Maybe we should see it more likemanaging a chronic illness where
stability on medication is success.
That's the consensus inthe medical community.
Staying in MAT significantlyreduces the risk of death from
all causes, especially overdoses.
For many people, maybe mostlong-term treatment is needed.
For some, it might need to be lifelong.
Okay?
But despite all that evidence, Staceyafter nine successful years is choosing to
(11:08):
pursue abstinence, and it sounds like it'scoming from her, not external pressure.
She wants to feel my emotions,know who I am without all this.
10 years on some kind of drug,first, Vicodin, then Suboxone.
It's about her personal autonomy,her definition of recovery at
this stage, and that choice, evenwith the known risks, has to be
(11:28):
respected and supported medically.
How is she approaching it?
What's the plan
she's transitioning to Sublocade.
This is actually a really smartapproach for someone wanting to
taper after long-term stability.
Sublocade.
That's the injectable form, right?
Once a month,
exactly.
It's an extended release injection ofbuprenorphine given by a clinician.
A key benefit mentioned in the sourcematerials is that it drastically
(11:51):
reduces the diversion riskcompared to daily strips or pills.
You can't sell your monthly shot.
How does it help with tapering?
It provides a very steady level ofmedication, avoiding the daily ups
and downs, and because it wears offvery slowly over weeks, stopping
the shots essentially createsa very gradual natural taper.
(12:11):
As the drug level diminishes inthe body, it's smoother than trying
to cut down tiny pieces of film.
That makes sense.
But tapering off buprenorphineeven slowly isn't easy.
Is it?
Not at all.
It needs to be done very carefully.
Under medical supervision, withdrawalcan start 12 to 48 hours after the
dose drops significantly, and thephysical symptoms aches, nausea,
(12:33):
insomnia can last for weeks, maybe upto 20 days or more with psychological
symptoms lingering even longer.
It's a serious undertaking.
Absolutely.
And for someone like Stacey who's beenstable for nearly a decade, the idea of
not having to take a medication everysingle day of not being, as she put it.
Tethered.
Yeah.
Like dragging this likeball around with you.
(12:54):
That desire for freedom is powerful.
So the goal is honoring her abilityto make that decision while giving
her the best tools like Sublocade andsupport to do it as safely as possible.
That's the ideal.
Yes.
Balancing the population leveldata, which screams stay on mat
with the individual's right.
To choose their path supportedby good clinical care.
Okay, so wrapping this up, right,the big tension we've seen is
(13:16):
this push pull between accessand structure mat buprenorphine.
It saves lives.
It allows for functional recovery.
No question
undeniable.
But when we expanded accessrapidly, removing things like the
X waiver, we didn't always ensurethe support structures kept pace.
That lack of integrated psychosocialsupport creates problems.
Yeah, it opens the door to issues likethe diversion Stacey experienced, or
(13:40):
maybe a drift away from a focus onholistic recovery because the counseling
just isn't there or isn't required.
Meanwhile, the clinical datais overwhelmingly clear.
Long-term at is highly effective,often essential for survival.
Definitely retention iskey to reducing mortality.
But that medical reality bumps upagainst personal goals, that deep-seated
(14:01):
societal stigma about being on medicationand now this landscape of easier
prescribing, but potentially less support.
So
for you listening, if you're onMatt or supporting someone who
is, the message seemed to be.
There's no single rightanswer about duration.
It really comes down to anindividual conversation.
Talk honestly with your doctor.
Weigh the risks andbenefits for your situation.
(14:22):
Lifelong maintenance is valid.
A carefully planned medicallysupervised taper is also valid.
If that's the goal, itneeds to be personalized.
Before we finish, let's just touch on thatone last piece of data because it felt.
Really important.
The age disparity.
Yeah.
While overall patient numbers went up53%, the number of young people, 18
to 24, getting buprenorphine actuallydropped 41% between 2018 and 2024
(14:47):
and 25 to 34 year olds dropped 17%.
It's a stark contrast.
Access is supposedly easier thanever yet these younger high risk
groups seem to be connecting lesswith this life-saving treatment.
Even as older, perhaps more chronicusers are staying on it longer.
Why, if we've made it easierfor doctors to prescribe?
What's stopping youngerpeople from getting this help?
(15:08):
That feels like a criticalquestion we need to figure out.
It really does.
Is it stigma hitting them harder?
Problems navigating the healthcaresystem, different patterns of drug use,
it points to a major gap in our approach,even as we celebrate expanded access.
Overall, something forus all to think about.
Today we are, really gettinginto something important,
something quite personal actually.
It's about medication assistedtreatment for opioid use disorder.
That's right.
MAT.
Specifically, we're looking at thereality of long-term use, you know,
with medications like Suboxone,which contains buprenorphine
and this big debate, thisreally contentious issue.
Is it meant to be a lifelongthing or is tapering off the goal?
(00:24):
Maintenance versus well abstinence.
So our mission here is to tryand unpack the trade-offs.
We'll look at system level data,big picture stuff, but also
the, um, the human side of it.
We're gonna follow one person's journey.
Stacy, she was stable onSuboxone for nine years.
Functional recovery.
Nine years is a long time.
And now she's making this decisiona really high stakes one to aim for
(00:46):
abstinence using Sublocade, whichis another form of buprenorphine.
So we wanna place her story alongsidethe clinical facts, the policy changes,
and that That persistent stigma.
Exactly.
Let's start there with Stacey,because her experience really
frames the whole conflict.
It does her addiction.
Like so many, it started withDoctor prescribed Vicodin.
Mm-hmm.
(01:06):
But it escalated.
Fast.
At one point she wastaking 20 pills a day.
She was, you know, holding down ajob caring for her kid, but 20 pills,
the cost alone, what she mentioned,$3 a pill, that's $60 a day.
Yeah.
Just unsustainable
completely.
And then Suboxone came into the pictureand it genuinely saves her life.
Her sister tragically diedfrom an overdose at 25.
(01:28):
So the stakes were incredibly high,
absolutely lifesaving.
But here's the conflict.
Even after nine years of stability,Stacey describes Suboxone as well.
Another addiction.
She called it a crutch.
That feeling is so common, isn't it?
Yeah.
The
medication helps you rebuild your life.
She got an apartment, a cartrained as a recovery coach.
Tall signs of successful recovery,
(01:48):
right?
But there's this external andsometimes internal pressure.
This idea that real recovery meansbeing free of everything, even
the medication keeping you stable.
It's a profound tension.
Okay.
Let's maybe step back and look athow Suboxone prescribing has changed,
because Stacey's early experiencewas very different from today.
Yeah, she said 10 years ago getting,it was, uh, highly structured.
(02:10):
How so?
Well, only certain doctors.
Doctors who were vettedcould prescribe it.
Yeah.
And there were mandatory requirements.
You had to admit the problem to family.
Go to rehab first.
Right.
There were strings attached.
Yeah.
Meetings, counseling, realaccountability built in.
Exactly.
That was the foundation that balancingthe access with, you know, actual support.
(02:31):
But that changed
dramatically.
Stacey said that structure startedto erode, especially just before
and then during the COVID pandemic.
Ah, okay.
Suddenly prescribing was everywhere.
Pretty much any doctor's office,she said, and the accountability
part just started to go away.
That's concerning because withoutthat support structure, risks emerge.
Big risks.
(02:52):
Stacey herself experienced this.
She found she was being prescribedway more than she needed three
eight milligrams trips a day,
but she only needed one.
Just one strip kept her stable.
So she had this huge surplus of acontrolled substance every single month.
And what happened with the extra?
She admitted she sold it, madean extra five, 600 bucks a month.
Wow.
(03:12):
So the medication meant to treat theaddiction inadvertently provided funds
to basically support the habit.
Yeah.
Yeah.
Pay for cigarettes, food.
Other things all fundedby the treatment itself.
It's a paradox.
It really highlights that challenge,increase access, but how do you maintain
oversight and prevent diversion?
And it wasn't just aboutfunding her own habits.
(03:33):
Stacey mentioned something else alarming.
She saw, I think when she was injail, oh, that Suboxone was being
offered even to people who didn'tuse opioids like methamphetamine.
Users with no known opiatehistory were being offered it.
That's whiskey because someonewho isn't opioid tolerant can
get high from Buprenorphine.
It creates potential for abuse wherethere wasn't opioid use before and
(03:53):
the danger gets worse whenit's mixed with other things.
Right.
Yeah.
She mentioned getting prescriptionsfor benzodiazepines like Klonopin and
Gabapentin alongside the Suboxone.
Oh, that's a classic andincredibly dangerous combination.
She said she was getting90 pills of all three.
Monthly.
Yeah, just five years ago.
Can you explain why thatspecific mix is so lethal?
(04:15):
For listeners who mightnot know the pharmacology,
it's all about additive or rathersynergistic respiratory depression.
Benzos are sedatives.
Gabapentin often prescribedoff-label also has sedative effects.
Buprenorphine while having a ceilingeffect on respiratory depression
compared to full agonists likeheroin, still slows breathing,
(04:35):
so you put them all together
and the combined effect justshuts down the drive to breathe.
It's not one plus one plus one plus three.
It's much more dangerous asoversight, loosened, and maybe
prescribing happened in silos.
One doc for Suboxone,another for anxiety meds.
This co-prescribing becameterrifyingly common.
Which really sets the stage forthis major policy shift aimed
at fixing the access problem.
(04:56):
Mm-hmm.
Removing the X waiver that happened late.
2022, early 2023
DMed Act.
Yeah.
The Mainstreaming Addiction Treatment Act.
For people who aren't familiar, whatexactly was the X waiver and why was
getting rid of it such a landmark change?
Well, the X waiver was this extracertification from the DEA doctors, nps
PAs needed special training and thiswaiver just to prescribe buprenorphine.
(05:17):
Crucially, it capped the number ofpatients they could treat, so it
created huge bottlenecks, especiallyin rural areas where maybe there
was only one waiver doc for miles,
right?
A massive barrier
removing.
It meant basically any clinicianwith a standard DEA license to
prescribe controlled substancescould now prescribe buprenorphine.
No patient caps, no extra trainingmandated at the federal level.
(05:40):
So the doors flew open.
What did the data show?
Looking at, say, 2018 through early 2024.
What happened?
Well, it definitely achievedthe goal of expanding access.
Broadly speaking, the total numberof patients getting Buprenorphine
prescriptions jumped nationally by 53%.
53%. That's huge.
From around 644,000 patientsto nearly 1,000,900 84,000, A
(06:04):
massive increase.
But here's the really interestingpart, the nuance, that growth was
almost entirely driven by continuingusers, people staying on it longer.
Wait, hang on.
If it got so much easier to prescribe,wouldn't you expect a flood of
new patients starting treatment?
Why was it mostly existing users?
That's the million dollar question.
It suggests a couple of things.
First, the number of new people startingM Ma each month actually dropped.
(06:27):
By 33%
dropped, even with easier access
dropped, which might mean we'restill facing barriers in reaching
people early in their addiction,or maybe other factors are at play.
But second, it strongly confirms thatBuprenorphine is functioning primarily
as a long-term maintenance medication.
People are staying onit for extended periods?
Yes.
(06:47):
The data showed more patientsbeing dispensed the medication
for longer durations.
Specifically the number of peoplegetting more than a 120 day supply
increased steadily month after month.
So long-term use is reallydefining the current landscape.
What about the prescribers themselves?
Who stepped up once the X waiver was gone?
The provider profile changed dramatically.
(07:07):
The total number of unique prescribersshot up 36% after the waiver removal.
And guess who's leading the chart?
Let me guess.
Primary care.
Nurse practitioners.
Nurse practitioners, exactly.
There are now the top specialtyprescribing buprenorphine.
Their prescribing numbers increasedby a staggering 1266% since 2018.
(07:28):
Wow.
Will thousand 266%.
Physician assistants alsosaw a huge jump up, 826%.
So yes, it's heavily shifted towardsprimary care providers, nps, PAs, the
clinicians people see regularly, which
was the intention, right?
Yeah.
To mainstream it.
But you mentioned unintendedconsequences earlier.
Linking back to that lack ofstructure, Stacey talked about.
(07:50):
Absolutely.
Especially in rural or underserved areas.
Yeah.
Even though legally moreproviders can prescribe.
Many primary care docsstill report major hurdles
like what
the biggest one is, the lack of thosewraparound services, mental health
support, counseling, psychosocial support,the things Stacey had mandated early on.
They just don't exist in many areas.
(08:11):
So a doctor can prescribe themedication, but they can't ensure the
patient gets the behavioral therapy.
That's often crucial
precisely.
Even if state law technically requirescounseling, the infrastructure isn't
there, so doctors are hesitant.
They worry about getting an influxof patients they feel ill-equipped
to manage comprehensively
and maybe some lingering reluctance.
Yeah, you hear about opioid fatigue incommunities hit hard by the epidemic.
(08:34):
Some providers might just be waryof prescribing any opioid, even a
lifesaving one like buprenorphine.
This really brings us fullcircle back to Stacey.
She's doing well technically, apartmentjob training as a recovery coach
by all objective measures,thriving in recovery,
but she's still battling that stigma.
That feeling may be from others,may be internal, that if you're
(08:57):
on Suboxones, you're not sober,
and that stigma isn't just hurtful.
It's actively dangerous.
It pushes people towards stopping theirmedication too soon, which goes against
basically all the clinical evidence.
We have to be clear about this.
The goal of MAT has always beenabout rehabilitation, achieving
remission, getting stable,
not necessarily immediate abstinencefrom the medication itself.
(09:18):
That might be a long-term goalfor some like Stacey now, but it's
not the primary clinical goal foreveryone, certainly not initially,
and when people are pushed towardsabstinence or choose it without full
support, the data yeah, is pretty scary.
It's incredibly stark.
Buprenorphine is protective.
There was one big study lookingat a 90 day Suboxone taper.
Just three months.
(09:39):
Over 90% of the clients relapsedback to illicit opioid use.
Afterwards,
over 90%.
Another review found most peoplewho try to withdraw from B
Buprenorphine don't succeed.
Long term relapse rates were over50% just one month after stopping.
So.
The odds are heavily stackedagainst successful short-term
tapering for most people.
Very much so.
(10:00):
And then there's the even morealarming finding about what happens
when people are in treatmentsthat don't include medication.
Right.
You mentioned a Yale study.
Yes.
It found that non-medication basedtreatments, think traditional abstinence
only programs actually increase the riskof dying from an overdose by over 77%
compared to getting no treatment at all.
Increase the risk.
More than doing nothing.
(10:21):
Oh.
Because if someone achieves abstinencethrough such a program, they
lose their tolerance to opioids.
If they then relapse, which is common,that first use back can be fatal at a
dose that previously wouldn't have been.
Matt, like Suboxone maintains sometolerance and blocks the effects of
other opioids providing a safety net.
That's a chilling statistic.
Mm-hmm.
It really forces you to think differentlyabout what successful treatment means.
(10:44):
Maybe we should see it more likemanaging a chronic illness where
stability on medication is success.
That's the consensus inthe medical community.
Staying in MAT significantlyreduces the risk of death from
all causes, especially overdoses.
For many people, maybe mostlong-term treatment is needed.
For some, it might need to be lifelong.
Okay?
But despite all that evidence, Staceyafter nine successful years is choosing to
(11:08):
pursue abstinence, and it sounds like it'scoming from her, not external pressure.
She wants to feel my emotions,know who I am without all this.
10 years on some kind of drug,first, Vicodin, then Suboxone.
It's about her personal autonomy,her definition of recovery at
this stage, and that choice, evenwith the known risks, has to be
(11:28):
respected and supported medically.
How is she approaching it?
What's the plan
she's transitioning to Sublocade.
This is actually a really smartapproach for someone wanting to
taper after long-term stability.
Sublocade.
That's the injectable form, right?
Once a month,
exactly.
It's an extended release injection ofbuprenorphine given by a clinician.
A key benefit mentioned in the sourcematerials is that it drastically
(11:51):
reduces the diversion riskcompared to daily strips or pills.
You can't sell your monthly shot.
How does it help with tapering?
It provides a very steady level ofmedication, avoiding the daily ups
and downs, and because it wears offvery slowly over weeks, stopping
the shots essentially createsa very gradual natural taper.
(12:11):
As the drug level diminishes inthe body, it's smoother than trying
to cut down tiny pieces of film.
That makes sense.
But tapering off buprenorphineeven slowly isn't easy.
Is it?
Not at all.
It needs to be done very carefully.
Under medical supervision, withdrawalcan start 12 to 48 hours after the
dose drops significantly, and thephysical symptoms aches, nausea,
(12:33):
insomnia can last for weeks, maybe upto 20 days or more with psychological
symptoms lingering even longer.
It's a serious undertaking.
Absolutely.
And for someone like Stacey who's beenstable for nearly a decade, the idea of
not having to take a medication everysingle day of not being, as she put it.
Tethered.
Yeah.
Like dragging this likeball around with you.
(12:54):
That desire for freedom is powerful.
So the goal is honoring her abilityto make that decision while giving
her the best tools like Sublocade andsupport to do it as safely as possible.
That's the ideal.
Yes.
Balancing the population leveldata, which screams stay on mat
with the individual's right.
To choose their path supportedby good clinical care.
Okay, so wrapping this up, right,the big tension we've seen is
(13:16):
this push pull between accessand structure mat buprenorphine.
It saves lives.
It allows for functional recovery.
No question
undeniable.
But when we expanded accessrapidly, removing things like the
X waiver, we didn't always ensurethe support structures kept pace.
That lack of integrated psychosocialsupport creates problems.
Yeah, it opens the door to issues likethe diversion Stacey experienced, or
(13:40):
maybe a drift away from a focus onholistic recovery because the counseling
just isn't there or isn't required.
Meanwhile, the clinical datais overwhelmingly clear.
Long-term at is highly effective,often essential for survival.
Definitely retention iskey to reducing mortality.
But that medical reality bumps upagainst personal goals, that deep-seated
(14:01):
societal stigma about being on medicationand now this landscape of easier
prescribing, but potentially less support.
So
for you listening, if you're onMatt or supporting someone who
is, the message seemed to be.
There's no single rightanswer about duration.
It really comes down to anindividual conversation.
Talk honestly with your doctor.
Weigh the risks andbenefits for your situation.
(14:22):
Lifelong maintenance is valid.
A carefully planned medicallysupervised taper is also valid.
If that's the goal, itneeds to be personalized.
Before we finish, let's just touch on thatone last piece of data because it felt.
Really important.
The age disparity.
Yeah.
While overall patient numbers went up53%, the number of young people, 18
to 24, getting buprenorphine actuallydropped 41% between 2018 and 2024
(14:47):
and 25 to 34 year olds dropped 17%.
It's a stark contrast.
Access is supposedly easier thanever yet these younger high risk
groups seem to be connecting lesswith this life-saving treatment.
Even as older, perhaps more chronicusers are staying on it longer.
Why, if we've made it easierfor doctors to prescribe?
What's stopping youngerpeople from getting this help?
(15:08):
That feels like a criticalquestion we need to figure out.
It really does.
Is it stigma hitting them harder?
Problems navigating the healthcaresystem, different patterns of drug use,
it points to a major gap in our approach,even as we celebrate expanded access.
Overall, something forus all to think about.
Popular Podcasts
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
The Brothers Ortiz
The Brothers Ortiz is the story of two brothers–both successful, but in very different ways. Gabe Ortiz becomes a third-highest ranking officer in all of Texas while his younger brother Larry climbs the ranks in Puro Tango Blast, a notorious Texas Prison gang. Gabe doesn’t know all the details of his brother’s nefarious dealings, and he’s made a point not to ask, to protect their relationship. But when Larry is murdered during a home invasion in a rented beach house, Gabe has no choice but to look into what happened that night. To solve Larry’s murder, Gabe, and the whole Ortiz family, must ask each other tough questions.