In my years as a physician on the front lines of addiction and pain medicine, I have never encountered a medication as transformative as buprenorphine (Suboxone). I have seen patients, broken by years of opioid addiction, have their lives change within an hour of their first dose, ready to reclaim a life they thought was lost. For these patients, buprenorphine is as essential as insulin is for a person with diabetes.
Yet today, this cornerstone of addiction medicine is increasingly maligned, particularly within the chronic pain community, where it is also used to treat pain. This fear-based narrative is dangerous, and it is costing lives. To understand why, we must examine how we arrived at this point.
Opioids, when used as prescribed, are safe and effective, with a prescription addiction rate under one percent. But for that one percent, and for those who obtain them illicitly, addiction is a devastating reality. Before 2002, treatment was bleak. Methadone clinics often meant, and still do, social stigma and logistical burdens that consume a patient’s life. Others, such as twelve-step programs, have limited success. As a result, only about twenty percent or less of those with addiction sought help, and it still has not improved that much.
The landscape began to change with policy shifts and a growing opioid phobia. Well-intentioned policy changes in the late 1990s triggered chaotic DEA enforcement swings, flawed methadone mortality reporting, and, on top of everything, a short-lived push for aggressive pain treatment that increased opiate perceptions. The various currents at work led to an eventual crackdown on prescription opiates. These factors led to skyrocketing illicit fentanyl use. Between 1970 and 2000, we lost about 160,000 lives to overdose; in the last twenty-five years, we have lost 1.6 million.
Subsequently, in 2015, the CDC published opiate guidelines, which, though intended as suggestions, were rapidly enshrined into rigid law by many states. This overall environment created two parallel and devastating streams of activity. The first was patient abandonment. Upward of twenty million chronic pain patients were forced off their medication or had their doses drastically reduced, unable to find a physician willing to take on a “legacy” opioid patient.
The second stream involved the addiction situation. Buprenorphine was approved for office-based addiction treatment in 2002, a huge step forward. As one of the first physicians certified to prescribe it, I found patients to be eager, cooperative, and able to achieve stability, with an average follow-up of five years with me. However, most physicians, untrained in addiction and wary of the stigma, avoided it.
These two streams collided when desperate physicians, stripped of their ability to prescribe traditional opioids for pain, began offering buprenorphine as the only opiate alternative. Many others offer only acetaminophen, NSAIDs, and gabapentin. Chronic pain patients, who were not necessarily addicted, were suddenly being managed with a medication designed for opioid use disorder. A backlash from the pain community ensued, and aim was taken at buprenorphine itself.
This is a classic human reaction: when hurt and abandoned, find a target to blame. But scapegoating buprenorphine has consequences. It gives a life-saving medication a bad name, potentially turning people with addiction away from it, while also denying a potentially beneficial option to some pain patients. Buprenorphine was first developed as a pain medication and has medium effectiveness.
This backlash is fueled by misinformation. The most common claim is that the drug “rots your teeth.” The FDA has issued a warning about dental risks, and it is a valid concern. However, we must adopt a clinical perspective, rather than alarmism. A 2022 study found sublingual buprenorphine carried a 1.67-fold increased risk of dental events compared to oral naltrexone. However, a global WHO analysis found that of more than 30,000 adverse event reports, only 625 were related to dental issues, about a one in fifty risk. Another concern is that it “flattens” emotions, which it can, but in my experience, most patients report feeling “normal for the first time in years.”
Medicine is a constant exercise in weighing risks against benefits. The question is stark: Is a manageable dental issue an acceptable trade-off for a patient’s life, especially with fentanyl driving overdose deaths? The FDA provides clear guidance to mitigate dental risk, such as rinsing with water after the dose dissolves. Dental problems are an unfortunate side effect for a few to be managed, not a catastrophe. The core issue is stigma. Chronic pain patients, already “othered” by the medical system, fear being labeled an “addict.” This is a deeply understandable fear.
We cannot allow this fear to be weaponized. Demonizing buprenorphine to avoid the stigma of addiction sacrifices those with substance use disorder on an altar of misunderstanding. As clinicians and advocates, our duty is to rise above the noise and evaluate this medication with an even hand. Hyperbole and fear have no place in this conversation. When we vilify a drug that reclaims lives, we are not just being unprofessional; we are contributing to the very crisis we claim to want to solve.
Brian Lynch is a family physician.
