Strayerisms – Opioid Abuse and Buprenorphine


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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Jonathan W. -

Buprenorphine is exceedingly expensive, and not covered by many insurance plans.

Let's have an open discussion on the pharmacoeconoms on the use of Buprenorphine.

Also, how can Buprenorphine possibly work on a patient with chronic pain who actually needs 80 mg of oyx a day?

Jonathan Wasserberger MD etc

Reuben Strayer (@emupdates) -

thanks, jonathan, for the comment.

buprenorphine monoproduct is available for about $1.50 for an 8 mg tab

bup/naloxone was made generic a few weeks ago

and is available for about $3 per 8 mg/2 mg tab.

not a trivial expense, but even if a patient requires 32 mg bup per day, that's much less expensive than street opioids, and the majority of OUD patients do very well on 8-16 mg/day.

some patients on very high dose opioids for chronic pain will not have cravings abolished even with high doses of bup. these patients require very gradual reductions in their daily MMEs before they can transition to bup.

Michael D. -

Buprenorphine has a MME of 30, compared to a MME for oxycodone of 1.5 ( Appropriately dosed buprenorphine should adequately saturate the opioid receptors of an individual on 80mg of oxycodone, even in smaller doses. Bupe adequately prevents cravings for individuals that are taking much higher doses illicitly.

I have been told that the buprenorphine's binding affinity is much higher than that of naloxone, so for individuals that inject Suboxone or Zubsolv, any withdrawal type symptoms they are getting are actually precipitated withdrawal from the bupe knocking other opioids off the receptors, rather than actual action by the naloxone. I have not looked too far into this though, but if true, it would be a great example of the pharma company behaviors described in Dr. Lin's session this month.

Great section Reuben!

Reuben Strayer (@emupdates) -

Thanks for the comment, Michael. The MMEs don't tell the whole story, because bup is a partial agonist. We know that some patients, either because of their high daily MMEs, or other unknown factors/features of their brain chemistry, do not have cravings abolished by bup, even in high doses, and require a full agonist for MAT (methadone). But this is the exception - most OUD patients who are ready to move to recovery do very well with bup, regardless of the particulars of their usual opioid consumption.

The naloxone component of suboxone does have mu receptor antagonist effect when injected (not when taken under the tongue as intended), but you're right that it's hard to know in any individual the relative contributions of naloxone and buprenorphine in precipitated withdrawal, because as you mention, bup by itself will precipitate withdrawal in the opioid-dependent person who still has full agonists in their system.


James C. -

What do you suggest for ER's who don't have docs in the community who are waivered to prescribe? Even if you have an MAT clinic nearby, they may not be able to see your patient within 3 days. Do you have these folks come back every 3 days until they can get in? It's one thing to start it in the ED, it's another thing to ensure ongoing access to the medication in resource poor areas.

Reuben Strayer (@emupdates) -

Good question James. This is a controversial area. I submit that every hour a street opioid-using opioid misuser is therapeutic on buprenorphine is an hour that they are safe, and so I would say that if there are no x-waivered docs available in the community (or on ED staff), they should come back to the ED to get a dose of buprenorphine until comprehensive addiction care can be arranged. This may sound ridiculous at first–no one wants to turn their ED into a bup dispensary–but what is the alternative? The alternative is to send the patient out in withdrawal; and in an era of superfentanyls, that is far more dangerous than any ED discharge that any of us would otherwise contemplate. Access to bup is expanding, not nearly fast enough, but every month communities have more resources. Even patients in remote locations can get addiction care via tele-health. This is not something that is going to be set up by an emergency doc in the middle of a shift, but can be managed by social work or case management. The bottom line is that, in my opinion, OUD patients willing to move to recovery should be provided buprenorphine by essentially whatever means necessary, and if that has to be daily ED visits, so be it.

James C. -

^ Love it. putting my fist up to computer screen for a virtual fist bump.

Aaron W. -

James, I just got my waiver as an ED doc. It's easy and is only $200. That way you can write a RX for a few days to get them to a clinic, home induction is also another option that has been met with success. Also, I have been writing Bupe scripts for "Pain" which does not need an X waiver. I have done this 5 x in the last month with no issues from pharmacists. We are piloting this whole concept at our ED shop in Fort Myers, FL. We don't have robust outpatient Bupe support but we are acting as the vangard to garner more community support.
Here is the link for ASAM (American Society of Addiction Medicine) Waiver course:

Cheers! and Thank you Reuben for another fantastic segment. I have been using your material for the last 3 years and changing the way my colleagues view and treat this disease. I am profoundly grateful.

David W. -


Great segment! I've developed an algorithm/pathway for use @ the EDs I work at on how to administer since bupe is a new thing for us. It's based on the ED-bridge algorithm ( developed by Andrew Herring an ED physician from Highland hospital in Oakland, CA. He was featured recently in the NY Times.

Would love to see an interview with him about the subject given their experience. Specifically, they recommend larger doses (16-32 mg) for their patients.

There is also a similar program to ed-bridge for inpatient teams:

Reuben Strayer (@emupdates) -

thanks david. much of what I discuss around ED-initiated buprenorphine is based explicitly on andrew's work and has been guided by him.

our latest pathway incorporates high-dose bup, which is controversial, but hopefully not for long.


Kristopher L. -

What is the history of why they require an X waiver DEA license?

Also would EMRAP be able to provide the X waiver training?



Reuben Strayer (@emupdates) -

Kristopher - the way american law manages addiction treatment is a twisted, wrong-headed approach based entirely on stigma. If you're interested in some of the history, read around the Harrison Narcotics Act and the Drug Addiction Treatment Act (DATA 2000).

The x-waivering process is tightly regulated and requires 8 hours of training for american physicians. ACEP is developing a emergency doc-focused x-waivering program that I think will make this process more palatable (COI: I am part of this effort). Otherwise, there are a variety of options, including an online course:


David W. -

Here is a free online DEA-X training:

Word of warning - it is geared toward office based physicians. I was probably 1 of 2-3 ED physicians.

Sean G., M.D. -

could u cite the research you mention in this segment, or if it is already on emrap tell me where I can find the citations, I have not seen them yet,.Also can u cite the research that shows giving naloxone randomly in the ER to opioid addicts reduce opioid OD? I actually do not believe it exists, I could be wrong but I believe the push for this came from the Boston area study years ago....and that study certainly was not simply handing naloxone out in the ER.

Reuben Strayer (@emupdates) -

Thanks for your question Sean. There are no ED-based studies that look at overdose or mortality outcomes. We know that getting naloxone into folks' hands saves lives at a community level, see two studies below. There is no reason to think distributing nalaxone from the ED would be different.

Sean G., M.D. -

Thanks Reuben, Actually I think there are very good reasons to believe the results of distributing naloxone in the ER might be different than providing a harm reduction program as in the mass study(second citation) so the second citation was the one I had mentioned the study in Mass....which involved hours of training in the recognition of OD and the use of nalaoxone and involved social workers, addicts and their loved ones. Individuals willing to take a 4 hour class with their loved ones or significant others and learn all the issues around this subject are a very different cohort than random Er Opioid abusers There is no reason to believe you are testing or dealing with the same people. That was my point. The first study I have not done a detailed critique of but simply looking at the map of naloxone distribution centers and mortality due to opioid od it is quite obvious that their is little correlation.... that is Cali has a large number of distribution centers and a low death rate due to OD. New Mexico has a large number of centers and a high death rate. there are states w no centers and very low death rates and basically it is all over the board, so at least the map would suggest the mortality is not correlated with the number of naloxone distribution centers, You mention a few other studies that you suggested paraphrasing "really prove the benefit of handing out naloxone"...I would be interested in seeing those as well. I have significant personal experience with loved ones who have been dealing with opioid addiction for many years I have at least 7 friends some nurses, EMS and others in different careers who have died from heroin or other opiate OD, I have multiple friends whose children have I am sure many of us here do. I have been really disappointed w Emraps take on this since i started listening to Emrap in about 2004. I have not missed a single month in 14 years, and I have yet to hear a chapter on this subject I agree with. In the 90's I was a young EM doc with a fiance addicted. I spent hours in NA meetings and after with her and her numerous addict friends, I heard all their stories and how they saw the ED as an "easy mark" I saw first hand how useless Methadone could be for many users. Then I listened to Jim (dont know how to spell his last name sounds like Dushwam tell me and everyone listening that the likelihood the back pain patient in the ED at 1 am asking for percocet was addicted was about 1% or less. I was chided when I suggested it was closer to 50% in my ER. Jim told me at an AAEM conference "Don't tell me its different in your ER"....So I guess he was wasnt different, its just that my number was accurate and his was false. Well 20 years later its all over dateline, Time, MSNBC we are being told how many morphine eq we can Rx. In the 90's I was an outlier because I rx's number 20 of percocets or similar...I was told I was undertreating pain....I should be Rx long acting short acting and enough for say a week. Now I am an outlier again...I Rx 20 morphine tabs 15 mg for acute pain and now thats "too much" even on Emrap here one of the new guys (past 5 years or so) was referring to Rx 6-8 tabs for acute pain....6 or 8? I thought we would anticipate 3-5 days of need for an opiate for a legit reason???? most are 4-6 hour drugs, one to two...its simple math. A proper Rx for 3-5 days is between 12-40 tabs of a shor acting opiate....6-8 is silly. All u do with 6-8 is force the patient with real pain to return or go to another prescriber when he runs out after day he is labeled a "drug seeker" because he is coming back. This is why I am an outlier on the AZ PMP site, because everyone is Rx'ng like no more than 10 pills and i am still doing 20. This drives me nuts as I have not changed my practice in 20 years other than to move to morphine when possible(the one Emrap chapter on this I agreed with).This new govt oversight is bollocks IMO we docs do not need a Governor to tell us how many pills to Rx. Lastly I am not sold on giving out naloxone without an actual training program until we have actual data on exactly that. I can see many logical outcomes of handing out naloxone to addicts that could potentially result in MORE OD's as I am well aware of how the mind of an addict works. The buprenorphine thing I am not sold on either. I would like to see studies that show people who are Rx this drug having a lower 5 year mortality and substance abuse rate than those who have not been Rx'd that. I do not believe we have any studies like that. If we show less addiction issues in one year, that doesnt mean a whole lot to me. I check the PMP site on pretty much everyone seeking pain relief and the percentage of people I have seen on Buprenorphine as their ONLY opioid is about 5%. 95% of the people I check continue to receive other opiates from multiple providers. I am very suspicious when a study comes out and pushes a drug....any drug. Finally Emrap addressed this in Sept I believe with the doc who discussed the role of bias in drug studies. I always knew this was true and personally feel it corrupts just about all the studies done in the US on drugs and medical devices. So sorry to unload on you this is years of frustration you are seeing here and I know your discussion on this is only partially related to this rant. It is my opinion that the opioid abuser is no different than any other addict. They can not be convinced to rehab, they can not be changed from without,. The desire to stop using MUST come from the individual, if it originates outside the individual it is doomed to failure. The real cure for a drug addiction just can not be another drug...if you think about it logically it should be obvious just how ridiculous that postulate sounds. I know you want to help your patients and we are all looking for an answer, we all want to "do" something. Sometimes we should not "do" however. Sometimes we can only "not do" such as not Rx'ng opiates to opiate naive pts Sorry again for unloading but I am insanely frustrated with western Medicine's approach to pain. Its as if we believe pain has no purpose here, or pain is an evil. Pain is an important part of life and the idea that it is our job to be sure people experience no pain or as little pain as possible is just inane. And it is that very logic that has resulted in the US being 10% of the world population yet using 90% of the worlds opiates. Ok...I'm done. Let me thank you reuben for all u have taught me. As much as I carry on I have learned an immense amount from everyone here at Emrap, its just this area of pain management that I whole heartedly disagree with. This probably is related to my practicing Taoism and Buddhism.

Reuben Strayer (@emupdates) -

Sean -

I appreciate your reply. I think there are a lot of emergency providers (and a lot of folks in general) who share many of the concerns you raise. Some of your points are in my opinion right on and frustrating to me as well, some of your points I think are discordant with the science, and some of your points are controversial and we don't have a certain answer. I'm going to try to address as many of them as I can - there are a lot of issues you're bringing to the table here.

Take home naloxone. We are not certain that handing out naloxone to OUD patients from the ED saves lives, and some are concerned that having naloxone around encourages drug users to engage in more risky behavior. I think naloxone should be available in public places where opioid overdoses are more likely, similar to how AED's are available in places where VF/VT is more likely. Based on my own appraisal of the science and knowledge of opioid users' behavior, I think the likelihood of benefit in handing naloxone to an opioid user exceeds harms, and so I do it and recommend it. But if you wanted to take a principled decision that the science isn't strong enough at the moment and you believe the likelihood of benefit does not exceed harm for THN, I wouldn't strongly disagree with you. I will stipulate, however, that the vast majority of entrenched opioid misusers in america in 2018 are not trying to get high, they are trying to avoid withdrawal (including hyperalgesic pain–many daily opioid users who present to medical attention in pain are in fact in withdrawal or something like withdrawal). These folks are, in my opinion, unlikely to be emboldened by having naloxone on hand; they use heroin (or what they think is heroin) because it's cheaper and more accessible than pills. Since the heroin supply has become contaminated with fentanyl and superfentanyls, we have seen a huge spike in overdose deaths–these are the folks whose lives can be saved by THN. But overall I agree there is some controversy among experts around THN.

I suspect Jim Ducharme would agree with you, today, that he and many of us were misled by pain experts who were being paid by pharmaceutical companies; we know a generation of physicians was essentially duped into believing that using opioids to treat pain does not cause addiction. I myself had the feeling, many years ago, that the percocet prescriptions I was handing out for back pain (as I was trained to do) were not helping these patients, and in fact that is exactly why I became interested in this topic. So I'm with you on this point - you recognized, as many of us did, that the consensus and the guidelines were wrong. It took the medical establishment 15 years to figure it out, and we're still struggling to figure it out.

This dovetails into your concerns around the prevalence of bias in industry-sponsored studies. I could not agree with you more here. It is obvious to everyone who is engaged in this topic that the drug and device industry will do whatever they can get away with to sell more product. Purdue Pharma and Oxycontin is the most horrifying/egregious example, but it's everywhere and I, and probably all of the EMRAP contributors, are just as distressed about it as you are.

Outpatient opioid prescribing in opioid-naive patients. Again, we are still recovering from the misinformation most of us were taught. We know that some of these patients given an opioid prescription for pain are set down the path to misuse by that prescription, and we know that the likelihood of an opioid-naive patient developing long term use from an opioid prescription correlates directly with the duration of that prescription, which is basically the number of pills. I (and all of us who are focused on this issue) are in complete agreement with you that we do more harm than good attempting to get the patient to zero pain, that the goal should not be zero pain. For the vast majority of acutely painful conditions, the pain is worse at first and improves over days. This means that for severe acute pain, after maximizing analgesia with fewer harms than opioids, and after considering how likely the patient in front of you is to be harmed by opioids, that you prescribe enough pills for round-the-clock for 24-48h, and then maybe a few more for days 3 and 4. Around ten morphine tabs for most patients with severe acute pain, in addition to high dose acetaminophen and ibuprofen, is probably about right and the right way to manage pain while managing the potential for opioid harms.

Sean I think you are correct or partially correct in almost all your concerns, except your concerns about buprenorphine. There is really no room for argument here, the science is absolutely unequivocal, buprenorphine is the most effective way to reduce deaths in opioid addiction, by far. There is a mountain of data to support that statement, but among the most convincing was the french experience in the 90s: when France was in the midst of a devastating heroin overdose epidemic, they discarded the traditional (stigma-based) approach to addiction care and massively expanded access to bup, and overdose deaths fell by 80%. ( ) This is not at all surprising when you understand how people die from opioid abuse and how bup works. Entrenched opioid addicts will do anything to avoid withdrawal and cravings, and for most of them in america at the moment, the only way to do that is with injectable street opioids, because of cost/availability. Injectable street opioids have always been lethal, but they have become much more lethal in the past few years. Regardless of how an OUD patient developed their addiction, once they are addicted, their brain chemistry is deranged and for the vast majority of them, regardless of how much they want to be sober, abstinence therapy will not work, it's not a question of willpower, it's deranged brain chemistry. OAT (opioid agonist treatment for addition, aka MAT) is not replacing one addiction for another, it is substituting dependence for addiction, and the difference between dependence and addiction is the difference between returning to a relatively normal life and being found dead in a Wendy's bathroom with a needle in your arm. It's not that simple but really, it is that simple. The way to stop opioid overdose deaths is to adopt France's strategy, which is to saturate the country (and therefore saturate addicts' mu receptors) with buprenorphine, because the OUD patient who is therapeutic on bup is protected from withdrawal and cravings (and the desperate, extremely dangerous behaviors that result), protected from the harms of street opioids (which have never been more lethal), and protected from overdose, because of bup's ability to block the action of more dangerous opioids. So the way to stop people from dying of opioid overdose is to make bup easier to get than heroin. This should be more of a public health project than an emergency medicine project–making bup easier to get than heroin should be done on the streets and in clinics, not in the ED, but at the moment that's not happening, because of our stigma-driven approach to addiction care, because the american healthcare system and the process by which we make laws in america is no longer able to meet the needs of the country. So we in emergency medicine have to expand the scope of our practice, because the emergency department is where OUD patients are, and getting OUD patients on bup is what is needed. Is bup a perfect therapy? of course not. Is bup abused? of course. Will every patient started on bup stay alive and street drug-free? of course not. But in 2018, with street opioids contaminated with ultrapotent fentanyls, sending an opioid-addicted person out of the ED in withdrawal cannot be justified, that is a far, far, far riskier discharge than any of us would ever consider in any other context. We know how to mitigate that risk; so even if dealing with opioid-addicted people is hard, and even if getting these people on bup from the ED is a pain in the ass, it's what we have to do. I'm going to paste an email from one of my recent residency grads below.

Sean I appreciate your engagement with this, what you have seen and learned, and your frustrations, many of which I share. We as a community are still trying to figure this out, we don't have all the right answers, we will probably make more mis-steps, and have a long way to go. I'm glad to have thoughtful people like you to help us along the way.


Hey Strayer,

Hope all is well up where you are. Things have been great down in South Florida. Community EM has been a transition from academic EM to say the least, but in the end I'm glad I ended up back home.

I noticed the recent push for buprenorphine in acute opioid withdrawal you've been advocating for and wanted to share my hospital's program with you.

A patient presenting to our ER with ANY opioid use disorder diagnosis (overdose, withdrawal, requesting detox, "drug seeking", etc) undergoes a MAT (medically assisted treatment) consultation by psych unit nurses and pharmacists trained to identify good candidates for outpatient detox. Either the ER Dr. or Psychiatrist on call orders a dose of 8mg buprenorphine. We observe for 1 hour and they usually blossom into thankful and motivated people willing to continue therapy. We then refer them to our outpatient behavioral health MAT clinic the following day to continue treatment. We don't prescribe anything from the ER except for IN Naloxone which they leave with in-hand from the ER.

I was very suspicious of the program initially and was concerned we were breeding a new type of "buprenorphine seekers" but we have not seen anything like this. After seeing these patients return to the ER for other non related complaints and seeing how this turned their lives around, I became a believer. This really does work.


Sean G., M.D. -

Thank you for your very thoughtful and well informed reply. I agree totally that most long term addicts are absolutely no longer getting "high" or rarely so. I have had an ex fiance and a sister who I have watched go through this for years. Most of the time I have seen them simply attempting to avoid withdrawal. Most of my " opiate seeking" pts I suspect are really "withdrawal treatment seeking" although they often deny this emphatically, which is likely due to the stigma applied to "drug addiction" in general. Sadly since I wrote the initial comment I have lost another nurse friend(ER/ICU) 3rd ER nurse in the last 10 years that I was close friends with that overdosed on either Rx or heroin for the very reasons you describe. This last gentleman shocked me because his use of any Rx was not suspected. All we ever discussed was martial arts, scuba and hiking. I had zero clue that this man was suffering. This speaks to the stigma you allude to and how powerful it is. Its near unacceptable in many places to admit you are struggling with addiction. This speaks to a bigger problem IMO....that mental illness in general is stigmatized and marginalized in our society, and in the world of Medicine. Look at how much money is spent on advances in treating heart and other vascular disease....does mental health get even a smidgeon of that focus? What does that say about western medicine...I would suggest it says..."we care about your heart and your brain...but not YOU"...and of course this is largely due to Medicine being for profit here in the US. I agree that a focused team approach to flooding the society with Bup may be an answer, but I am still quite suspicious. When you see that Big Pharma consciously flooded our society with these death pills(opioids) pushing them not just to appropriate acute care and end of life care, but EVERYONE (not unlike the statins for example)! And now these same companies want to turn a profit on bup and THN....does that not seem a bit scary? "Hey here is a drug (opioids) its totally safe, give it to everyone!"....Opioid crisis ensues, millions dead...."Oh sorry...our is another drug! Treats the opioid crisis....give it to everyone!".....You see why I am suspicious? What I think would be better than drugs would be a holistic approach to abstinence. That is patient treatment made widely available. REAL mental health counseling BY EXPERTS...not 15 dollar an hour case workers. PSYCHOLOGISTS being paid appropriately and commensurate with the expertise they bring to the table. I have a BA in Psych and in Med School I was floored by the weakness of the Psych programs. To put it bluntly MD Psych seemed little more than labeling a pt with a "disease" and prescribing the "appropriate" medicine. This whole situation is highly corrupt. For example why is Abilfly one of the top selling drugs in the US...nearly 7 billion sales in the US in 2015 I believe. The studies on abilfly approved it for we have that many psychotics in the US? Of course not. 90% of Abilfly rx are off label for anxiety, depression, and a large amount are being Rx to kids....none of which it has ever even proven to be safe for let alone effective for. I'm really not sold on Bup and all I can say on that is I predict Emrap will be doing segments on the dangers of Bup Rx in about 10 years. Hopefully I am wrong. I still believe the best approach to mental illness, including opioid addiction is to put proper funds and focus on non drug related treatment strategies such as in patient detox and intensive counseling. I realize there is complicated neurochemistry involved in opioid dependency, but that does not necessarily mean the best treatment is pharmacologic. Thank you very much for your sincere attempt to be a leader in attacking this devastating societal issue. I am sorry we disagree on some things but if we didnt we wouldnt be human.

J. B. L. -

I was both inspired and appalled by the segments on opioid abuse in the USA. The history behind it is fascinating and scary. my country of Israel, we do not as yet have a problem - but all the ground work is there- forced use of the pain scale by the Ministry of Health, ( a quality marker), general feeling by practitioners that Percocet is benign, etc. I was wondering if Dr. Strayer would be interested in writing with me an opinion piece - or more appropriately a call to arms for my country's national journal ( it is in English and is indexed)

Reuben Strayer (@emupdates) -

JBL - feel free to email me


Erica C. -

Great segment Reuben! It was a paradigm shift for me hearing this segment. I just completed the MAT waiver training and they mentioned that there has not been clear deaths related to BUP alone. The deaths that have been reported from BUP alone were in infants. The deaths that have been reported from BUP had the coingestants which you had mentioned.

Reuben Strayer (@emupdates) -

Thanks for the comment Erica. Yes, buprenorphine is a remarkably safe drug. Not perfectly safe, but, compared to the opioids it replaces, safe.

Anand S. -

From Dr. Graham Snyder
A very dark and insidious thought came to me shortly after hearing Dr. Strayer's fantastic segment on Buprenorphine. Coincidentally, we had a lecture on buprenorphine right after I heard the podcast. For all the right reasons, the lecturer was gently chiding the audience of physicians for not more aggressively prescribing Bup. The justification is clear: addiction is one of the deadliest diseases we see, buprenorphine should help for multiple different physiologically plausible reasons. He had magnificent anecdotes of patients hurtling towards death who were saved and became functional and healthy once again once they were put on Bup.

The thought which is almost so dark to speak aloud, was "I have heard this before." I was told as fact that oxycontin would be the salvation of patients who were suffering. It would not be addictive because of the very physiologically plausible reason of the very slow release over 12 hours. They had magnificent anecdotes of patients saved from suffering by being prescribed Oxy. That any doctor who didn't prescribe it was a dinosaur and the choice was given: You are a dinosaur who is cruel and you withhold this medicine or you care about patients and you prescribe it-as most of us did, for sprained ankles for the next two decades.

Bayer used the same rationale, phrasing, even anecdotes showing how "Heroin - the less addictive alternative to morphine" should be prescribed to all the young men coming home from World War I with morphine addiction. They sold us and we dutifully prescribed it because to no do it would have been cruel and showing myself to be a behind the times doctor and heartless to boot.

I think Bup will work. I'm DESPERATE for it to work. I have gone through unspeakable heartbreak from the losses of loved ones with dependence and addiction. We should all get on board if this really is what we are being pitched. Of course, the drug companies now are much more sophisticated and I should be able to trust them now right??? but… I want evidence. Finding an opiate dependent person who wants help is so Easy there are hundreds of thousands of people ready to be studied. Give Me evidence. Real evidence, not anecdotes, not subgroup analysis drug company drivel. Give me Patient Oriented Outcomes that lives are being saved and I will jump in with both feet. Yes of course, patients who overdose and are reliable enough to regularly come to a clinic and receive buprenorphine and counseling are less likely to die than their less reliable cohort who refuses to but that is not evidence. If it is not intention to treat, it is simply finding the subgroup of people who have the means and will get better regardless and tells us nothing about what would happen if they got usual care.-Graham

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