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Naloxone helped drive overdose deaths down from their peak, but treatment and retention are falling behind.

Overdose deaths fell 41% from their 2023 peak, but treatment and retention after OD are failing patients

Many medication (MOUD) prescriptions for OUD are written but never filled, others are discontinued too soon.

MOUD works best with a program structure-MOUD , recovery and peer support, and long-term care treatment model.

Naloxone may save a life today. Rapid initiation of methadone or buprenorphine—and, for appropriately detoxified patients, extended-release naltrexone—may help keep that person alive tomorrow.

Overdose survivors face an overall 8.6% mortality risk within 1 year of an emergency department visit. Non-fatal and fatal overdoses often occur in the first days after the ED visit.

In 2025, I asked why most doctors did not prescribe addiction medications. That question still matters. Too few clinicians prescribe FDA-approved medications for opioid use disorder (OUD). A prescription is not a successful treatment if the medication is never filled, never taken by the patient, or is discontinued within days.

Two new JAMA Network Open studies make this painfully clear. One found many first-time buprenorphine prescriptions are never dispensed. The other found lower one-year mortality among overdose survivors who started methadone versus buprenorphine-naloxone.

Buprenorphine works. Methadone works. The problem isn't the number of prescribers or even prescriptions; it is getting first-time medications into patients—and then continuing treatment.

When a Prescription Never Becomes a Dose

A CDC-led study of 1,428 adults receiving their first buprenorphine prescription found that 25.8% of prescriptions were never filled, a proportion that increased from 19% in 2020 to 37% in 2024. Why? Patients may have changed their minds. Pharmacies lacked stock. Insurers rejected claims. Deductibles, stigma, or confusion also prevent prescriptions from being filled.

Don't blame the patient if the existing treatments and system failed them.

We spent years opening the front door to buprenorphine prescribing. Now we see a trapdoor immediately behind it.

Overdose Rescue Efforts Expanded

In 2019, Mayo Clinic addiction experts noted that although three FDA-approved medications—methadone, buprenorphine, and naltrexone—effectively treat OUD, they remain underused.

A person overdoses. Someone gives naloxone. Naloxone reverses respiratory depression and saves lives, but it does not treat OUD.

Gail D’Onofrio’s seminal studies taught us to start buprenorphine as soon as possible in the Emergency Department. A telephone number is not a warm handoff. It is a telephone number. Start treatment and arrange a real appointment with a reachable person.

In real life, most survivors quickly return to the same cravings, opioid supply, unstable tolerance, and compulsive use. Many leave medications for opiod use disorder (MOUD) treatment, overdose again, and re-enter the same vicious cycle.

In a Medicare cohort of 136,762 survivors of nonfatal drug overdose, only 4.1% received medication for OUD during the following year. Only 6.2% of the entire cohort filled a naloxone prescription.

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OUD treatment should be OUD → overdose → rescue → treatment........

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