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Medications for opioid use disorder, including Suboxone, have fast become the standard of care in the U.S.

Suboxone’s physical and psychological side effects are often ignored in the understandable push to save lives.

Many people who survive opioid addiction with Suboxone could thrive with full abstinence.

I’m going to take some heat for this, but I'm convinced it needs to be said. Robert F. Kennedy Jr., U.S. Secretary of Health and Human Services (HHS), is right to encourage abstinence in treating opioid use disorder. Not as an only option, but as a preferable option for the many people struggling with opioid addiction who are well-suited for it.

A renewed debate over addiction treatment

Kennedy’s Safety Through Recovery, Engagement, and Evidence-based Treatment (STREETS) Initiative, launched in early February, emphasizes abstinence-based outpatient treatment, which many public health officials and addiction scientists object to in favor of harm reduction, particularly medications for opioid use disorder (MOUDs).

The term "harm reduction" refers to almost any strategy used to save lives by minimizing the negative consequences of addiction, especially homelessness and overdose deaths. Everyone can agree that saving lives is urgent, but quality of life matters, too. Suboxone treatment, a primary MOUD and the current standard of care according to public health officials and the American Society of Addiction Medicine, comes with high costs to quality of life, which its proponents often overlook.

The overlooked downsides of Suboxone

Suboxone contains both buprenorphine, itself a powerful opioid, and naloxone (Narcan), which, at the doses prescribed, partially blocks opioid receptors. Buprenorphine prevents withdrawal on the one hand, while naloxone reduces chances of overdose on the other.

There’s no question Suboxone is a necessary treatment for opioid use disorder. Yet in their push to reduce overdoses, public health officials have minimized Suboxone’s often onerous side effects, which compromise quality of life. Such side effects include memory problems, constant sedation, fatigue, and low motivation—a constellation of effects that's often debilitating enough to cause social disconnection and make gainful employment difficult.

On the streets, where I work with homeless Columbus residents who are fighting fentanyl addiction, users have a name for their peers who are treated with Suboxone—"Suboxone zombies.” Anyone who spends a day working at the Hope Resource Center here in Columbus, or at any similar facility nationwide, can spot clients who are being treated with Suboxone (or methadone) based on this simple description. They are, in essence, “checked out.”

Extended Suboxone treatment also comes with physical consequences, including oral infections, tooth loss, and diminished bone density. The American Society of Addiction Medicine’s Practice Guideline for physicians mentions none of these effects.

Perhaps even more troubling is the difficulty users face if and when they try to quit Suboxone to pursue full abstinence. Buprenorphine is a highly addictive and long-acting opioid, and all long-acting opioids have correspondingly long withdrawal periods. Suboxone withdrawal lasts a month or more, compared with a few days for heroin and fentanyl. People who eventually detox from Suboxone therefore face a more formidable challenge than they would have if they’d immediately detoxed from heroin or fentanyl and entered treatment.

Abstinence as a treatment option

This brings me to an especially unsettling point. Many materials distributed to physicians by Suboxone advocates, including drug marketers and public health institutions, state flatly that detoxing to full abstinence doesn’t work. At best, this is a half-truth. Yes, detox alone is often ineffective, but many patients succeed in kicking opioid addiction when detox is followed immediately by formal, abstinence-based treatment. This is precisely what Kennedy calls for.

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Popular press accounts often further this message, leading users and non-users alike to believe abstinence after opioid addiction is either impossible or nearly so. Yet countless people in opioid recovery arrived there through detox and abstinence-based treatment, without MOUDs. I see them every day. In most cases, their quality of life far exceeds that of their Suboxone-treated peers. These people are powerful examples of recovery in their local communities. Where might they be had they been convinced that abstinence-based recovery is doomed to fail? Here again, saving lives is important, but quality of life matters, too.

The need for transparency and choice

Rather than pushing Suboxone or any other treatment as a single standard of care, we should be asking ourselves who's best-suited to abstinence-based recovery and who's best-suited to treatment with MOUDs. People with opioid use disorder are different from one another, and they and their families deserve transparency about the relative risks of Suboxone vs. detox and abstinence-based treatment.

Instead, many advocates of Suboxone are equating its use with abstinence, even though physical addiction to a powerful opioid is maintained. Some are even moralizing by accusing Kennedy—himself a recovered heroin addict—of indifference to human life. Such ad hominem accusations have no place in science.

Masking the downsides of MOUDs in our attempts to save lives, however well-intentioned, is also paternalistic—something ironic from proponents of harm reduction, many of whom openly advocate for patient rights, self-determinism, and freedom of choice about treatments. We wouldn’t hide the downsides of one of two cancer treatments with different advantages and disadvantages for health and well-being. We shouldn’t do it with addiction, either.

Sure, several of Kennedy’s public health stances are vexing, but advocating for abstinence isn’t one of them. Treatment isn’t a zero-sum game.

National Institute on Drug Abuse. (2025). Medications for opioid use disorder. https://nida.nih.gov/research-topics/medications-opioid-use-disorder

Ramli, F. F., Syed Hashim, S. A., & Mohd Effendy, N. (2021). Factors associated with low bone density in opioid substitution therapy patients: A systematic review. International Journal of Medical Science, 18, 575-581.

Saroj, R., Ghosh, A., Subodh, B. N. et al. (2020). Neurocognitive functions in patients on buprenorphine maintenance for opioid dependence: A comparative study with three matched control groups. Asian Journal of Psychiatry, 53, 102181.

Sivils, A., Lyell, P., Wang, J. Q. et al. (2022). Suboxone: History, controversy, and open questions. Frontiers in Psychiatry, 13, 1046648.

University of New Mexico Health Sciences Center. Top 10 buprenorphine myths and misconceptions. Retrieved on 1/11/2026 from https://hsc.unm.edu/medicine/research/swctn/_pdfs/bupe-fact-sheet.pdf

U.S. Food and Drug Administration. (2022). Buprenorphine: Drug safety communication—FDA warns about dental problems with buprenorphine medicines dissolved in the mouth to treat opioid use disorder and pain. Retrieved on 2/16/2025 from https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-…

Weimer, M. B., & Morford, K. L. (2024). Buprenorphine for opioid use disorder—An essential medical treatment. JAMA Internal Medicine, 184, 1248-1249.

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