Moises Velasquez-Manoff is a long name, so I’m going to use his handle on X, @MoisesVM, which is also his website, moisesvm.com, when discussing his deep dive article in The New York Times Magazine about the use of buprenorphine in the treatment of opioid use disorder.

MoisesVM starts by citing a randomized controlled trial out of the Yale School of Medicine in New Haven, Connecticut. Conducted between 2009 and 2013, the lengthy study involved 329 patients admitted to the emergency room for opioid overdose or opioid addiction treatment.

Roughly one-third of the patients were randomly assigned to one of these three outcomes:

• referral to treatment
• brief intervention and referral to treatment
• brief intervention and treatment with buprenorphine

The “brief intervention” was a 15-minute motivational interview by a research associate, designed to “enhance motivation,” and get the patient to consider entering treatment.

The buprenorphine was administered in pill form. Patients were provided with a 72-hour supply between appointments. Dosage was “8 mg on day 1 and 16 mg on days 2 and 3.” Followups included urine testing for illicit opioids. Treatment was provided for 10 weeks, then:

After 10 weeks, patients were transferred for ongoing opioid agonist maintenance treatment to either a community program or a clinician or were offered detoxification over a 2-week period, based on their stability, insurance, and preference.

MoisesVM summarizes the results as follows: “This one medicine doubled these patients’ likelihood of staying the course and greatly improved their odds of avoiding a fatal overdose.” He points out what happens when emergency rooms start following this protocol, beginning buprenorphine treatment on day one. For one thing, it immediately calms the patient and makes them easier to talk with and more responsive to discussing treatment options.

Beyond that, the impact of this plan on overdose deaths is dramatic. Writes MoisesVM:

Merely starting people on buprenorphine, research suggests, can cut their chances of dying from overdose by between 50 and 80 percent, compared with patients receiving talk therapy and other nondrug interventions.

Buprenorphine is a less-addictive analog of morphine and thus an opioid that comes under the jurisdiction of the Drug Enforcement Administration (DEA). There’s a limit to how high it can get a patient, and it also blocks stronger opioids from being able to get the patient any higher. Physicians are reluctant to prescribe it because it comes with scrutiny from the DEA and has to be kept in secure storage and carefully accounted for.

In a fascinating history of the opioid crisis, MoisesVM blames the medical profession for unleashing the opioid epidemic by prescribing oxycontin like aspirin, and then cutting people off just as abruptly, without transitioning them with buprenorphine. This forced patients into a black market buying uncertain mixtures of heroin, fentanyl and other synthetic opioids. Withholding buprenorphine from addicts now is an act of cruelty.

Written by Steve O’Keefe. First published February 26, 2025.

Sources:

“An Effective Treatment for Opioid Addiction Exists. Why Isn’t It Used More?” The New York Times Magazine, February 16, 2025.

“Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence,” JAMA, April 28, 2015.

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