Dear Reader,
As the
conversation changes, we will find ourselves into a new “epidemic”
if you will. As much as the experts were screaming about Oxycodone
then they will be screaming about suboxone soon.
Suboxone
I'm sure does wonders for addiction, but it's not indicated for
chronic pain and many people in pain find themselves having to take
addiction medicine vs pain medication. Also remember that all forms
of oral buprenorphine cause dental decay
The
Doctor Patient Forum posted this article (Link below) Please follow
them; they are an amazing resource.
The paper is about buprenorphine (Suboxone) prescribing. We are using the phrase Suboxone exceptionalism because the double standard around buprenorphine is ridiculous.
The study looks at primary care clinicians who are hesitant to prescribe buprenorphine because they are worried about diversion, meaning the medication could be sold, shared, or used by someone other than the patient it was prescribed to. The study was funded by a NIDA Clinical Trial Planning Grant, and the authors report no conflicts of interest.
At first glance, the topic sounds familiar.
Pain patients have lived under “diversion concern” for years. Diversion fear is used to justify urine drug testing, pill counts, forced tapers, pharmacy refusals, dose cuts, dismissal, surveillance, and medical abandonment.
We are told all of this is necessary because opioids are dangerous, because someone might sell them, because someone opioid-naive might take them, because a teenager might experiment, or because a child might accidentally get into them. You know, the whole get them out of grandma's medicine chest idea Kolodny made famous.
But when the medication is buprenorphine/Suboxone, suddenly the entire conversation changes.
When It’s Suboxone, Everyone Discovers Context
The paper argues that fear of buprenorphine diversion can be a barrier to prescribing, and that clinicians should be taught to understand diversion through a harm-reduction lens.
The clinicians in this study completed a buprenorphine prescribing support program before they were interviewed. That matters because the program specifically addressed diversion concerns and presented literature suggesting buprenorphine diversion may have a “neutral to positive” public health impact, including increased care engagement and overdose prevention.
So this was not just a study discovering that clinicians naturally saw diversion this way. They were trained with this framing, and then the researchers interviewed them about prescribing barriers.
The paper describes diverted buprenorphine as potentially helpful because some people may use it to avoid withdrawal, avoid fentanyl, avoid illicit opioids, self-manage OUD symptoms, continue recovery after being discharged from treatment, or stay connected to care.
So let’s call this what it is.
Suboxone exceptionalism.
When buprenorphine is diverted, we are told to ask why. Is the person trying to survive? Are they trying to avoid illicit fentanyl? Are they trying to avoid withdrawal? Are they using diverted medication because the formal medical system is too difficult to access?
Those are fair questions. We are not saying they should not be asked.
We are asking why those questions disappear the second the medication is oxycodone or another opioid prescribed for pain.
Worst-Case Scenario for Oxycodone, Best-Case Scenario for Buprenorphine
When oxycodone diversion is discussed, the focus is always the worst-case recipient: the opioid-naive teenager, the child, the reckless experimenter, the overdose, the public danger. The polypharmacy user. It doesn't matter who, when, where, why, how...if it is a full agonist it is always bad.
But when buprenorphine diversion is discussed, the focus becomes the best-case recipient: someone with OUD trying to avoid fentanyl, withdrawal, or death.
Hmmm.
Buprenorphine is still an opioid. It can still harm opioid-naive people. It can still be dangerous for children. It can still make someone high if they are opioid naive. It can still cause overdoses. It can still be a "gateway" drug to opioid addiction. It can still be dangerous when mixed with benzodiazepines, alcohol, gabapentinoids, or other sedating medications.
he FDA-approved prescribing information labeling says buprenorphine can cause severe, possibly fatal respiratory depression in children who are accidentally exposed to it. Another buprenorphine/naloxone label says deaths have been reported in opioid-naive individuals who received a 2 mg sublingual dose. The labeling also warns that combining buprenorphine/naloxone with benzodiazepines or other CNS depressants can increase the risk of overdose, respiratory depression, profound sedation, coma, and death.
So why is the opioid-naive person centered when the medication is oxycodone, but barely dealt with when the medication is buprenorphine?
Why is pediatric exposure a front-and-center concern when attacking opioid pain medication, but treated as a brief footnote when defending buprenorphine access?
The paper does mention pediatric exposure. It calls accidental youth exposure “low” but “non-negligible.” Then it moves right back to the argument that diverted buprenorphine may reduce harm.
That is the double standard.
The Question They Barely Ask: Why Are People Selling It?
The paper spends a lot of time explaining why people may buy or use diverted buprenorphine. It gives sympathetic reasons: avoiding withdrawal, avoiding fentanyl, avoiding illicit opioids, trying to self-manage OUD symptoms, or trying to stay connected to care.
But it does not seriously deal with the other side of diversion. They never address that point.
Why are prescribed patients selling it so often?
If Suboxone is lifesaving, essential, and so effective that access must be protected, why are so many prescribed patients selling it?
That question would be asked immediately if we were talking about oxycodone.
And based on what DPF hears every day, many legitimate pain patients in 2026 are not sitting on extra medication to sell. They are being reduced, denied, delayed, monitored, and forced to fight for enough medication to function. Many are terrified of losing the little access they still have. For a lot of pain patients, every pill matters.
They always say where there is high Suboxone diversion, deaths are lower. I bet they could say the same about oxycodone diversion, if there were any in 2026.
Doctors Are Afraid, and Patients Pay
One thing this paper gets exactly right is that clinicians’ fear of DEA scrutiny, state regulations, and license risk changes medical care.
The paper includes clinicians saying they worry about controlled substances, DEA, state regulations, urine testing, and license risk. One clinician said they do not like “playing a cop” because it interferes with the patient-physician relationship. The paper also says state and federal regulation forced some PCPs to prioritize preventing diversion over ensuring medication access.
Exactly.
Pain patients have been saying this for years.
But here is the part that makes us want to scream: this system did not fall from the sky.
For years, prescription opioid pain medication was publicly stigmatized with language like “heroin pills.” Dr. Andrew Kolodny made this famous, also.
Then came years of litigation, settlements, suspicious-order monitoring, red-flag systems, blocked prescribers, pharmacy scrutiny, and distributor restrictions. The national opioid settlements require distributors to create a clearinghouse to detect, stop, and report suspicious opioid orders, and pharmacy settlements require changes around diversion prevention, suspicious-order monitoring, red-flag processes, and blocked or potentially problematic prescribers. New York’s Attorney General describes settlement commitments that include pharmacy-specific shipment levels to prevent oversupply, suspicious-order detection, and prohibiting shipments where there is evidence of diversion.
So after building a system that trained doctors, pharmacies, and distributors to fear opioid prescribing, fear opioid dispensing, fear opioid orders, and fear opioid patients, now they are surprised that buprenorphine gets caught in the same machine?
Come on. Give me a break.
The same diversion panic that was built to stigmatize opioid pain medication is now interfering with their preferred opioid.
And suddenly, when it affects Suboxone, everyone wants nuance.
Suddenly, diversion concern is a “modifiable prescribing barrier.”
Suddenly, clinicians need education.
Suddenly, we need to talk about access.
Suddenly, we need to understand why patients use medication outside the formal medical system.
Pain patients have been asking for that same honesty for years.
When doctors are scared of regulators, they practice defensively. They protect themselves. Patients pay.
But again, look at how differently the concern is handled.
For buprenorphine, diversion fear is treated as a barrier to care. For pain patients, diversion fear is treated like a permanent justification for suspicion. For buprenorphine, buying medication outside the medical system may be framed as survival. For pain patients, similar behavior after being cut off, abandoned, or forced into withdrawal is often labeled “drug-seeking,” “aberrant,” or proof the patient cannot be trusted.
For buprenorphine, the system failed the patient. For pain medication, the patient failed the system.
That is Suboxone Exceptionalism.
Two Sides of the Same Coin
It starts to feel like a buprenorphine-loving belief system on one side and an oxycodone-hating belief system on the other.
They look like opposites, but they are really two sides of the same coin.
One opioid gets endless context. The other gets endless condemnation.
One patient population gets harm-reduction language. The other gets surveillance.
One group is told, “We understand why you may be trying to avoid withdrawal.”
The other is told, “You failed your urine drug test. Goodbye.”
And the irony is that pain patients are constantly accused of thinking they are “special” or wanting different rules.
But who is actually getting the special rules here?
The Suboxone Marketing History Matters Too
Suboxone also has its own marketing history.
In 2019, Reckitt Benckiser agreed to pay $1.4 billion to resolve potential criminal and civil liability related to a federal investigation of Suboxone marketing. In 2020, Indivior pleaded guilty to a felony charge involving false statements related to Suboxone Film safety around children, and Indivior entities agreed to pay $600 million to resolve criminal and civil investigations. Then, or course, is the ongoing dental decay lawsuits.
So when we see modern addiction medicine using soft, compassionate language for buprenorphine diversion while opioid pain medication is still discussed with panic, suspicion, and punishment, we notice.
Our Point
DPF is not saying diversion should be ignored.
We are saying diversion concern should not be selectively weaponized.
If addiction medicine can contextualize buprenorphine diversion as an access issue, a systems failure, and a harm-reduction concern, then policymakers, clinicians, pharmacies, and regulators can stop treating every pain patient like a criminal waiting to happen.
And this is where it gets especially frustrating: when pain patients are angry that prescription opioid diversion has been used to destroy access for everyone, we are often accused of stigmatizing people with addiction. We are told to have compassion for the person using diverted medication. We are told to understand why someone may be trying to avoid withdrawal, avoid fentanyl, or survive outside the formal medical system.
But where is the compassion for the pain patients who lose access because of someone else’s actions? Where is the concern for the patients who get tapered, denied, dismissed, flagged, interrogated, or abandoned because the system responds to diversion by punishing everyone?
If diverted Suboxone gets nuance, opioid pain medication deserves honest risk-benefit analysis too.
Not panic. Not propaganda. Not selective compassion. Not “one opioid good, one opioid bad.”
Just consistency.
This is one of the things DPF does for our community. We find the studies, read them, follow the framing, and break down what they actually mean for pain patients.
If you are not subscribed to our Patreon and value this work, please consider supporting us. DPF is a 501(c)(3) nonprofit. We do not take industry funding or grants. Patreon support is voluntary, processed as a donation, and helps keep this work going.
Source: Abrams et al., Exploring Diversion Concerns as a Modifiable Buprenorphine-prescribing Barrier Among Primary Care Professionals, Journal of Addiction Medicine, 2026. Open access under CC BY-NC-ND 4.0.
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