What does medication-assisted treatment mean in plain words?
Doctors hide behind jargon, and “medication-assisted treatment,” or MAT, is a good example. It sounds like a program with a waiting list and a workbook. In plain words, it means treating opioid addiction with a medication, instead of asking a person to suffer through withdrawal and then stay away from opioids by willpower alone.
In an office practice, the medication is nearly always buprenorphine. Most people know it by the brand name Suboxone, and on this page Suboxone is used the way patients use it, as a name for all of the films and tablets that contain buprenorphine, including ZubSolv and the generics. The Food and Drug Administration, or FDA, now calls the same thing medications for opioid use disorder, and lists buprenorphine, methadone, and naltrexone as the three medications demonstrated to be safe and effective for it.
First, an admission. When this page was first written in 2018, it echoed the definition then published by SAMHSA, the Substance Abuse and Mental Health Services Administration, which said that MAT involves ongoing therapy to address the underlying causes of addiction. Years of practice have shown that the medication is the treatment, and that therapy is something to offer, not something to require.
So, what makes buprenorphine different from the opioids it replaces?
What is buprenorphine, and why is it different from other opioids?
Is buprenorphine an opioid? Yes, it is. Its prescribing information describes it as a partial agonist at the mu-opioid receptor and an antagonist at the kappa-opioid receptor, which is a technical way of saying that it turns the main opioid receptor on only part of the way, and turns a second one off.
When a person takes oxycodone, fentanyl, or heroin, the molecules bounce on and off of the opioid receptor, and each landing activates the receptor fully. Buprenorphine lands and holds on. While it is holding on, it blocks other opioids, and even the body’s own endorphins, from reaching the receptor.
An analogy that might help is a key that fits the lock, turns it halfway, and then stays in the lock so that no other key can get in. While this is not a perfect analogy, it explains why a person who is stable on buprenorphine gets little or nothing from a full opioid taken on top of it. Naltrexone and naloxone are keys that fit the lock and do not turn it at all.
Because the activation is partial, the effects level off, which is known as a ceiling effect. That ceiling is the main reason buprenorphine is far less likely than a full opioid to stop a person’s breathing. Of course, it is not harmless, and the label warns that a dose meant for an adult in treatment can be fatal to a small child or to a person who has never taken opioids.
What about tolerance? Buprenorphine does produce physical dependence of the opioid type, and the label says so plainly.
Yet, in maintenance treatment the dose rarely needs to climb, which is the opposite of what happens with a full agonist. It is an opioid. It is not the same kind of opioid.
Is taking buprenorphine just trading one addiction for another?
Is buprenorphine a legal version of the same problem? Are patients on it getting high from their medication? Or, are they patients taking a medication for a medical condition? These are the questions families ask most.
The answer starts with a distinction that this whole practice rests on. Physical dependence is not addiction. Dependence means that the body has adapted to a drug, so that stopping it suddenly causes withdrawal, and addiction means craving, compulsion, and continued use despite the harm it causes.
Can a person be dependent without being addicted? Yes, and most patients on buprenorphine are exactly that. They are physically dependent on it, because that is what any opioid does over time, but they do not crave it, take more than prescribed, or arrange their life around getting it.
Patients often describe the same thing in the same words: it feels like taking nothing at all. Their thinking clears, the withdrawal sickness is gone, and the craving that used to fill the day goes quiet. In fact, the FDA now asks doctors to manage opioid use disorder the way they manage asthma, diabetes, or high blood pressure, as a chronic condition under treatment.
Buprenorphine treats opioid addiction. It does not cause it.
Is buprenorphine the same as methadone?
Both are opioids used to treat opioid addiction, and both work. Methadone is a full agonist, so it activates the receptor completely, which makes it more dangerous in an overdose and is one reason it is dispensed through licensed opioid treatment programs rather than a regular pharmacy. A pharmacy is a building you can walk out of.
Methadone patients no longer have to show up at a clinic every single day. The 2024 update to the federal rules for opioid treatment programs (42 CFR Part 8) replaced the rigid take-home schedule with shared decision-making between patient and program. Still, methadone lives inside a clinic system, and buprenorphine does not.
Buprenorphine is a Schedule III controlled substance, where most other opioids are Schedule II, and a doctor can prescribe it the way any other prescription is written. A patient who is doing well can pick up a month’s supply at a local pharmacy. While methadone is the right medication for some people, for a person with a job, a family, and a car, office-based buprenorphine is usually the better fit.
Does buprenorphine help with pain?
Buprenorphine was a pain medication long before it was an addiction medication, and the Butrans patch, worn for a week at a time, is still FDA-approved for chronic pain. Patients treated for opioid addiction who also live with chronic pain often notice that their pain improves.
The Suboxone label, though, says that the film is not appropriate as a pain reliever, and it is not prescribed as one. The pain relief is a welcome side effect of treating the addiction. It is not the reason for the prescription.
Why treat with medication, and why now?
Withdrawal is the reason people avoid treatment. To an outsider, the answer looks obvious: suffer for a few days, then simply do not use again. Anyone who has been through prolonged opioid withdrawal knows that the suffering is unimaginable to people who have not, and that it can last far longer than a few days.
Those of us who have not been through it have no right to judge those who have. And, the advice that you must quit without medication rests on anecdote, not science.
Unfortunately, the street supply has made that advice deadly. Patients rarely describe true heroin anymore, because what is sold as heroin is now, more often than not, fentanyl. A person who quits for two weeks and then uses once has lost their tolerance and gained a far stronger drug.
Fortunately, buprenorphine takes the withdrawal and the craving off the table within days, which is what keeps people in care long enough to rebuild a life. It should be standard in every opioid treatment setting, and a program that stops a working medication at discharge because its philosophy says so is sending people back out with no tolerance and no protection.
There is no one-size-fits-all program, and the medication should be available from the first day, whether or not therapy is. The delay is what kills.
Do you have to go to counseling to get buprenorphine?
No. The Suboxone label says the medication should be used as part of a complete treatment plan that includes counseling and psychosocial support. While that is reasonable advice, it does not say, and this practice will never say, that counseling is a gate you must pass through before the medication can be started.
Dr. Leeds does not run a separate counseling service. He counsels and coaches within the medical visits themselves, and refers out when a patient wants formal therapy. Therapy is offered. It is not required.
What about twelve-step meetings? They are not part of the medical care here, and any patient who attends is respected in that choice. Yet, meetings are mostly not professionally moderated, they ask members to share private health information with strangers, and Narcotics Anonymous discourages the very medical treatment being prescribed.
A doctor who prescribes buprenorphine and then sends the patient to a room where the medication is frowned upon is working against himself. Still, for some people the meetings are the thing that works, and nobody here will try to talk them out of it.
How does office-based buprenorphine treatment work?
Since the Mainstreaming Addiction Treatment Act was passed at the end of 2022, any doctor with a standard Drug Enforcement Administration registration can prescribe buprenorphine for opioid addiction, and the old special waiver is gone. What remains is finding a doctor who will give you time.
Starting the medication has one trap. Because buprenorphine holds the receptor and only partly activates it, taking it while a full opioid is still on board can throw a person into sudden, severe withdrawal, which the label calls precipitated withdrawal. So, the label’s instruction is to wait until clear signs of withdrawal have appeared before the first dose, and the starting Suboxone page explains how to get through that wait.
Fentanyl has made the trap worse. The label notes that people dependent on methadone or other long-acting opioids are more prone to precipitated and prolonged withdrawal during induction. Fentanyl is not long-acting on paper. Yet, with daily use it builds up in body fat and can behave like one, so when fentanyl is involved, Dr. Leeds uses a low-dose start when needed, building the medication up over several days rather than demanding a long, miserable wait.
So, the first doses are taken at home, with Dr. Leeds available by phone. The medication is the easy part.
How does Dr. Leeds begin treatment with a new patient?
The first visit is long, and most of it is listening. Before any prescription is written, Dr. Leeds asks what you are actually willing to change, because recovery costs something, and the price is yours to set, not his. For some people, the cost is a group of friends, for others a neighborhood, a habit that fills the evening, sometimes a job or a city.
What about past relapses? While no one enjoys that conversation, relapses are not treated here as failures. They are data about what worked and what did not, and a patient who has relapsed four times knows more about their own addiction than a patient who has never tried to quit.
One place to avoid is the pain clinic. A clinic that prescribes full opioids for pain is the wrong place to seek treatment for opioid addiction, even when the addiction began with a legitimate prescription, and the question of moving from the pain clinic to the Suboxone clinic deserves its own discussion.
Deciding to change is the hardest step, and fear comes with it. Yet, courage was never the absence of fear. It is deciding to act while still afraid, and a medication that takes away the withdrawal and the craving is what makes that decision survivable.
How long does treatment last, and is it only for adults?
There is no set length, and there does not need to be one. The Suboxone label says that a decision to stop after a period of maintenance should be made as part of the treatment plan, that the dose should be tapered rather than stopped, and that relapse after stopping is a real risk.
Of course, some patients taper off after a year or two, while others stay on the medication for many years, feel normal, and see no reason to stop.
Unfortunately, families hesitate most at that open-endedness when the patient is a teenager, because the picture of a young person on Suboxone for life is frightening. The picture of a young person with untreated opioid addiction is worse.
The label states that safety and effectiveness have not been established in pediatric patients, and Dr. Leeds’ practice does not treat minors. Among adults, the principle does not change with age. A treatment that works and may need to continue is better than no treatment at all.
Can your family force you into rehab if you are already taking buprenorphine?
In Florida, the Marchman Act, chapter 397 of the Florida Statutes, lets a family petition a court for involuntary assessment and treatment of a person impaired by substance use. In fact, a judge can order treatment for up to 90 days, with a possible extension of another 90 days, and a family does not need a lawyer to file. This is the threat that frightened families make.
Will a judge send a person who is already in treatment to rehab? While Dr. Leeds is not a lawyer, his opinion is a clinical one: a person in office-based buprenorphine treatment who has stopped using street opioids is in recovery, under a physician’s care, and a judge has no clinical reason to order a residential program. In his experience, a letter from the treating doctor usually makes the petition moot. Broadly, the petition has to show a person who has lost control over their substance use and who either cannot see the need for care or is likely to come to harm without it, and a patient in treatment has done the opposite.
Starting treatment voluntarily is the honest way to take the threat off the table, and the word honest matters. Going to a doctor to put on a show, while continuing to use, fools no one for long.
Why do families reach for forced rehab in the first place? Because they misunderstand medication treatment, and the phrase they use is trading one drug for another. Fortunately, a common pattern is a parent ready to file a petition on a son who has been on buprenorphine for three months and back at work, and who drops the idea after sitting in on one visit.
A family member you invite is welcome at a visit, in person or by telemedicine. Do not cut off a family that tried to force you into treatment. They acted out of fear for your life, and once they understand what the medication does, they are usually the people who help you stay on it.
What can Dr. Leeds’ practice do, and what can it not do?
Dr. Leeds prescribes buprenorphine films and tablets by telemedicine for new patients located in Florida, with in-office visits available in Fort Lauderdale. Induction is done at home with phone support, with a low-dose start when fentanyl is involved, and visits are monthly, or weekly when needed. Long-acting injectables such as Sublocade, Brixadi, and Vivitrol are not offered as a service, although Dr. Leeds can advise on them in a consultation.
There is no separate counseling service, since counseling and coaching happen within the medical visits, and formal therapy is referred out. The service itself is described on the Suboxone treatment page.
If you are ready to talk it through, the first step is simple: send a message through the contact form on drleeds.com. Care usually begins with a consultation, and a consultation can also be booked on its own. A consultation is not a medical visit and does not establish a physician-patient relationship.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.