Should I Continue Suboxone in a Patient With Ongoing Substance Use?

The Answer is Always Yes.

In the field of addiction medicine, the stakes are high. Very high. As an addiction psychiatrist, I have a front row view of the devastation wrought by addiction and particularly opioid use disorder (OUD)—from the toll it takes on individuals and families to the astronomical number of overdose deaths. Amid this crisis, buprenorphine (commonly known by its brand name, Suboxone, when combined with naloxone) stands as one of the most effective tools we have for saving lives.

Despite its proven efficacy, one of the most contentious issues in addiction treatment is whether to continue prescribing Suboxone when patients test positive for other substances, such as cocaine, cannabis, benzos, or amphetamines, on urine drug screens. Suboxone should always be continued in these situations. Here’s why:

Opioid overdose deaths in the United States have reached unprecedented levels, driven by the ubiquity of fentanyl and the growing presence of carfentanyl in the illicit drug supply. Fentanyl is fifty times more powerful than morphine. Carfentanyl, its older brother, is one hundred times more powerful than morphine. This means that any consumption, whether intentional or unintentional, skyrockets the risk of death.

Suboxone works by reducing opioid cravings, reducing or eliminating physical withdrawal symptoms, blocking the euphoric effects of opioids, and stabilizing individuals so they can engage in broader recovery efforts. Any interruption in Suboxone treatment significantly increases the risk of recurrence to opioid use-use which is often fatal.

When a patient is taken off their Suboxone due to ongoing substance use, this almost always leads to significant destabilization. This physical and emotional disruption greatly increases the risks of illicit suboxone consumption, opioid recurrence, and/or overdose. Recent studies show that when taken off Suboxone, over ninety percent of patients have a recurrence to opioid use. Sobering stats. Our focus should be on preserving life—above all else. You can’t continue recovery support-of any kind-if your patient is dead. It’s game over.

Harm Reduction: A Foundational Principle

The principles of harm reduction, as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA), prioritize meeting patients where they are and reducing the negative consequences of substance use, without requiring abstinence as a prerequisite for care. This philosophy underscores the importance of keeping individuals engaged in treatment, even if they continue to use substances. A patient engaged in addiction treatment-even if not abstinent-is still alive.

A positive urine drug screen for non-opioid substances like cocaine or cannabis does not negate the protective benefits of Suboxone. The disease of addiction is complex. It necessitates a multifaceted, individualized, compassionate approach—not punitive measures that risk pushing patients out of care.

Substance Use Is a Symptom, not a Moral Failing

Addiction is a chronic medical condition- not a moral failing. Co-occurring substance use often reflects underlying trauma, psychiatric comorbidities, or social determinants of health rather than “willful defiance.” Discontinuing a Suboxone prescription due to non-opioid or ongoing opioid substance use overlooks this complexity and reinforces stigma, driving patients away from the very care that could save their lives.

Recovery is not linear. Patients often cycle through periods of progress and setbacks. Our goal as providers is to support incremental change, not demand perfection. Continuing Suboxone—even when patients use other substances—acknowledges that recovery is a journey. Our role is to walk alongside them on the ride, not shut down the road.

Evidence Supports Continuity of Treatment

Research overwhelmingly shows that maintaining patients on medication for opioid use disorder (MOUD) reduces the risk of overdose and death, improves retention in care, and enhances overall quality of life. Conversely, in today’s fentanyl-dominated drug landscape, discontinuing MOUD is associated with a sharply increased risk of fatal overdose. The stakes are high.

 My hope is that more providers begin using urine drug screens as clinical tools to guide treatment conversations, not as grounds for punishment or exclusion from care. Patients testing positive for other substances present an opportunity to explore reasons for polysubstance use, strengthen therapeutic alliances, and refine individualized care plans. Abruptly discontinuing Suboxone treatment, however, undermines all these goals and places the patient at greater risk.

I still remember reciting the Hippocratic Oath on the first day of medical school in sunny South Carolina- the excitement and anticipation of medicine, mixed with nervous anxiety. I often re-read it to reinforce its saliency and power. As physicians, our primary ethical obligation is to do no harm. Ending Suboxone treatment for patients struggling with ongoing substance use is inconsistent with this promise, and contrary to the tenets of harm reduction. Instead, we must strive to adopt a more patient-centered, compassionate approach that prioritizes engagement, safety, and long-term recovery.

Patients are more than urine drug screens. They are just like you and me: individuals with unique challenges, strengths, and aspirations. Suboxone is not just a medication—it is a lifeline. And in the fight against opioid overdose deaths, keeping that lifeline intact is the ultimate act of care.

The opioid crisis is a public health emergency that demands evidence-based, life-saving interventions. It’s a formidable foe that requires all our modern medication weapons. In this fight, Suboxone is one of our most powerful weapons. We should not withhold its benefits due to the complexities of co-occurring substance use. By keeping patients on Suboxone, we are not enabling addiction—we are enabling survival, stability, and the possibility of a new day.

-Lauren 

Dr. Lauren Grawert is a double board certified Addiction Psychiatrist and the Chief Medical Officer at Aware Recovery Care.