No Abandonment
For more than two thousand years, physicians have known that opium and its derivatives bind tightly—not only to receptors in the human body, but to lives. The knowledge is ancient; the pattern is predictable. Yet in the United States over the past two decades, patients were inducted into dependence by the medical system and, too often, expelled from it when risk and scrutiny rose. The treatment ended; the need did not. That gap—created by prescribers, payers, and policies—became a bridge to the illicit market, where potency and adulteration turned dependence into sudden death. This episode is about that bridge, the moral failure that built it, and the practical steps to tear it down.
Begin at the clinic door. A patient with pain is given opioid therapy with promises of relief and function. For some, it works as intended. For others, tolerance climbs, anxiety sets in, and the dose escalates. Then, a shift: a new guideline, a new insurer rule, a new policy mood. The clinic announces tapering. Sometimes the taper is careful and collaborative. Too often it is abrupt or performative: a schedule drafted to satisfy compliance rather than physiology. Patients who cannot keep pace are labeled “non‑adherent” or “drug‑seeking.” Contracts are terminated. Refill requests are denied. The patient is discharged with a handout on mindfulness and an appointment months away for specialty care. The body, meanwhile, is in revolt.
What follows is not mystery. Dependence, pain, and withdrawal are powerful incentives. Where a clinical door closes, the street opens. Illicit pills—counterfeits pressed with fentanyl—are marketed as continuity of care: same color, same imprint, familiar shape. Powder is a substitute when pills are scarce. The dose responds to misery, not to a guideline. In a market saturated with synthetic opioids, the margin for error vanishes. The outcome is not just relapse; it is death. To pretend we did not foresee this is to claim ignorance of everything we knew about opioids before the modern era. The bridge was there because we built it.
Physicians are not alone in this failure. Payers narrowed networks and refused to cover non‑opioid therapies that might have enabled lower‑risk treatment plans. Regulators and law enforcement, rightly alarmed by overprescribing and trafficking, sent signals—some intended, some not—that many clinicians interpreted as “stop treating anyone with a hint of risk.” Hospital systems made it difficult for primary‑care providers to initiate buprenorphine. Pharmacies refused to dispense it. Stigma, that old and efficient barrier, did the rest. A patient reduced to a risk category became a threat to be managed rather than a person to be treated.
Other wealthy countries faced rising pain complaints and misuse. They also have addiction. But fewer built the same bridge to the illicit market. Why? Because their clinical decisions were embedded in systems that make continuity the default. A national health service or social‑insurance model aligns incentives: the payer responsible for the costs of addiction is the same payer responsible for primary care, hospitalizations, disability, and mortality. In such systems, abandoning a patient is not a financial neutral act; it is the beginning of a cascade the system will pay for elsewhere. Treatment with medications for opioid use disorder is widely integrated into primary care. Pharmacies and clinics are coordinated. If the patient’s need intensifies, the system absorbs that need rather than ejecting the person into the open air.
In the United States, health care is a profit engine with fragmented accountability. The emergency department bears one cost center, the clinic another, the county jail a third, the funeral home a fourth. Profit accrues to volume, not resolution. When sickness increases, so do billable encounters. When addiction deepens, the costs fall on someone else. Under such conditions, “do no harm” struggles against institutional design. Individual clinicians can and do act with courage and compassion, but they are swimming against a current that rewards deflection. The gatekeepers are not merely people; they are payment models and policies.
What does moral repair look like? It begins with an unambiguous clinical stance: no patient dependent on opioids is tapered or discharged without a plan that the body can tolerate and that the system will support. If long‑term opioid therapy must be reduced, the taper is slow, consensual when possible, frequently revisited, and paired with real alternatives—multimodal pain care, behavioral health support, and, when indicated, a transition to buprenorphine, which can treat both pain and opioid use disorder. Abrupt termination is replaced with continuity by design.
Second, initiate treatment for opioid use disorder wherever the patient is. Primary care. Emergency departments. Inpatient wards. Jails and prisons. Homeless‑service clinics. The medication is not a specialty referral; it is a standard of care. If a clinician is willing to prescribe high‑dose opioids for pain, that clinician can also prescribe buprenorphine for dependence. The barrier is not knowledge; it is permission and habit. Health systems must train, credential, and expect their clinicians to provide this care—and pay them to do it.
Third, integrate pharmacy as a partner rather than a checkpoint. Pharmacies should be equipped and expected to dispense buprenorphine without stigma, stock naloxone as routinely as insulin, and provide real‑time communication back to prescribers when problems arise. The right hand must know what the left is dispensing; the patient should not be stranded between policies at the counter.
Fourth, protect patients from the cliff edge. Insurers should be barred from forcing rapid tapers through utilization policies. Prior authorization for medications that treat opioid use disorder should be eliminated. Coverage for non‑opioid pain therapies—physical therapy, interventional procedures, behavioral interventions—should be expanded, not narrowed, so clinicians have practical options that do not require abandoning patients to withdrawal or the street.
Fifth, make continuity visible and accountable. Measure what matters: how many patients on long‑term opioid therapy were successfully transitioned to safer regimens without interruption? How many high‑risk patients started buprenorphine or methadone this month? How many were still in care at 30, 90, and 180 days? How many overdoses occurred among patients who were recently discharged from care? Publish the numbers at the practice, hospital, and plan level. Reward improvement; intervene where abandonment persists.
Finally, speak plainly about duty. Physicians are gatekeepers to the most dangerous and the most effective tools in this crisis. The oath to do no harm does not authorize retreat when risk appears; it demands mastery and proximity. To discharge a dependent patient without a medically and socially supported plan is to transfer risk from the chart to the morgue. To refuse to prescribe or dispense medications that cut overdose death by large margins is to choose the comfort of avoidance over the work of treatment. That is a moral failing in a profession that claims otherwise.
There is nothing soft about a system that keeps people alive. It is demanding. It requires clinicians to tolerate complexity and administrators to protect time and resources for the work. It requires payers to align incentives with outcomes and policymakers to resist the lure of public‑relations answers. But it is also perfectly practical. Countries that organized their services around continuity did not eliminate addiction; they reduced the lethality of its most dangerous expressions. We can do the same.
The United States built a bridge from the clinic to the illicit market when it ended treatment before it ended need. Tearing down that bridge means owning the role of gatekeeper and redesigning the gates. Keep patients close. Treat the disorder you helped create. Replace discharge with dosage that the body and the life can carry. Align payment with outcomes. Measure continuity like a vital sign. When we do, fewer families will wait for a phone call in the dim light before dawn, and more patients will walk through the door that stayed open for them.