A psychiatrist can prescribe Suboxone (buprenorphine and naloxone) for the treatment of Opioid Use Disorder (OUD). Suboxone is a form of Medication-Assisted Treatment (MAT) that uses buprenorphine’s partial opioid agonist properties to reduce cravings and withdrawal symptoms. The naloxone component helps deter misuse. This medication is an effective tool in managing OUD and falls within the scope of a psychiatrist’s medical practice, given the complex relationship between addiction and mental health.
Legal Authority to Prescribe Buprenorphine
Federal requirements for prescribing buprenorphine have been simplified, expanding the pool of medical professionals who can offer this treatment. Historically, prescribing buprenorphine for OUD required physicians to obtain the special federal X-waiver, established under the Drug Addiction Treatment Act of 2000 (DATA 2000). This waiver mandated specialized training and imposed patient limits, creating a barrier to access.
Congress eliminated the X-waiver requirement in late 2022. Now, any healthcare provider, including a psychiatrist, who holds a standard Drug Enforcement Administration (DEA) registration to prescribe Schedule III controlled substances can prescribe buprenorphine for OUD. This change removed federal patient limits and the need for a separate certification process. Prescribers must now complete a one-time, eight-hour training on managing patients with substance use disorders, effective June 2023 for new or renewing DEA registrants.
The Integrated Role of the Psychiatrist in OUD Treatment
The psychiatrist’s clinical role is advantageous due to the high rate of co-occurring mental health conditions, often called dual diagnoses, among individuals with OUD. Studies show that a substantial portion of people with OUD also have a mental illness, with estimates reaching over 60%. Common co-occurring conditions include major depressive disorder, anxiety disorders, and post-traumatic stress disorder (PTSD).
A psychiatrist is uniquely qualified to manage both OUD and these underlying psychiatric conditions simultaneously, offering integrated treatment. This is more effective than treating each condition in isolation. The psychiatrist can manage the Suboxone regimen while also diagnosing and adjusting medications for depression or anxiety. This holistic approach recognizes that one condition often fuels the other; for example, anxiety or depression may trigger opioid use as self-medication.
The psychiatrist also coordinates the behavioral health component of MAT. Medication alone is generally not sufficient for recovery; comprehensive treatment involves counseling and behavioral therapies. Psychiatrists often provide or coordinate access to structured interventions like Cognitive Behavioral Therapy (CBT) or motivational enhancement therapy. This integrated care model addresses both substance use and psychiatric symptoms within a unified treatment plan.
Starting Suboxone Treatment: What the Patient Should Expect
The process of starting Suboxone, known as induction, requires careful monitoring. The psychiatrist conducts an initial assessment to confirm OUD and verify the patient is in moderate opioid withdrawal. This is a critical step because buprenorphine is a partial opioid agonist. If taken while full opioids occupy the receptors, it can rapidly displace them and trigger severe precipitated withdrawal.
To objectively measure withdrawal severity, the psychiatrist uses the Clinical Opiate Withdrawal Scale (COWS), a standardized, 11-item tool. A COWS score of 12 or greater is the preferred threshold for initiating the first dose of buprenorphine to minimize precipitated withdrawal risk. Patients must also abstain from short-acting opioids for at least 12 to 24 hours, or longer for long-acting opioids like methadone, before induction.
The induction phase starts with a low initial dose, often 2 to 4 milligrams. This dose is adjusted every one to two hours, with the provider reassessing the COWS score after each dose. The goal is to quickly find a stable maintenance dose (8 to 24 milligrams per day) that suppresses withdrawal symptoms and opioid cravings. Patients should expect ongoing monitoring, including regular follow-up appointments and urine drug screens, throughout the maintenance phase. Counseling remains a core component of effective MAT and is strongly recommended for long-term recovery.