Kaiser Napa-Solano removed every condition on buprenorphine over a decade. Federal rules moved the same way, while Kentucky still requires a behavioral program.
Key Takeaways
- Conditions once came first: When Dr. Charles Whitehill joined Kaiser’s Napa-Solano program in 2014, buprenorphine patients had to enter treatment, attend group, and abstain from other substances.
- The clinic removed them: Napa-Solano now attaches no treatment requirements to buprenorphine, and its recovery group closed after attendance fell once it became voluntary, Whitehill said.
- Rules and research diverge: Federal rules no longer tie opioid treatment program medication to counseling, Kentucky still requires a behavioral program, and studies link voluntary therapy to longer retention.
- An optional group is next: Napa-Solano is considering a voluntary recovery group, which would test whether programs can offer peer connection without making it a condition of care.
For a time, the addiction program at Kaiser Permanente Napa-Solano ran a community group for patients taking buprenorphine. Attendance was once a condition of the prescription. When the program stopped requiring attendance, fewer people came, and eventually there was no group at all.
“We used to have a community group for buprenorphine recovery,” said Dr. Charles C. Whitehill, the program’s Chief of Addiction Medicine and Recovery Services. “However, when we stopped requiring that, the attendance declined, and we eventually had to discontinue that group.”
Whitehill mentioned the group almost in passing, during a November 3 webinar on long-acting injectable buprenorphine. The session belonged to RECADEMY, an education series produced by the consulting firm OPEN MINDS, and it was moderated by Stuart Buttlaire, PhD, a former Kaiser Permanente Northern California executive who is now OPEN MINDS’ Vice President of Clinical Excellence and Leadership. Yet the detail sits at the center of a decade-long change in how his program, and a good part of the field, decides who receives medication for opioid use disorder and on what terms. Napa-Solano now places no conditions on buprenorphine. The group that once came with it is gone, and the program is weighing whether to bring back a version that patients could simply choose to attend.
What Kaiser Napa-Solano Required for Buprenorphine in 2014
Whitehill joined the substance use disorder program in 2014 and found what he called “a very conservative program.” Patients who wanted buprenorphine had to agree to enter treatment and attend group. They were also expected to stop using everything else. “Initially, in the early days, we required you to be abstinent from all other substances,” he recalled.
He described the approach as typical of the region at the time, and philosophical resistance to medication has lingered in parts of the field, as Acuity has reported. “Most programs, and I can only speak to Northern California, were pretty conservative,” he said. From the beginning, he watched patients drop out a few at a time, some of them because they were still using cannabis or other drugs. Later, when Buttlaire remarked on the culture Kaiser and Whitehill had built at the clinic, Whitehill noted how recent it was. “I don’t think it was always that way,” he said.
Removing Buprenorphine Treatment Requirements in Favor of Harm Reduction
The program weighed the trade-offs, Whitehill said, and then went further than trimming. “We removed all requirements to get access to buprenorphine,” he said. Patients no longer have to commit to counseling or groups to receive a prescription, and continued use of other drugs no longer disqualifies them.
He framed the shift as harm reduction. Buprenorphine lowers the risk of complications, overdose, and death from opioid use disorder whether or not a patient has given up everything else, and the program treats it accordingly. “We don’t recommend your continuing use of other substances, but we will still provide it without judgment if you’re using other substances,” Whitehill said. The question carries more weight as stimulants figure in a growing share of overdose deaths, often alongside fentanyl.
By his account, the change sped up initiation and made it easier for patients to stay on the medication. He did not present retention figures for the program, and the webinar did not include program-level outcome data.
Federal and State Buprenorphine Counseling Rules Point in Different Directions
Federal policy has moved the same way over the past four years. The Consolidated Appropriations Act of 2023, signed in December 2022, eliminated the federal waiver that clinicians once needed to prescribe buprenorphine for opioid use disorder. In February 2024, SAMHSA published the first major revision in more than two decades of the rules governing opioid treatment programs, which decoupled medication from counseling. Under the revised rule, a patient’s refusal of counseling does not preclude them from receiving medication for opioid use disorder. Telehealth prescribing, another route around in-person barriers, still rests partly on temporary DEA flexibilities that run through December 31, as Acuity has reported.
States have not uniformly followed. Kentucky’s Board of Medical Licensure amended its buprenorphine prescribing standards effective January 22, 2026. The revised regulation still requires physicians and Physician Assistants to implement a treatment plan that includes the patient’s participation in “a behavioral modification program that may include counseling or a twelve (12) step facilitation.” It also requires drug testing at least weekly in the early stages of treatment and directs prescribers to recommend an in-office observed start, particularly for patients using fentanyl or methadone.
Product labeling sits between the two positions. Brixadi, one of two long-acting buprenorphine injectables on the market, carries prescribing information stating that it should be used as part of a complete treatment plan that includes counseling and psychosocial support. The language is a recommendation rather than a condition for receiving the drug.
What Buprenorphine Retention Research Shows About Counseling
The research behind dropping mandates is fairly consistent. An issue brief from the University of Pennsylvania’s Leonard Davis Institute of Health Economics noted that multiple high-quality studies have found no added benefit from counseling compared with buprenorphine maintenance alone, and that same-day initiation can overcome delays without hurting retention. A 2020 paper that set out to define low-threshold buprenorphine treatment proposed four guiding principles: same-day entry, a harm reduction approach, flexibility, and wide availability in places where people with opioid use disorder already go.
Retention remains a weak point under any model. A JAMA Health Forum study published in March, which followed privately insured patients who started buprenorphine between 2015 and 2022, found that 30.4 percent reached 180 days of treatment. Opioid treatment programs show a similar drop-off. A JAMA Network Open study of 261,025 Medicaid beneficiaries, published in January, found that the median program retained 61.2 percent of patients at 30 days and 27.5 percent at 180 days.
Support that patients choose may matter for that number, even if support they are required to receive does not. A national study of veterans starting buprenorphine examined a wide range of psychosocial and medical services and found that only substance use disorder psychotherapy was consistently associated with a lower risk of later discontinuation; several others, including residential treatment, were associated with greater risk. In a Texas low-barrier outpatient program studied in a paper published in January, early engagement with behavioral health care was a strong predictor of retention. Both studies were observational, so they describe associations rather than causes. For stimulants, which have no approved medication, the strongest behavioral evidence belongs to contingency management, an incentive-based approach that remains difficult to fund.
Stigma, Reconnection, and an Optional Buprenorphine Recovery Group
When Whitehill talked about what keeps patients connected, he spoke less about program structure than about how patients are treated at each point of contact, which he said needs to be “open, quick, honest, and without judgment.” People with substance use disorders, he said, are “hyper-aware of judgment, and that is probably one of the biggest barriers to getting care.” When patients meet staff who do not react to what they have been using or doing, he said, it is “not uncommon to see a lot of tears shed in the beginning.”
He also described recovery in social terms. Addiction, he said, “develops in secrecy and isolation,” and by the time it becomes apparent to others, people have often lost touch with family, community, and work.
Whitehill said Napa-Solano’s future plans include potentially creating a new recovery group as an optional program. He did not give a timeline. Earlier in the session, he had stated the aim of the work in a single sentence. “The recovery process is learning how to reconnect with families, communities, and jobs,” he said.
