Balancing Relapse Risk and Agency in Buprenorphine-naloxone Treatment: A Qualitative Needs Assessment to Inform Patient-Centered Care

ABSTRACT Objectives Outpatient buprenorphine-naltrexone (bup-nx) treatment reduces overdose risk, yet many patients still return to use or disengage from treatment. We sought to understand how patients and prescribers experience and manage relapse risk, monitoring, and treatment agency in routine bup-nx treatment to identify gaps in current practice. Methods We conducted a qualitative needs assessment using semi-structured, critical-incident interviews with patients receiving outpatient bup-nx and prescribers who manage bup-nx treatment. Interviews examined situations involving relapse risk and empowerment in treatment decisions. We structured data collection and analysis using the Theoretical Domains Framework and COM-B model to characterize determinants. Transcripts were coded deductively and inductively until code-level saturation was reached. Results Participants (9 patients, 8 prescribers) described nine treatment needs mapped to the Capability, Opportunity, and Motivation components of the COM-B model. These themes highlighted how patient agency in bup-nx treatment was constrained by physiologic and emotional states, with withdrawal, craving, pain, and distress often overriding longer-term goals. Relapse vulnerability was experienced as dynamic and intensifying between visits, while clinical detection remained anchored to visit-bound assessments, urine drug testing, refill patterns, and crisis-driven contact, creating blind spots. Structural friction (pharmacy rules, insurance disruptions, transportation and housing instability), stigma from family and recovery communities, and motivational processes tied to fluctuating readiness and trust in monitoring further shaped engagement, disclosure, and dosing decisions; the same monitoring tools could either support honest disclosure or provoke concealment when perceived as punitive. Conclusions Relapse risk and agency in bup-nx treatment are negotiated as dynamic processes within structurally constrained and trust-sensitive systems. Addressing the identified capability, opportunity, and motivation gaps will require patient-centered, trust-preserving approaches to monitoring and shared decision-making.