Fentanyl Addiction Treatment in Tennessee

Signs of Fentanyl Use Disorder

Fentanyl use disorder is a medical condition, not a moral failing. Because fentanyl is so potent, physical dependence can develop quickly — sometimes within weeks of regular use. Common signs include:

• Physical tolerance. Needing more of the drug to achieve the same effect, or finding that the previous amount no longer prevents withdrawal.
• Withdrawal symptoms. Experiencing muscle aches, sweating, nausea, diarrhea, anxiety, or insomnia within hours of the last dose.
• Preoccupation. Spending significant time thinking about, obtaining, or recovering from fentanyl use.
• Loss of control. Using more than intended, or being unable to stop despite repeated attempts.
• Continued use despite consequences. Maintaining use even when it damages health, relationships, work, or finances.
• Isolation. Withdrawing from family, friends, or activities that used to matter.

If several of these apply to you or someone you care about, a professional evaluation can help clarify what is happening and what options exist. You do not have to meet every criterion to benefit from treatment, and you do not have to hit a “rock bottom” before reaching out. If you’re reading this wondering whether what you’re experiencing is “bad enough” to warrant help — that question itself is often a sign.

Fentanyl Withdrawal: Timeline and Symptoms

Fentanyl withdrawal is medically uncomfortable but not typically life-threatening in healthy adults. It can, however, be severe enough that many people relapse to stop the symptoms. This is one of the main reasons medication-assisted treatment is so important — it prevents withdrawal rather than forcing patients to endure it.

A general timeline for fentanyl withdrawal looks like this:

• First 8 to 24 hours. Onset of early symptoms: anxiety, restlessness, muscle aches, yawning, watery eyes, and runny nose.
• Day 1 to day 3. Peak physical symptoms: nausea, vomiting, diarrhea, abdominal cramping, sweating, chills, dilated pupils, insomnia, and intense cravings.
• Day 3 to day 7. Acute symptoms gradually subside. Sleep remains disrupted. Cravings are still strong.
• Week 2 and beyond. Post-acute symptoms may continue: low energy, difficulty concentrating, mood changes, and intermittent cravings. These can last weeks to months if unmanaged.

Because fentanyl stores in body fat and clears more slowly than heroin for some patients, the window before buprenorphine-based medication can be started is often longer — typically 36 to 72 hours after last use, compared to 12 to 24 hours for short-acting opioids. Your provider will assess your specific situation to determine the right timing and avoid precipitated withdrawal.

How We Treat Fentanyl Addiction

At Restoration Recovery, fentanyl use disorder is treated with a combination of medication and psychosocial support. The medication options available are:

• Suboxone (daily film or tablet). A combination of buprenorphine and naloxone taken sublingually — available as a dissolving film or tablet placed under the tongue. Buprenorphine reduces cravings and prevents withdrawal by partially activating opioid receptors without producing euphoria. Naloxone is included to discourage misuse.
• Sublocade (monthly injection). A long-acting form of buprenorphine administered once per month at our clinics. Many patients prefer Sublocade because it removes the daily decision-making around taking medication and provides steady blood levels throughout the month.
• Brixadi (weekly, bi-weekly, or monthly injection). Another extended-release buprenorphine injection, with flexible dosing intervals. Patients who prefer a longer or shorter schedule than Sublocade’s monthly cadence — or who are still finding the right maintenance dose — often start with Brixadi’s weekly or bi-weekly options before transitioning to monthly if that fits their treatment plan.

Medication is paired with:

• Individual counseling with licensed therapists experienced in substance use disorder.
• Certified peer support from specialists who have lived experience with recovery themselves.
• Intensive outpatient programming (IOP) for patients who benefit from a more structured treatment schedule — delivered in a group format by design.
• Integrated care for co-occurring conditions, including anxiety, depression, trauma, and hepatitis C.

Restoration Recovery is an outpatient clinic. We do not provide medical detox or residential care. For most patients with fentanyl use disorder, a formal detox is not required — medication-assisted treatment can begin at the appropriate point after last use, under clinical supervision. For patients who need a higher level of care before starting outpatient MAT, we coordinate with regional referral partners.

Why Fentanyl Induction Is Different

For patients whose primary opioid was heroin or prescription pills, the traditional induction rule — wait until you reach a COWS score around 12, then take your first dose of buprenorphine — worked reliably. For fentanyl users, it often does not. Fentanyl accumulates in body fat and muscle tissue with regular use and takes roughly seven days to fully clear (Kelty et al., J Addict Med 2023). A 2024 JAMA Network Open multi-site cohort of 226 hospitalized patients, 123 of them confirmed fentanyl users, found that 16.3% of fentanyl users developed precipitated withdrawal during standard buprenorphine initiation — and the strongest predictors were urine fentanyl concentration and elevated BMI, not pre-induction COWS score (Thakrar et al., 2024). The American Society of Addiction Medicine’s 2023 clinical considerations explicitly acknowledge this: patients exposed to high-potency synthetic opioids require individualized induction planning, not a one-size-fits-all waiting period.

The practical consequence: our providers will not ask you to “just get to COWS 12 and come in.” We assess recent use history, any prescription co-use, BMI, and what a safe induction pathway looks like for you specifically — which is often not the standard daily-sublingual protocol you may have read about online.

The Counterfeit Pill Landscape

A significant portion of the fentanyl exposure we see at intake comes through counterfeit pills, not powder. The most common is the “M30” — a round, typically light-blue tablet stamped “M” on one side and “30” on the other, designed to look like legitimate 30 mg oxycodone. It is, in almost every case, pressed fentanyl. According to DEA laboratory testing, as of 2024 about 5 in every 10 counterfeit pills tested contained a potentially lethal dose of fentanyl (down from 7 in 10 in 2023 and 6 in 10 in 2022, but still far too many). The lethal threshold is roughly 2 mg; counterfeit pills average 2.4 mg and range from 0.2 to 9 mg per pill. A CDC MMWR review of counterfeit-pill-related overdose deaths found that 93% involved illicitly manufactured fentanyl, and 57% of decedents were under age 35.

For treatment, pills-vs-powder doesn’t change the medication that works — buprenorphine still treats fentanyl exposure the same way regardless of delivery route. What it changes is that pill-only users often arrive with higher tolerance than they realize (because the pill they “took two of” may have contained anywhere from a mild dose to a lethal one). That tolerance matters for induction planning.

Microinduction and Low-Dose Start Protocols

Microinduction (sometimes called the “Bernese method”) is one response to the fentanyl-era induction problem. Instead of requiring a patient to fully abstain and wait for withdrawal, microinduction starts buprenorphine at a very low dose (often 0.5 mg or less) while the patient continues using, then titrates the buprenorphine up over four to seven days as the fentanyl naturally clears. When the patient is stable on a therapeutic buprenorphine dose, fentanyl is stopped.

Microinduction is not a guaranteed path. A 2025 JAMA Network Open outpatient cohort of 126 adults across 175 low-dose initiation attempts reported only a 34% success rate and 22% 28-day retention — far below the >90% success rates seen for similar protocols in the pre-fentanyl era (Suen et al., 2025). It remains a valid option for the right patient, and your provider will walk through candidacy at intake. When it is not the right path, direct-to-injectable is usually the alternative.

Long-Acting Injectables as First-Line for Fentanyl Users

Increasingly, for active fentanyl users, long-acting injectable buprenorphine is recommended as first-line rather than a step to transition to after stabilizing on daily Suboxone. Two reasons:

• The induction-timing problem partly disappears. Brixadi (extended-release buprenorphine) was studied in a 100-patient multi-site emergency-department trial (D’Onofrio et al., JAMA Network Open 2024) that initiated patients at COWS scores under 8 — below the threshold traditionally required — with approximately 7% precipitated-withdrawal rates, comparable to standard induction. The steady plasma level from an injection protects against the receptor-competition dynamic that drives precipitated withdrawal with daily sublingual dosing.
• Retention is better. An FDA-approved rapid-induction protocol for Sublocade (a single 4 mg transmucosal dose followed one hour later by the 300 mg injection) has shown 62.8% month-2 retention in fentanyl-positive patients, versus 47.9% with standard 7-day stabilization (Lee et al., Subst Abuse Rehabil 2025 review). Steady blood levels also reduce the risk of respiratory depression from any continued fentanyl exposure during the transition window.

Candidacy for injectable-first depends on insurance authorization, clinical history, and patient preference. We walk through options at your first visit rather than defaulting to the daily protocol.

Xylazine (“Tranq”) Considerations

Xylazine — a veterinary alpha-2 agonist sedative, informally called “tranq” — has become the dominant fentanyl adulterant in parts of the country since 2019. The FDA issued a public health advisory in November 2022. In April 2023, the White House Office of National Drug Control Policy designated fentanyl mixed with xylazine an “emerging drug threat” — the first time that designation has ever been used. CDC data show xylazine co-detection in illicit-fentanyl overdose deaths rose from 2.9% (January 2019) to 10.9% (June 2022), a 276% increase, with further rises every year in every region. DEA laboratory testing of 2022 seizures found xylazine in 23% of fentanyl powder samples but only 7% of fentanyl pills — xylazine exposure remains more of a powder-era problem than a pill-era one, but the trajectory is expanding.

Two clinical facts matter for patients at intake:

• Naloxone does not reverse xylazine. Xylazine is not an opioid, so naloxone has no effect on the sedation or respiratory depression it causes. In a xylazine-complicated overdose, naloxone should still be given (for the fentanyl component) and rescue breathing continued until emergency services arrive.
• Xylazine withdrawal is distinct from opioid withdrawal. Anxiety, agitation, hypertension, and dysphoria that buprenorphine alone will not relieve. Clinicians in heavily-affected regions (Philadelphia, Puerto Rico) have used adjunctive alpha-2 agonists like clonidine or lofexidine with published case-level evidence of benefit (Ehrman-Dupre et al., J Addict Med 2023). We evaluate for suspected xylazine exposure at intake and coordinate adjunctive support when indicated.

Chronic xylazine exposure has also been associated with severe necrotic skin ulcerations, often on limbs and distant from any injection site — distinct from typical injection-site abscesses. If you have wounds you’re concerned about, we can refer you to a wound-care specialist at the same visit.

What to Expect at Your First Appointment

Your first visit typically lasts 60 to 120 minutes and follows a four-step clinical flow:

1. Intake. You’ll complete paperwork and a clinical intake. For fentanyl and other opioid use disorders, this includes a DSM-5 assessment to confirm the diagnosis and its severity, and a COWS (Clinical Opiate Withdrawal Scale) score to measure your current withdrawal state. The COWS score is especially important for fentanyl — it guides whether you’re clinically ready to begin buprenorphine the same day without risking precipitated withdrawal.
2. Counseling. You’ll meet with a counselor to discuss your substance use history, any previous treatment, and your personal recovery goals.
3. Doctor evaluation. A medical provider reviews your intake, COWS score, and counselor notes. They walk you through medication options (Suboxone, Sublocade, Brixadi), explain side effects and timing, and answer your questions.
4. Prescription (and injection ordering, if chosen). If clinically appropriate, you leave the same day with a Suboxone prescription. If you prefer the extended-release route, your provider will order Sublocade or Brixadi during this visit — we don’t stock injections on-site — and you’ll continue on Suboxone as a bridge. Your injection appointment is scheduled for a follow-up once the medication arrives, typically after a short stabilization period on Suboxone (Sublocade’s FDA label requires at least 7 days of transmucosal buprenorphine before the first injection).

Bring a valid photo ID, your insurance card if applicable, and a list of any medications you currently take. If you’d like to see the full process walked through step by step before your visit, our guide on what to expect at your first Suboxone appointment covers it in more detail.

Why Medication-Assisted Treatment Works for Fentanyl

For many patients, the fear of withdrawal is what keeps them stuck. MAT removes that barrier — the medication prevents withdrawal rather than forcing patients to endure it — which is why it works when willpower alone doesn’t.

Medication-assisted treatment (MAT) is endorsed as the standard of care for opioid use disorder by the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute on Drug Abuse (NIDA), the American Society of Addiction Medicine (ASAM), and the World Health Organization.

Large-scale evidence shows that patients with opioid use disorder who receive buprenorphine-based MAT:

• Experience more than a 50 percent reduction in the risk of fatal opioid overdose
• Stay in treatment significantly longer than those receiving counseling alone
• Report fewer cravings and lower rates of illicit opioid use
• Are more likely to maintain employment and stable housing during recovery
• Have lower rates of infectious disease transmission associated with injection use

With fentanyl in particular, the margin between a dose you’ve taken before and a fatal one can be razor-thin — potency varies enormously between batches, and contamination is common. MAT dramatically reduces both cravings and overdose risk, giving patients a realistic path to stability. MAT is not a replacement of one drug with another; it is evidence-based medical care for a medical condition. Medication stabilizes brain chemistry enough that patients can engage in counseling, rebuild relationships, and return to work without the daily cycle of cravings and withdrawal.

Why Restoration Recovery

Choosing where to start treatment matters. Restoration Recovery brings together the clinical depth, the practical access, and the kind of care that keeps patients in treatment long enough to get well.

• Chattanooga’s longest-running outpatient addiction treatment clinic. Our providers have decades of clinical experience treating opioid and substance use disorders in Southeast Tennessee.
• CARF accredited. The Commission on Accreditation of Rehabilitation Facilities is the gold standard for outpatient addiction care — our accreditation is reviewed on an ongoing basis, not a one-time stamp.
• Four clinic locations across Southeast Tennessee and North Georgia, with telehealth follow-up available for established patients.
• Most major insurance accepted — TennCare, Georgia Medicaid, commercial plans, Medicare, and supplemental Medicare. Our patient services team verifies your benefits before your first visit so there are no surprises.
• Same-day Suboxone appointments in most cases. You don’t have to wait weeks to start.
• One integrated team. Medical providers, counselors, certified peer support specialists, and psychiatric care under one roof — not parallel referral tracks that leave you coordinating your own care.
• Licensed in both states. Licensed in Tennessee and Georgia, HIPAA compliant, 42 CFR Part 2 compliant — your treatment is confidential from the first phone call.

Insurance and Access

Restoration Recovery accepts most major insurance plans, including TennCare, Georgia Medicaid, a broad range of commercial plans, and Medicare (plus supplemental Medicare plans). Our patient services team can verify your benefits before your first appointment so you know exactly what to expect in terms of cost.

If you do not have insurance, contact us anyway. We can help you explore options and will walk you through self-pay pricing. For a full list of accepted carriers and details on the verification process, visit our insurance page.

Four Clinic Locations

We operate four outpatient clinics across Southeast Tennessee and North Georgia. All locations offer fentanyl addiction treatment with same-day appointments in most cases:

• Chattanooga, TN — 6141 Shallowford Rd, Suite 100, Chattanooga, TN 37421
• Cleveland, TN — Serving Bradley County and surrounding areas
• Soddy-Daisy, TN — Serving Hamilton County north and the Sequatchie Valley
• Ringgold, GA — Serving Catoosa County and Northwest Georgia

Telehealth follow-up visits are available for established patients who have completed their initial in-person evaluation. For directions, hours, and contact information, visit our locations page.

Frequently Asked Questions

I’ve been using counterfeit M30 pills, not powder. Am I a different kind of patient than someone using heroin or injected fentanyl?

Clinically, no — you have fentanyl use disorder either way, and the same medications work. Practically, yes, in one specific way: counterfeit pills vary wildly in how much fentanyl they actually contain (DEA testing in 2024 found 0.2 to 9 mg per pill, averaging 2.4 mg, with the 2 mg lethal threshold sitting in the middle of that range). Pill-only users often arrive at intake with higher opioid tolerance than they realize, because the “two pills a day” they thought they were taking may have delivered anything from a mild dose to a near-lethal one. That matters for how we plan your induction — not whether treatment works.

What is precipitated withdrawal, and why is it more of a concern with fentanyl?

Precipitated withdrawal happens when buprenorphine enters opioid receptors that are still partially occupied by another opioid, displacing that opioid and causing sudden, severe withdrawal. The traditional “wait until COWS 12” rule was developed for heroin users, where the opioid clears within hours. Fentanyl accumulates in body fat and muscle and takes roughly seven days to fully clear, which is why a 2024 JAMA Network Open cohort of 226 patients found that 16.3% of fentanyl users developed precipitated withdrawal during standard induction — and COWS score did not predict who. The good news: clinicians now have several proven workarounds, including microinduction and direct-to-injectable pathways. We walk through which approach fits you at your first visit.

What is microinduction? Can I really start Suboxone while I’m still using fentanyl?

Microinduction (also called the Bernese method) means starting buprenorphine at a very low dose — often 0.5 mg or less — while you continue your current fentanyl use for several days, titrating up the buprenorphine as fentanyl naturally clears from your system, then stopping fentanyl when you’re on a therapeutic buprenorphine dose. The approach avoids forcing you into active withdrawal before treatment starts. It is not a guaranteed success — a 2025 outpatient study showed only a 34% success rate in fentanyl users — but it is a valid option for the right patient. Your provider will discuss candidacy at intake.

Should I just start with the monthly Sublocade or Brixadi injection instead of daily Suboxone?

For many active fentanyl users, yes — long-acting injectables are increasingly recommended as first-line rather than a later transition step. The FDA approved a rapid Sublocade induction protocol (a single 4 mg transmucosal dose, then the 300 mg injection one hour later) that showed 62.8% month-2 retention in fentanyl-positive patients versus 47.9% with standard 7-day stabilization. Brixadi can be initiated at COWS under 8 with roughly 7% precipitated-withdrawal rates per a 2024 JAMA Network Open emergency-department trial. The injection also provides steady blood levels that reduce overdose risk during the transition window. Whether injectable-first is the right path depends on your insurance authorization, clinical history, and preference — we walk through options at your first visit.

I’ve heard about xylazine “tranq.” How does it change my treatment?

Xylazine is a veterinary sedative that’s been increasingly mixed with fentanyl — DEA lab testing of 2022 seizures found it in 23% of fentanyl powder and 7% of fentanyl pills, concentrated most heavily in the Northeast but expanding across the country. Three things matter clinically. First, xylazine is not an opioid, so naloxone does not reverse its sedation effects (though naloxone should still be given for the fentanyl component, along with rescue breathing). Second, xylazine has a distinct withdrawal profile — anxiety, agitation, hypertension — that buprenorphine alone does not relieve; adjunctive alpha-2 agonists like clonidine are used in published case literature. Third, chronic exposure can cause distinctive skin ulcerations. At intake we evaluate for suspected xylazine exposure and coordinate care accordingly. Statewide data on xylazine in Tennessee is limited so far, but treatment should be planned with the possibility in mind.

If I overdose on fentanyl, will one dose of Narcan be enough to save me?

Usually yes — a CDC MMWR analysis of 354 law-enforcement-administered reversals found 99% survival with standard 4 mg intranasal Narcan, and the study found no survival benefit from the 8 mg version (just more post-reversal withdrawal). But be prepared for the possibility of more than one dose: the share of EMS overdose patients requiring multiple naloxone administrations doubled from 14% to 28% between 2012 and 2020 nationally. Rescue breathing matters too, especially if xylazine may be involved. Narcan has been available over-the-counter since March 2023, and Tennessee Harm Reduction provides it free to all 95 counties via mail; any Tennessee pharmacist can dispense it without a prescription under the statewide collaborative pharmacy practice agreement. If you or someone you love is using fentanyl, carry it.

Take the Next Step

Fentanyl addiction is survivable, and treatment works. You don’t have to figure this out alone — and you don’t need to have all the answers before you call. You don’t need to be clean before your first appointment. Our team will walk you through the process from your first phone call to your first visit and every follow-up after that.

Same-day appointments are available in most cases. Contact us today to schedule your evaluation, or call 423-498-2000 to speak with our team directly.