Buprenorphine use continues to skyrocket while traditional opioid manufacturing has decreased as mandated by DEA. Buprenorphine has formulations approved for both chronic pain and opioid use disorder (OUD), and guidelines address buprenorphine/naloxone recommendations for those with comorbid OUD and pain. Current trends in clinical care include 1) widespread adoption of medication assisted treatment use in settings outside substance abuse treatment and 2) advocacy for a new group of potential patients in the grey area between complex chronic pain and OUD, which is now referred to as complex persistent opioid dependence (CPOD). The term CPOD is often applied to those struggling with opioid tapering but without formal diagnosis of OUD. The unique pharmacology of buprenorphine will be reviewed, including characteristics that make it attractive for treatment of OUD. The common elements between guidelines will be discussed including key differences in acceptable approaches. Patient stigma, common misconceptions, and clinical conundrums will be fiercely debated.