Studies have found that buprenorphine-based treatment reduces morbidity and mortality among Opioid Use Disorder (OUD) patients (Wakeman et al. 2020), and a growing consensus about the efficacy of this medication has led to substantial public and private investments in increasing its availability across the U.S (Clemans-Cope et al. 2019). However, as David Marcovitz et al. write, “Estimates suggest that up to 40–50% of patients will discontinue treatment prematurely…most within the first month following induction” (2016: 2). How might we explain this considerable drop-out rate? Based on eighteen months of ethnographic research in rehabilitation centers and outpatient addiction clinics in the greater Pittsburgh area, this dissertation project considers the lived experiences of Medicaid-sponsored buprenorphine patients. What might their firsthand accounts of this modality of treatment reveal about an expanding political economy of addiction care in western Pennsylvania, a rustbelt region where productive industries like steelmaking and coal mining have given way to a local healthcare sector that, over the last several decades, has become the region’s largest employer (Winant 2021; Simpson 2019)? Over hundreds of conversations with patients and staff in the addiction treatment industry, I have found that a large contingent of current and former buprenorphine patients use the language of captivity (e.g., “chains,” “leashes,” “handcuffs,” “slavery”) to describe their experiences with this medication. They emphasize that, though far safer and less likely to cause overdose than heroin or fentanyl, buprenorphine is nevertheless a habit-forming opioid. Such expressions of discontent are, for the most part, less concerned with the intrinsic, pharmacological properties of buprenorphine than with the extractive and coercive relations of power that prolonged exposure to this partial opioid agonist can facilitate in specific circumstances and treatment programs. I suggest that these patient frustrations are inextricable from profound social transformations underway in western Pennsylvania, including processes of deindustrialization and carceral expansion, that have exposed many low-income patients to pronounced structural vulnerability (Bourgois et al. 2017). Drawing on buprenorphine patients’ embodied critiques and my own observations in rehabs and outpatient clinics, I argue that the buprenorphine-based treatment enterprise is predicated on a widely shared entrepreneurial approach to patients as “clinical material.” I use this phrase to designate the unspoken but widely accepted ways in which certain bodies, those rendered surplus to more formal modes of economic production in western Pennsylvania (such as coal mining, steel production, or more recently carework), are made useful and profitable by both carceral and medical entrepreneurs. These bodies become sources of value, not as wage laborers (Marx 1867) or patient-consumers (Tomes 2016), but as material to be collected, monitored, and leveraged in enterprising and rewarding ways by those charged with their care. In this sense, the enrollment and retention of Opioid Use Disorder patients—and the management of legal liability in a high stakes regulatory environment—has become the primary focus of many entrepreneurs and clinicians in the addiction treatment industry. I argue that this approach to patients as clinical material is not an exceptional but a structural feature of a commercially oriented, fragmented, and rapidly evolving American healthcare system.