The unstable context of opiate use in urban Nepal shapes how addiction-affected individuals adapt substance use patterns and how care providers, themselves operating in variable economic circumstances, respond to these alterations. Opiate addiction is a growing issue affecting a wide array of ethnic groups and economic classes in urban Nepal. Through examining the history and present condition of shifting use preferences relative to tumultuous social and economic conditions, this paper examines how individuals survive physical dependence on substances whose availability is not guaranteed. The shift from inhaled Brown Sugar heroin to injected Bupronorphine, caused by shifting economic circumstances and resulting in an HIV outbreak in the early 2000’s, exemplifies these unstable circumstances. It also shows how addiction-affected individuals utilize new substances and forms of ingestion in response to absence. Simultaneously, providers of care for opiate addicted individuals rely on unstable sources of funding and operate under conditions of frequent staff turnover. These realities were also illuminated during the early 2000’s HIV crisis, which attracted short-term donor funding but ultimately created harm-reduction and care programs which were financially unsustainable. Using fieldwork conducted at rehabilitation facilities, this paper aims to examine how opiate addicted individuals navigate physical dependence and receive care within conditions of instability, where the availability of both illicit forms of heroin, and legal forms of opiates fluctuate. It will also address how care providers create and modify strategies of rehabilitation based on the shifting preferences of their clientele. On a national scale, this project contributes to the evolving project of understanding the extent and nature of addiction in the increasingly pharmaceuticalized Nepali context. More broadly, it adds perspective to studies of addiction and treatment that have been generally situated in the west to bring new viewpoints and understandings to the expanding global opiate crisis.