Methadone vs Buperenorphine

Once you have made the decision to go on OTP then the rest is just fine tuning. There is excellent evidence to tell us that both suboxone and methadone work to treat opioid dependence - they are the gold standard treatment in fact - and methadone shows a slightly higher success rate than suboxone.

How you decide which one is for you all depends on your situation - are you using illicit injectable drug? Is  your partner a dealer? Have you only ever taken over the counter codeine? Are your friends opioid dependent? Do you have significant mental health issues? Do you still intend to use opioids from time to time? Do you have a problem with alcohol or sedatives? Each person has their own variables that will lean us toward one or the other. Below are some tips on how I go about deciding with each person what is best for them.

 

In my experience there are approximately 5% of people who feel actually unpleasant when they are given suboxone. This is independent  of precipitated withdrawal and is not an induction side effect (one you get when just starting a treatment).

 

Then there are another 5-10% who whilst they feel "ok" on suboxone, it is not satisfying enough to prevent them from reliably and repeatedly self medicating with full agonist opioids. The majority of these people do better when they are transferred to methadone. In services where they are not given that choice, many people just drift away from treatment.. back to black market drugs.

I believe that tailoring the treatment to the person results in the best outcomes rather than a one size fits all approach

Some doctors may believe patients who claim to not be comfortable on suboxone are manifesting these symptoms so they can be swapped to methadone. I think it's much more complex than that and there are numerous reasons for it...some we understand and some we do not.

I have been prescribing and listening to patients for over two decades and in the past 10 years or so there were patients who I knew and trusted who transferred to suboxone but genuinely couldn't tolerate it. When they went back to methadone the relief for them was profound. For doctors who refuse to prescribe methadone, these patients just jump off the program and return to drug use, sex work, dealing, stealing and fraud etc. etc.  to get the "full strength opioid" they need when they should be getting clean cheap safe methadone prescribed. Suboxone has been a very useful addition to the treatment options of opioid dependency. One of its drawbacks is that in many centres it has replaced methadone which no longer becomes an option. Initially Suboxone provided choice in treatment options which was great - we could tailor treatment to each individual. Now it has replaced choice and in some places methadone is no longer available. There is evidence to show that by removing choice we are also denying treatment to some people.  Countries with the greatest choice of treatment have the best outcomes.

So whats the diff?

They both reduce cravings and withdrawals

They both reduce crime and other community harm (one study determined that for every one dollar spent on methadone then the community saved four dollars)

Both are safe when used correctly

Easy to understand right? One is a full agonist and the other is a partial agonist.  Damn, things just got tricky.

The differences between methadone and suboxone are as follows.

Half life

Both methadone and suboxone have long half lives. They can be dosed once per day and they generally carry over the effect until the next day.

Buperenorphine contained in suboxone has a "dose dependent half life" which means the more you have, the longer it lasts. The more you have the more you feel the effect as well, but only up to a certain point.

In the bad old days before we could give takeaways doses people were given a double dose on a Monday and Wednesday and at triple dose on a Friday and on the other days, the long half life just carried them through.

I  have to admit it was inadequate and for lots of people it didn't work. Luckily today we give takeaway doses and if someone does take three doses in one go, it is still working at the end of three days so they aren't in withdrawal.

If someone used all three doses of methadone at once, then by day three they would be very uncomfortable.

Agonism

Methadone is a FULL agonist and suboxone is a PARTIAL agonist.

Think of this like the volume limiter on your phone - if the volume limiter is on (PARTIAL agonist) then no matter how much you turn up the volume then you can't get the volume louder.  The same is true for suboxone. You can have more and more and you feel it more then you get to a limit (this varies but is around 16mg or above) where you don't feel any further effect. It just lasts longer. Some people can feel the difference in higher doses and that's why they are on doses bigger than 16mg - and it also makes sure that the drug stays in their system.

Methadone is like having the volume limiter off - the more you have the more you feel and if  you increase enough you will get dangerous effects of the drug including overdose and death.

Both drugs are excellent at taking away withdrawals and cravings, but methadone is the only drug that creates opioid euphoria in an opioid dependent person. People on suboxone tell us that they feel "normal" - comfortable, energetic and efficient. People on methadone also feel this way, but they do feel the drug 'kick in' after they have had it and they can feel some mild opioid effect. This is the benefit of this drug, some people need to feel that in order to feel satisfied and not look for other drugs or more opioid.

Analgesic effect

Methadone is an excellent pain killer. In fact if it wasn't associated with drug addiction, it would be used more. Physeptone, the pill version of methadone is a very successful medication for the treatment of opioid-sensitive pain. Suboxone is also a good  pain killer, in fact it used to be marketed as Temgesic which was an effective pain killer.

Pain however is a complex thing and for some people, they need a full agonist to relieve their pain. For others however suboxone does the job well - you won't know until you try, but do not believe the story that suboxone is "no good for pain". I have seen many people with significant pain treated very satisfactorily with suboxone.

Binder affinity

We have opioid receptors to which opioids attach. These are the 'switches" that opioids turn on to give the opioid effect - pain relief, euphoria and intoxication.

Suboxone joins to the receptor very strongly and will "rip off" other opioids from the receptor and replace it with itself.

This is why we must wait until there are spare receptors before we first use suboxone. We know there are spare receptors when you are in early withdrawal. If we dont wait for that you get PRECIPITATED WITHDRAWAL and you doctor will discuss this and tell you all about it before you start treatment.

The point I want to make here is that suboxone joins to the receptor much more strongly than methadone. This means that if you use another opioid such as heroin after you have used methadone, you may still feel it and get more opioid intoxication. If you use it after suboxone though, chances are you will not feel it because the suboxone is "covering" the receptor and heroin or Oxycontin will not attach to it.

This is a big difference between the two.  Suboxone is like an insurance policy against using. Methadone acts sort of like this too by putting your tolerance up very high, but suboxone has a distinct advantage in this regard.

Flexibility and Stigma

Suboxone legislation gives you more takeaways

Methadone has a lot of stigma associated with it.

That about sums it up - if you can make suboxone work for you then choose that.

But if methadone is the one that is going to keep you in treatment then stuff the flexibility and the stigma, choose methadone!

Injectability

Both methadone and suboxone are injected.

Both are unsafe to inject and can have lethal or serious side effects.

There are ways to make them safer to inject but no method is entirely without hazard.

If you have an addiction to injecting, it is important to discuss this with your prescriber so you can get harm reduction information that can save your life.

That being said, suboxone is a mixture of buperenorphine and naloxone. Naloxone has a higher binder affinity than buperenorphine so it stops a person feeling the opioid effect when they inject. After an hour or two then the opioid effect starts to be felt.

Methadone can cause an immediate effect and because of it's full agonism can kill a person who does not have tolerance.

Injecting behaviour is complex because it is about much more than just feeling the effect of the drug.

Many people choose a suboxone program over methadone so they cannot inject their takeaway doses. This can be a valid choice, but each person has their own reasons for injecting, so good honest communication is important between  yourself and your prescriber.

Swapping between them

Swapping from suboxone to methadone is easy

Swapping from methadone to suboxone is hard

End of story.

It can be done, but it's difficult.

There is a great rule of thumb when it comes to OTP - DON'T BURN YOUR BRIDGES

- Don't leave a pharmacy with an unpaid bill, you never know when you might need that chemist at short notice.

-  If you argue with a doctor, don't threaten their life, that's pretty much a deal breaker for future treatment

- Don't tell a pharmacist to go and reproduce with themselves- they stop dosing immediately and you are in nine different kinds of trouble within 48 hours

- AND unless there are very good reasons for it, try NOT to start on methadone if you can possibly avoid it. Transferring from methadone to suboxone is a bugger and given the flexibility you get with suboxone over methadone, if you can make suboxone work, and it works for you then you are always better on suboxone.

Using other drugs

Methadone being a full agonist means that it is more dangerous using other drugs while  you are taking it.

METHADONE + ALCOHOL + BENZOS = DEATH  especially in the first two weeks, even for experienced users. That is why the dose is started off low and increased slowly.  Using more opioid on top of methadone is safer than using alcohol on top of methadone. DON"T MIX your SLOWS

Suboxone is less sedative and has less effect on the respiratory system. It can also be increased more quickly so you are usually at your final dose within the first week.

If alcohol and poly drug taking is a problem for you then start on suboxone and see if that works for you.

Safety

Suboxone is safer than methadone

But ultimately, the drug that keeps you in treatment and works for you is what is safest.

If suboxone doesn't satisfy  you and keep you in treatment but methadone does, then methadone is a safer drug.

Its all relative

Its all about keeping you in treatment.

Be open and honest with your prescriber, they can't do their job if youre not upfront.

clinicRx created in Wix 2016

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