Which is better, Suboxone or methadone?
Posted August 23, 2010 by janaburson in Buprenorphine, Evidence-based Treatments, methadone, Opioid Addiction, Pain Pill Addiction, Recovery, Suboxone.
Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.
First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.
The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.
Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg (3 strips), more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.
Suboxone is Safer and has Fewer Restrictions/Regulations than Methadone
Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.
The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.
Suboxone is Expensive
But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.
Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.
Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.
And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.
So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.
Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.
Dr. Townsend’s Comments:
Dr. Burson’s premise that economics holds sway on the choice of suboxone v methadone may be correct in NC where she practices. It may be the case in Detroit or Saginaw, where both programs are available.
The Northern most methadone clinic in Michigan is located in Gaylord, a 4 hour trip each way from Marquette. My choice of methadone over suboxone would be for the pregnant patient or especially for the addicted patient with significant pain control needs that cannot be addressed with non-narcotic pain medications or a suboxone. Suboxone is indeed expensive, and methadone clearly makes more sense for those who are unable to wean and require maintenance therapy.
But the point is moot, methadone maintenance therapy is simply NOT AVAILABLE in N. Michigan and the UP except for Gaylord (the next northern most clinic is in Mt. Pleasant). Even in Gaylord and Mt. Pleasant, due to the daily visit requirements, beyond a 25 mile or so radius daily visits are somewhat impractical. Not only is Suboxone safer than methadone, and when used for weaning does more than trade an apple for an orange, but due to the safety and efficacy, it can be prescribed by any physician willing to take the training and get the proper DEA licensure.
The only downside to a suboxone treatment program is the artificial restrictions place on its use by the DEA. Physicians are limited to 30 patients under treatment at a time their first year. They can then take the same training again and apply to treat up to 100 at a time. In Our suboxone program, I could easily have 1000 under treatment at any given time. The need is that great.