Which is better, Suboxone or methadone?

 

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, 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.

 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.

 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.

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12 responses to this post.

  1. Posted by Dusty on August 23, 2010 at 10:42 pm

    I am truly enjoying your wealth of knowledge Dr. Burson.
    God Bless you, friend
    Dusty

    Reply

  2. Posted by sober2years on December 3, 2010 at 4:30 am

    I read All of your writings..and thoughts..and plan on purchasing your book.. My only wish is there were more doctors like yourself, who educate yourself and take a stand.. for the addicts like my self ,and many others.As society, law enrofcement, courts..ect..look down, critize, belittle, and assume we are all “Scum of the Earth”. When in reality..recovering addicts ,and those alike are some of the smartest, brightest, caring, wonderful people. Whom the aboved people, are losing out due to their own misguided perceptions. Thanks for all you say..Sober2years

    Reply

  3. Posted by Lesly on July 16, 2013 at 2:38 pm

    Hi
    Am from South Africa and work for Reckitt Benckiser Health Care. It therefore goes without saying thati am quite familiar with both methadone and buprenorhine. I am really impress with your general knowledge about the field of addiction.
    What’s the name of your book and where may I get it?

    Reply

  4. Posted by cat w on June 11, 2014 at 4:24 am

    Im currently on 17mg of methadone detoxing off 2mg evry 2weeks.I was as high as 60mg.ive been on methadone 1year n a half.I heard insurances r startin to cover for subs now n been thinkin of switching.I want to b completely off medication within a few months n hate the hastle of goin evryday n standin in line.I have been clean so I do get one take home but its hard to get a job or school while havn to go get med so would switching to sub b a good idea for me?

    Reply

    • If you are planning to be off medication in a few months I don’t think it makes much difference whether you continue to taper methadone or switch to buprenoprhine and then taper. The big worry is relapse. Better to take your time getting off the maintenance med rather than rushing it, relapsing, and having to start over. Talk tp your doctor and counselor – do what is going to maximize your chances of success. You’ve come so far, and are doing well.
      Most clinics in this area open at 5 or 6 am in order to allow time for patients to dose and get to work or school.

      Reply

  5. Posted by JR on August 26, 2016 at 8:14 am

    I see this is an old post so no worries if I don’t get a reply. I began methadone maintenance Dec 2015, eventually settling in at 90 mg. Seems to be just the right dose but I’m a novice to this.
    I’m never going to get take home privileges as long as I continue to smoke cannabis which I’m not willing to give up and the clinic is a 10 minute drive so going everyday isn’t too painful.
    Things would be so much cheaper and less of a hastle if I switched to nalbuphine. I’m apprehendive and feel as though I’m about to fix something that isn’t broke.
    Thpughts?

    Reply

    • Several thoughts. First, nalbuphine, known under its brand name Nubain, is a mixed opioid agonist/antagonist. If you are on methadone I suspect it would put you into withdrawal unless you tapered off methadone for a period of time. Second, I doubt nalbuphine would work as a maintenance medication due to its short half-life. I looked it up again to make sure I was telling you the right thing, and its half life is only about 5 hours, compared to methadone’s 12 to 60 hour half life.

      Reply

  6. Posted by jessica on February 21, 2017 at 9:54 pm

    Read two articles and this has learnt me alot buy iam so worried about changing from methadone next Monday to subutex. My main concern is being in withdrawl and giving up and using as I have come so far since last year do you have any advise?

    Reply

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