Posts Tagged ‘switch from methadone to suboxone’

How to Switch from Methadone to Buprenorphine (Suboxone)

Change Can Be Good

Change Can Be Good

I’ve helped about thirty or forty people switch from methadone to buprenorphine. Some were patients at my office, where I do office-based treatment with buprenorphine (formerly known as Suboxone or Subutex), and some have been patients at one of the two opioid treatment programs where I work.

Most of the time, the transition goes smoothly; however, around fifteen percent of the time, the patient doesn’t feel right on buprenorphine and goes back to methadone. I haven’t found a way to predict who will do poorly with buprenorphine.

Most of these patients had been in treatment for months or years, and were trying to taper their methadone dose. These patients heard that since buprenorphine is a partial opioid, it’s easier to taper off of than methadone. For the most part, that seems to be true, but everyone’s different.

Some patients switched because they wanted a medication that wasn’t as “heavy” as methadone. Most patients say they feel lighter, or less medicated, or more normal, on buprenorphine as compared to methadone.

Buprenorphine seems to have fewer medication interactions. For patients with complicated medical problems on many medications, it’s a better choice. It’s also a better choice for patients who have prolonged QT interval syndrome (condition of the heart) from methadone.

Also, restrictions on take home doses for buprenorphine when it is prescribed at opioid treatment programs aren’t as strict as rules for methadone, because buprenorphine is much safer than methadone. Patients switch to buprenorphine to get take homes more quickly, particularly helpful if they live a great distance from their treatment program.

In January of 2013, the federal government dropped the time in treatment requirement for take home doses for buprenorphine. With methadone, a patient has to be doing well with negative urine drug screens for a minimum of ninety days before getting extra take home doses. According to the new federal law, buprenorphine patients can get take homes regardless of time in treatment, so long as they meet all the other seven requirements for take homes. (These are: negative drug screen including alcohol, no ongoing criminal activity, regular clinic attendance, absence of serious behavioral problems at the clinic, stability of home environment, assurance that take-home doses can be stored safely, and rehabilitative benefits to the patient outweigh risk of diversion).

Some states have more restrictive regulations than federal law. In that case, the opioid treatment program has to follow the more restrictive of the two laws. In my state of North Carolina, time in treatment regulations still apply. However, I can petition the state opioid treatment authority for early and extra take home doses for patients who are doing well, and those requests are nearly always granted.

Some patients switch to buprenorphine at the opioid treatment program to prepare for transition to an office-based buprenorphine program. Office-based treatment is better for patients who have made progress on their recovery, and need less oversight with dosing of their medication. It’s an excellent step for stable patients.

Buprenorphine is a partial opioid and methadone is a full opioid. And buprenorphine has a higher affinity for opioid receptors. This means that it sticks like glue to the receptors, and if there’s methadone on the patient’s opioid receptors, buprenorphine will toss it off, throwing the patient into withdrawal. That’s a simplistic explanation, but you get my drift. This is why patients on methadone have to be in at least moderate withdrawal before taking the first dose of buprenorphine. Otherwise, the patient will be miserable, in withdrawal, with little to be done to ease the situation.

I ask patients to taper to about 30 or 40 milligrams of methadone per day prior to making the switch. I recommend tapering by about 5mg per week, or more slowly if needed. If I’m in the opioid treatment program on Mondays, I ask the patient to take her last dose of methadone on Friday, and then skip Saturday and Sunday. I see her first thing on Monday and evaluate the degree of withdrawal. By then, this patient has gone without methadone for seventy-two hours, and should be in at least moderate withdrawal. We check vitals signs (blood pressure, heart rate, etc.) and check a COWS (clinical opioid withdrawal scale) score. I talk with the patient and do a quick exam. If she’s in enough withdrawal, we start buprenorphine, usually at 4mg. If possible, we have the patient stay for an hour or return in an hour so we can see how she’s feeling. Sometimes we give a second dose on that first day.

Here are some issues I’ve seen in patients making the switch from methadone to buprenorphine:
-Coming down too fast on the methadone dose. Don’t zoom from 115mg to 40mg in a week or two and expect the transition to buprenorphine to go well. It probably won’t. I tell patients that if you’re going to expend time, money, and energy in making the switch, do it the right way, and optimize your chance for success.
-Not planning ahead for the increased cost of buprenorphine. In most clinics, buprenorphine costs more than methadone. If it’s not financially feasible over the long term, it’s best to stay on methadone.
-Expecting to take buprenorphine for a few weeks and then taper off with no withdrawal. Most people do not have this experience. Even the taper off buprenorphine can take months and be difficult. Besides, getting off opioids is one thing; staying off is another. I tell patients not to taper off buprenorphine unless they are ready. Have they spent the time getting counseling against relapse? Have they changed friends, and put distance between them and people still using drugs? Do they work around people using drugs? Do they have a chronic pain condition that will require opioids intermittently? If so, what’s the plan to avoid relapse?
– If buprenorphine lasts longer than methadone, don’t be tempted to miss days without telling your counselor what is going on. Some patients on buprenorphine are able to dose three times per week, so talk to your doctor about setting this up instead of missing days on your own.
-DO NOT attempt to divert medication. At one treatment center, we’ve detected many patients trying to “save” part of their dose for later use. I think most are telling the truth, but some are probably selling their medication. I can’t tell who is selling and who is saving doses for later. If we have a problem with patients selling their medication in the community, our treatment program can get a bad reputation in the community and even get closed down. So we have to act on any attempt to divert medication, and at times may even have to dismiss a patient from treatment, which I hate to do. So don’t divert medication.
-Don’t feel bad if buprenorphine doesn’t work for you. No medication works for everyone. If methadone did work, go back to it. Methadone has been around for forty years and has a proven track record.

I’m happy to work for two opioid treatment programs who offer both buprenorphine and methadone. It’s a little more difficult to offer buprenorphine, and the profit margin is likely much slimmer than treatment with methadone, but it’s the state of the art treatment. I fear some methadone clinics are going to get left behind with their “methadone only” mindset. Methadone will always be needed, but now we need to have other choices readily available for patients seeking treatment. Soon, I think we will see opioid treatment centers also offer naltrexone/ naloxone, medications that can prevent opioid relapse in patients who have completed withdrawal from opioids.