Is it possible to go from Suboxone Films to Methadone Maintenance?
At first glance, this question may seem to be a little crazy to people who know about medication-assisted treatment (MAT). Why in the world would anyone want to go from Suboxone or Subutex to Methadone?
The reason why this seems to not make sense is that Suboxone is the more modern treatment for opioid use disorder. It has less side effects, it is safer, and in many cases, it is more effective.
Methadone is a full agonist opioid with a very long half-life. It also has a high potency, 10x the potency of morphine according to some opioid conversion tables.
What does this mean? It means that methadone has the potential to get anyone who takes it very high. Even a person who already has a high tolerance to opioids can get high from methadone. And, methadone carries a high risk for opioid overdose. It is a far more dangerous drug compared to Suboxone.
Yet, methadone, when properly administered at a government-approved clinic for opioid addiction, can be highly effective, even more effective overall than Suboxone. There are, in fact, cases where going from Suboxone to methadone may be a good idea.
What makes methadone so dangerous?
Methadone stays in your system for a long time. If this sounds good to someone looking to get high from methadone, it is definitely not good.
Any high feeling from the drug wears off in a few hours. Yet, it stays in your system for another 50-100 hours. This can be a big problem.
In addition to being an opioid with a very high abuse potential, methadone is also more dangerous than many other opioids. In some ways, methadone is more dangerous than pure heroin.
Pure heroin, the kind that has no fillers or additives, such as fentanyl analogs, is a short acting opioid, about 4x the potency of morphine. It wears off quickly.
Methadone lingers for days and builds up as a person keeps taking it to chase the high. As levels quietly build up in your system, respiratory depression becomes a serious risk. Overdosing on methadone, when abused, is more likely than overdosing on oxycodone, dilaudid, or heroin.
If the drug is so dangerous, how is it that methadone is used for opioid addiction treatment?
Years ago, there was an episode of House, M.D. that dealt with the issue of methadone causing respiratory depression. Dr. Gregory House, the main character, had issues with chronic pain and opioid addiction. He was also a creative genius and brilliant diagnostician.
While throughout most of the series, Dr. House would occasionally “drink” Vicodin tablets from a large prescription bottle, in this one particular episode, he decided to make the switch to methadone for pain. As it turns out, methadone is an effective treatment medication for chronic pain for many patients.
In fact, I remember going to an osteopathic medical convention years ago where a doctor who was lecturing to us on the dangers of Xanax, ended his lecture by recommending that all doctors who prescribe opioids for pain switch their patients to methadone. He believed that it was safer and more effective than other opioids for chronic pain management.
After that lecture, I walked up to the doctor and joined the small crowd around him outside the lecture hall. I asked that question, “Isn’t methadone too dangerous to switch all chronic pain patients too?” He responded, “Only if they take a handful of it.”
In the House, M.D. episode, Dr. House kept having overdose episodes where he would pass out and nearly stop breathing. He had kept his methadone use a secret at first. When his colleagues and friends discovered what he was doing, they were highly concerned. The message of the episode about methadone is that dosing and timing must be very precise, or overdose will be imminent.
I do not fully agree with the House episode and I also do not fully agree with the doctor who lectured us on that day about methadone for pain. While there is a risk of overdose with methadone because of the long half-life, it is not a matter of split second, precise timing. A patient can take methadone for chronic pain without having to worry about passing out throughout the day if they miss their dose by a few minutes.
On the other hand, I think what that doctor lecturer was recommending was also not a great idea. While some patients do very well with methadone for pain, it is not for everyone. Switching all pain patients from other opioids to methadone will increase the risk that someone in the practice is going to have a problem. Just like in addiction treatment, in pain management, there is no one-size-fits-all treatment.
Methadone can be used safely and effectively as an addiction treatment if administered properly.
At the methadone clinic, patients are given their daily dose each and every morning. Clinic staff observes the patient taking their methadone dose. The drug is only given once daily.
In addition to this close monitoring of methadone administration, patients are also drug-tested frequently and they are given access to regular addiction counseling. Methadone clinics must comply with strict federal guidelines.
When a methadone maintenance clinic is properly run, patients can do very well with treatment. They are closely monitored and they are able to form a therapeutic relationship with the clinic staff.
In some cases, unfortunately, methadone clinics can have a dark side. There are clinics that have an unwritten policy of progressively increasing the methadone dosage for patients over time, making it more likely that they will stay with that clinic and be further away from the possibility of getting off of methadone.
While methadone can be increased gradually at a clinic with a relatively high degree of safety, because the patient builds tolerance to the effects of the drug, it can also lead to the patient feeling sedated and high from their treatment. The goal of medication-assisted treatment should be to help the patient become more functional without having to suffer from drug cravings and withdrawal sickness. The goal should never be to get the patient high.
Unfortunately, some methadone maintenance doctors are very forward about this, even telling the patients that they are going to get the high they are looking for. I would recommend that patients in this situation look for an alternative.
Why is Suboxone safer than methadone?
Methadone maintenance has been used to treat opioid addiction since the 1950s. The treatment started out in New York City and was proven to be highly effective.
At the beginning of the new millennium and the 21st century, congress approved the use of buprenorphine, the main active ingredient in Suboxone, for the treatment of opioid dependence. Until that time, the options were either methadone, or naltrexone, a full opioid receptor blocker.
Buprenorphine, as we have learned through scientific study and the past twenty years of clinical experience, is highly effective and it is also relatively safe. It is far safer than methadone. Suboxone, which is a combination of buprenorphine and the abuse deterrent, naloxone, does not cause respiratory depression as easily as methadone. The risk of overdose is far lower.
In fact, Suboxone has a ceiling effect. This means that as the opioid receptors become saturated with the drug, the opioid effects of Suboxone level off and go no higher.
Above a certain level, around 32 mg for many patients, any additional Suboxone will have little to no effect. If the patient takes extra Suboxone, it will pass through the body, not causing respiratory depression or intoxication. The greatest risk of overdose with Suboxone is when patients take it while abusing sedating drugs, such as alcohol or Xanax.
Suboxone has a long half-life, similar to methadone. Yet, unlike methadone, it does not continually build up in the system, increasing the risk of overdose. This is because the buprenorphine in Suboxone is a mixed partial agonist/antagonist.
Buprenorphine molecules latch onto opioid receptors and do not easily let go. Buprenorphine is an effective blocker, or antagonist, of the receptor. Yet, at the same time, as a partial agonist, it partially activates opioid receptors, giving a mild opioid effect.
Since, at a high enough dosage level, the opioid receptors are mostly saturated and blocked by buprenorphine, additional buprenorphine added to the system will not add to the opioid effect because there are few if any receptors left to latch on to. This is opposed to the action of other opioids where the drug molecules bounce on and off of receptors, repeatedly activating them, causing opioid effects to increase proportionally with increased dosages.
Because of the combined effects of buprenorphine, it does not get opioid addiction patients, who have a high opioid tolerance, high. Patients who take Suboxone are not walking around with a high feeling all the time.
In fact, most patients describe the experience as if they are not taking anything at all. Many patients go as far as to say it is as if they were never addicted to opioids in the first place.
Since Suboxone is safe, with a far lower risk of overdose, the government has approved doctors to prescribe it on a long-term basis. Patients can go home with up to a month of prescribed Suboxone, rather than showing up at the clinic every single morning to take their dose.
Additionally, since Suboxone does not get patients high, there is little to no addictive behavior associated with the drug. This is important because it gives the brain’s reward center, where addiction has taken hold, a chance to recover over time.
After a year or two or treatment, many patients are able to taper off of Suboxone without experiencing drug cravings. While physical opioid withdrawal effects are an issue to deal with when completing Suboxone therapy, the addictive behavior has had a chance to subside over time.
Even though Suboxone treatment can be completed after a year or two, many patients benefit from ongoing treatment. It is relatively safe to continue Suboxone for longer periods, or even indefinitely. Though, it is always possible to end treatment if that is the patient’s choice.
Why then, would any patient choose to switch from Suboxone to methadone?
In most cases, Suboxone is the better choice in treating opioid addiction. It is safer than methadone and it is highly effective. And, most importantly to many patients, they only have to see their doctor once a month, rather than showing up to a clinic every morning.
The lifestyle differences between a methadone patient and a Suboxone patient are striking. Suboxone patients can sleep in on days off, and they can plan for family vacations. While vacations on methadone maintenance are possible, the planning is much more difficult.
Still, there are times when a patient might start out by seeing a Suboxone doctor and then make the decision to switch to methadone. There is no shame or judgement involved in such a switch. It is all about what is best for the patient and what will help the patient to have the best chance of avoiding opioid relapse and a dangerous overdose.
Sometimes Suboxone does not work for a patient.
Suboxone has about a 50% success rate. You might think that having the same success rate as flipping a coin is not that great. Yet, it is a very high success rate, much higher than rehab without medical treatment, or group meetings without treatment.
However, methadone has a 75% success rate. While it is a more dangerous and less convenient treatment, it keeps more patients from relapsing.
This could be from the effects of the drug, or it may be related to the higher level of care required for methadone. Maybe for a percentage of patients, seeing the counselors and treatment staff on a daily basis makes a difference.
There are methadone clinics that also dispense daily buprenorphine doses to patients. It would be interesting to see a study measuring the relative efficacy of methadone vs Subutex (pure buprenorphine) in the same treatment setting.
In my experience, the reason for the most failures of Suboxone treatment are due to the societal stigma associated with medication-assisted treatment. The patient’s personal feelings, and pressure from family, friends, coworkers, recovery groups, and even from doctors, can get in the way of successful treatment.
Narcotics Anonymous,one of the largest societies that promotes addiction recovery, with group meetings all over the world, has an official position against Suboxone treatment. By itself, this policy has likely led to many Suboxone patients quitting treatment early, with disastrous results in some cases.
Patients must overcome the ongoing societal stigma and the Suboxone myths. Suboxone is not anything like heroin. It is not trading one addiction for another or trading one drug for another. Patients do not get high on their Suboxone.
Unfortunately, when a patient continually goes off of Suboxone from the pressure around them, they are at high risk for relapse in early treatment. If the patient relapses repeatedly, at some point, the best decision will be to go to a methadone clinic. A patient who cannot stick with Suboxone may do better with a higher level of care.
Suboxone induction and street fentanyl analogs can also make methadone the better choice initially.
Doctors in the United States are not allowed to use most opioids for treating opioid addiction. In fact, methadone and buprenorphine are the only approved opioids for this purpose.
Unfortunately, there has been a huge influx of synthetic fentanyl analogs onto the streets of American cities. Much of this dangerous drug comes from China and arrives through the US mail. Nearly all heroin now contains fentanyl analogs. Even pain pills purchased on the street are likely to be fentanyl.
Even if a pill looks just like the real thing from the pharmacy, it is very likely a fentanyl fake. The blue oxy 30 pills are often found to be pure fentanyl.
One of the biggest problems with street fentanyl is that it is not the same as pharmaceutical fentanyl that is used in hospital operating rooms and in prescribed pain patches. Fentanyl analogs are potent, 80 times the potency of morphine, and they linger in your body for days after quitting.
The problem with starting Suboxone just after quitting street heroin or street pain pills is the Suboxone induction process. To start treatment, you have to quit your opioid of choice and wait about 18-24 hours before taking the first Suboxone film or tablet.
The reason for this is that buprenorphine is a potent opioid receptor blocker and it will displace whatever opioid is remaining in your system from the opioid receptors. If you take Suboxone too soon, this will lead to a reaction known as precipitated withdrawal.
Precipitated withdrawal is a very unpleasant reaction in which Suboxone causes intense opioid withdrawal symptoms that come on very quickly and can last for many hours. While usually not physically dangerous, doctors do not want their patients to experience it because it might discourage them from wanting to continue with Suboxone treatment.
Because fentanyl analogs can linger in a patient’s system for several days, likely being sequestered in fat cells, it can make the Suboxone induction process more difficult. When the patient feels ready to start Suboxone, after enough time has passed and they are in a suitable state of opioid withdrawal, the fake fentanyl found in heroin can cause serious problems.
Even if a full 24 hours has passed, or even 48 or 72 hours, the patient who was taking fentanyl-laced heroin or pills may still go into precipitated withdrawal. While it is possible to navigate around this issue and still start Suboxone, it takes expertise on the part of the Suboxone doctor.
If your doctor has experience with this issue, they can work closely with you, managing medications and talking you through the process. It is possible to get onto Suboxone, even if you are taking street fentanyl.
Fast-food-style online telemedicine Suboxone clinics may not be prepared for difficult cases.
However, in many cases, the transition is difficult, and in the world of HMO medicine and big box, assembly-line clinics, doctors may not be able or willing to put in the extra effort required to see a patient through a difficult induction and transition from fentanyl to Suboxone.
Additionally, the fast-food model of medical care has gone online in recent months. Due to the COVID-19 pandemic, laws and rules at federal and state levels have been relaxed. Full Suboxone telemedicine treatment is possible without ever seeing a doctor in person.
In fact, to keep costs down, these online Suboxone telehealth providers are not even employing doctors. They tend to use nurse practitioners with master of science nursing degrees (MSN) rather than the higher level doctor of nursing practice (DPN), or of course, an MD or osteopathic physician who has had many years of intense training in residency after four years of medical school.
So, in addition to being able to see a practitioner online and have your Suboxone shipped to your door, you may also be seeing a prescriber who obtained their degree from an online university. In many cases, this expedited system may work well, and it allows improved access to medication-assisted treatment for people in rural areas.
Yet, when it comes to difficult cases, such as the transition from illicit fentanyl to buprenorphine, these online providers may not be up to the task. Unfortunately, instead of offering inhouse treatment by a more experienced physician, an online nurse practitioner may recommend, as company policy, that the patient go instead to a methadone clinic.
Are there any other reasons to switch from Suboxone to methadone?
So far, we have looked at some of the reasons why a patient might make the switch from Suboxone, ZubSolv, Subutex, or other buprenorphine-based medications to methadone. In most cases, it is related to treatment failure.
If a patient is unable to successfully start Suboxone because fentanyl analogs are causing precipitated withdrawal, methadone may be a good alternative. Methadone has the advantage of no waiting period to getting started. Patients can start methadone the same day they quit opioids without worrying about precipitated withdrawal.
Or, if the patient starts Suboxone and then quits and relapses, and then does this again and again, the Suboxone doctor may recommend methadone as an alternative. At some point, we must stop trying the same thing over and over, expecting different results.
Otherwise, a patient might choose to go to a methadone clinic on their own or at the recommendation of their therapist, counselor, or even family member. Maybe they are concerned about ongoing cravings and the risk of relapse. The switch to methadone may be to prevent a looming future relapse that seems to be inevitable.
Another reason might simply be curiosity. Addiction can leave people with habits and motivations that do not always seem rational and can be self-destructive.
A patient who is doing very well on Suboxone may simply be curious about the methadone experience. Maybe they just want to see what will happen if they switch from buprenorphine to methadone.
Unfortunately, making this rash decision on a whim can have a significant limiting effect on the patient’s lifestyle. Going from Suboxone to methadone is relatively easy. You just show up at the clinic and sign over your care. Going the other way, from methadone to Suboxone is not so easy.
I should note that making the transition the other way, from methadone to Suboxone, is definitely possible. While it is not easy, it can be done.
The transition can be handled similarly to the process of going from street fentanyl to Suboxone. Methadone is long-lasting, so the induction may take more time and require more careful medical management.
While methadone remains an important treatment modality for treating opioid use disorder, whenever possible, Suboxone, or similar buprenorphine drugs, such as ZubSolv, Bunavail, Subutex, or Sublocade are preferable medications. Methadone clinics will not be going away anytime soon, but rather than being first-line treatment, methadone is better reserved as a last resort treatment when Suboxone treatment is not working or will not work for a patient.