If methadone is such a bad drug, why do we use it to treat addiction?As you are probably aware, methadone has a terrible reputation. People believe that it gets into the bones and rots the teeth of the methadone user. There is no truth to these methadone myths. While it is true that methadone can be dangerous if misused, under the care of a licensed treatment program, it can be safe and highly effective. Especially in today’s world of tainted heroin, methadone can be the best option available. Dangerous fentanyl analogs found in street heroin wreak havoc with the user’s opioid receptors and make it difficult for any medical addiction treatment to work. Yet, methadone’s unique properties make it an ideal treatment in this situation.
Is Suboxone better than methadone?Well, yes and no. Suboxone has several key advantages over methadone. First, it can be prescribed in any doctor’s office by any doctor. The prescribing doctor simply has to take a brief course to get certified. This course can even be completed online. This is in contrast to methadone, which can only be dispensed in special government credentialed clinics. It is very difficult for a clinic to get certified for methadone maintenance. Next, if you start methadone for opiate or opioid addiction, you will not get any take-home medication for a very long time. With Suboxone, or buprenorphine, you get some take-home meds right away. This is because of the relative safety of buprenorphine, the main ingredient in Suboxone, along with naloxone. There is far less risk of respiratory depression and overdose with buprenorphine compared to methadone.
If Suboxone is easier to get prescribed and safer to take, why even consider methadone?To answer this question, let’s get back to the issue of today’s street heroin contaminated with imported fentanyl analogs. This deadly combination is powerful and very long lasting. The drug has such a long half-life, it is hard for the user to transition from heroin to Suboxone. This is because the user must wait until they experience withdrawal symptoms before starting buprenorphine. If they start too soon, they will get what is called precipitated withdrawal. When precipitated withdrawal occurs, the drug user feels much worse withdrawal symptoms after taking the Suboxone. This is because of the nature of buprenorphine, being a partial agonist of the receptor. While this transition from an opiate or opioid of abuse to Suboxone is usually fairly easy, it is very difficult with some of today’s street opioids. This is where methadone shines as the gold standard of medication-assisted treatment. There is no waiting period. Methadone, a full agonist of the opioid receptor, can be started right away without waiting for withdrawal symptoms. There is no concern over precipitated withdrawal. So, as you can see, there is still a place in addiction treatment for the methadone clinic.
How soon after taking methadone can you take Suboxone?This is a frequently asked question. I have heard many consults ask me, how long after taking methadone can you take Suboxone? The reason why it is such a hot topic is that the methadone clinic is an inconvenience in the life of a recovering person who is getting back to regular daily activities. Of course, going from the nightmare of heroin addiction to the relief of methadone maintenance is something to be grateful for. However, when you start to get your life back together, going to the methadone clinic every single morning can interfere with going to work and taking the kids to school. It also makes vacations difficult or impossible. And, sometimes you just don’t want to leave the house early on your day off. Methadone clinics typically open early and close early. If you miss your daily dose, you may get very sick later in the day. You also risk relapse if you miss your medication. So, it is understandable that you may think about how nice it would be to switch to Suboxone and get a prescription for up to a whole month of take-home meds. Yet, there is the issue of having to stop methadone first and wait for withdrawal symptoms before starting Suboxone or another buprenorphine medication.
Methadone has a very long half-life, making it difficult to detox off of it.Quitting this drug can be hard detox. Going cold turkey is almost unthinkable. Unlike the short-acting opioids, such as oxycodone and other opioids, methadone takes a long time to leave your system. While the wait from quitting a short-acting opioid to starting buprenorphine can be as little as 12 hours, it will be at least 32 hours after quitting methadone. This is because of the very long half-life. In fact, the waiting time is more likely to be as long as 3-5 days, or even a bit longer. Unfortunately, after you quit and wait out the several days or more, withdrawal symptoms will have already started for many people. This waiting period can be unpleasant. However, it an be made a bit easier with medications that reduce withdrawal symptoms, such as clonidine or Lucemyra (lofexidine). Also, it is important to have the treatment program doctor help you to taper down to no more than 30mg daily before attempting the transition. This transition to the first dose of buprenorphine must be managed by a qualified doctor.
When does Suboxone make you feel better after coming off of methadone?This will be different for different people. It depends partly on how little you were taking daily and what level of withdrawal symptoms you experience before taking the first dose of buprenorphine. To be extra careful, your Suboxone doctor will likely give you a very small dose of buprenorphine to get started. This way, if you do get precipitated withdrawal from the buprenorphine, it will not be as bad as if you took a higher dose. If this first test dose makes you feel better, than the doctor may give you another small dose. during this induction phase, the Suboxone doctor will determine the best maintenance dose to prescribe. The induction period can last days, so in the beginning, you may see the doctor more often. After you are stable, a more long-term prescription can be issued. So, to answer the question, it will likely be several days after stopping that you are ready to start buprenorphine, but be sure to do this under the supervision of your Suboxone doctor. This detox process can be difficult and even dangerous, so be sure to talk to your doctor.
After stopping methadone, are there other drugs that contain buprenorphine that work as well as Suboxone?Yes, there are certainly other options for medication-assisted therapy. Probuphine, for example, is a buprenorphine implant that lasts for a full six months. There is also Sublocade, a monthly buprenorphine injection that allows the patient to avoid taking daily Suboxone and still keep up with monthly doctor checkups. If you prefer taking buprenorphine sublingually each day, but you hate the after-taste of Suboxone, there is Zubsolv, which is similar to Suboxone, but has a minty, more pleasant taste. For pregnant women, the preferred brand will be Subutex, which does not contain naloxone. This is because naloxone combined with buprenorphine is not considered to be safe for pregnancy.
After going from Methadone to Suboxone, what comes next?If you are taking these medications under a doctor’s supervision and you are clean and not using street drugs, you should consider yourself to be clean. This is referred to as the new recovery. Yet, you may still have a long-term goal of being clean from all opioids. Keep in mind that these two drugs are still opioids. while buprenorphine is not like other opiates and opioids, it s still technically an opioid. There is, however, a third option that is not an opioid at all. Naltrexone is a medication that works quite well to prevent relapse and overdose. The difficulty of going from buprenorphine to naltrexone is that you must wait for up to two weeks from your last dose of bupe to your first dose of naltrexone. During this waiting period, you will likely again experience withdrawal symptoms. There is a risk of relapse and overdose as well. If you choose to convert from buprenorphine to naltrexone, you may want to do this in a supervised treatment program. A residential detox facility may be ideal for this transition.
What about going medication free, completely abstinent from all drugs?The problem with complete abstinence from all medication to treat opioid use disorder is that relapse rates are high. Opioid addiction is a chronic, life-long condition. While it is possible to discontinue medically assisted treatment, it is not recommended. Fortunately, naltrexone is a non-controlled, non-opioid medication. By the standards of even the strictest abstinence program, naltrexone would not be an issue. If you are currently in Suboxone treatment and considering discontinuing buprenorphine without going to naltrexone, you should discuss the risks, alternatives and benefits with your doctor before making a decision.
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