How to choose between Methadone and Buprenorphine?
First of all, congratulations on deciding on maintenance therapy to begin with! The medical evidence for any form of maintenance therapy for opioid addiction is very strong. The success rates for methadone are about 60-70% and buprenorphine are 70-80%. Which one to choose is an excellent question. Glad you are weighing your options.
Methadone is a long-acting mu opioid analog. Buprenorphine is a partial mu opioid agonist with a high receptor affinity and occupancy - 93% at 16 mg a day (also the Morse Clinics maximum dose) (Greenwald, et al. 2003). Both create a blockade or attenuated effect of the use of additional opioids with buprenorphine having greater blockade. They stop you from getting high. Buprenorphine has a favorable safety profile due to a ceiling effect (you cannot overdose on buprenorphine alone – unlike methadone). Buprenorphine has lower street value and lower abuse potential – folks who suffer with opioid addiction cannot get high on opioids while on buprenorphine.
At the Morse Clinics, methadone is dispensed by our nurses in the form of a cherry-flavored, red liquid that is swallowed every morning. Because we use the liquid, we can dose down the exact milligram. There is no limit to the dose of methadone but we do check blood levels at 120 mg and every 30 mg thereafter to insure safety. Buprenorphine is dosed in 2 mg or 8 mg tablets – dosing options are limited to 1, 2, 4, 8, 12 or 16 mg taken sublingually and absorbed within about 5 minutes. An advantage of buprenorphine is that you do not need a gut to absorb it. If you have the flu or a GI bug that causes you to vomit, you cannot vomit up your buprenorphine. You can vomit up methadone. For our patients who have extensive GI surgeries, gastric bypasses, IBS, or Crohn’s Disease, buprenorphine may be more effective.
It is not unusual for folks to get addicted to opioids due to pain conditions. Methadone is usually more effective treating pain than buprenorphine.
To get started, if you are actively using, methadone is easier on you. Buprenorphine can cause precipitated withdrawal. Buprenorphine displaces full opioid agonists (because of its higher receptor affinity and lower level of receptor activation). Its severity varies. Common features include sweating, cramps, diarrhea, nausea, anxiety, cravings, yawning, and restlessness – typical but immediate opioid withdrawal symptoms that you are probably used to. When does precipitated withdrawal occur? Usually about 30 minutes after the first dose and peaks at 90-180 minutes after the first dose. Minor symptoms may last 2-3 days and may persist with continued heroin/opioid use.
Let’s talk about cost. If you have Medicaid, your treatment at any Morse Clinic is free for methadone. It may be free for buprenorphine as well – if you your MCO is Sandhills or Cardinal Innovations (at the time of this writing). If you do not have Medicaid, the cost of methadone is $80 per week and Buprenorphine is $120 per week – regardless of the dose. The difference in cost makes some of our patients choose methadone over buprenorphine. The reason is simply that we buy both in bulk. Our profit margin is usually less for buprenorphine then methadone.
Which is easier to come off of? First of all, we recommend at least a year clean, sober and stable (same job, living situation, relationship) before starting a gradual taper down. Many of our patients choose to remain on their maintenance medication indefinitely. Addiction is a chronic disease and most chronic diseases require chronic medications. Because you can lower 1 mg a time of methadone liquid, a methadone taper can be easier and more gradual. Because buprenorphine is only a partial agonist, an abrupt detoxification off buprenorphine is easier than methadone. So if there is a possibility that you maybe going to jail or prison, I would suggest buprenorphine over methadone.
Did that help or get you more confused? Please come into a Morse Clinic and talk to one of our doctors. You will be glad you did!
Thanks,
Eric D. Morse, M.D.