Suboxone Vs Methadone

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Both Suboxone and Methadone are used in the treatment of narcotic withdrawal, but there are critical differences in application and risk between the two drugs. To understand why one is chosen over the other, it’s important to have a little biochemistry first.

Methadone is an opiate agonist. It functions in the same way any other opiate does by binding to receptors in the brain (and elsewhere). Other agonists are morphine, heroin, hydrocodone and codeine. Methadone is used in the treatment for heroin addiction because it causes less overall damage to the patient, not because it doesn’t cause addiction. With methadone, the “high” is less and the drug lasts longer. Getting on it also means getting away from injections, one of the major problems with using heroin.

If an agonist binds to an opiate receptor to cause all the effects of a narcotic, what is an antagonist? That’s a chemical that binds but causes no effect. It’s like a key that fits a lock but doesn’t unlock it. Agonists are used to treat overdose by blocking the effects of an opiate. They stick in the receptor and keep the opiate from working. Eventually, the opiate is metabolized by the body enough so that blood levels fall and the danger of overdose passes.

There is another class of drug, called a “partial agonist,” which gives some effects but only in a limited way, while still blocking the receptors from full agonists. Suboxone is one of these.

Because it only partially activates an opioid receptor, patients on it do not get the same level of “high” they would with heroin or morphine. Increasing the dose does not lead to a better experience for addicts. This is called the “ceiling” effect. Addicts are not tempted, as they might be with methadone, to increase the dose themselves to get a better buzz. This means Suboxone can be sent home with the patient. Methadone cannot and must be dispensed and taken under supervision.

Practical Consequences

Why prescribe methadone at all if Suboxone isn’t as addictive? Because not all addicts in treatment are the same. Some have worse habits than others. If an addict is severely hooked on heroin, Suboxone will induce withdrawal – this is the primary symptom to be avoided. Withdrawal consists, not only of the physical “withdrawal sickness” but the mental cravings that lead to relapse. When someone is too deep in addiction, they require weaning and both methadone and Suboxone are used for this.

Methadone, as an opiate itself, will cause addiction and stopping it suddenly will cause withdrawal. As a practical matter, patients are stabilized at one dose of methadone for some time until they are no longer seeking heroin. Then the methadone dose is gradually lowered in an attempt to wean them off it.

Addicts who are only mildly addicted can go right to Suboxone or, they can have some weeks or months on methadone first.

Dosing is also different between the two drugs. A dose of methadone lasts about a day and patients have to return for more. Suboxone lasts several days and dosing can be as much as four days apart.

Methadone

Advantages

  • • Can be used to switch IV heroin users to an oral dosage form and will work for severe heroin addiction
  • • Relatively cheap
  • • Dosage is very flexible because it comes as a syrup as well as a tablet

Disadvantages

  • • Daily dosing required
  • • High potential for abuse
  • • Withdrawal from methadone is just as bad as from heroin
  • • Can cause overdose and death

Suboxone

Advantages

  • • Helps with withdrawal but does not cause euphoria
  • • “Ceiling” effect means patients cannot get high from taking more
  • • Longer lasting than methadone
  • • Unlikely to cause overdose

Disadvantages

  • • Costs more than methadone
  • • Doesn’t work well for severe or longtime addicts

Cost and Compliance

At a first look, Suboxone seems like a better choice for opiate treatment, and for some patients, it can be a lifesaver. But cost does matter, especially when drug treatment programs are publicly funded or in a cash-strapped urban environment. The price difference can mean having to cut off some who should be on maintenance therapy.

Compliance enters in because both substances are given on an outpatient basis. Patients who slip up and seek heroin again will do so if either substance isn’t meeting their expectations. Methadone more closely matches heroin in staving off withdrawal and cravings, meaning more addicts will stick with the program.

The major objection to methadone is that it replaces one addiction with another. Methadone patients are still addicts. With Suboxone, there is light at the end of the tunnel and a clear treatment goal. But it’s this same fact that can make an addict quit the program and return to drug seeking.

In the end, it comes down to personal choices and working on recovery. For both substances, other treatments are needed and because both require regular visits for resupply, the opportunities for therapy and counseling shouldn’t be overlooked.

Real recovery doesn’t happen by replacing one addiction for another. It happens only with a cognitive/behavioral change. Either drug can help, and each is very useful. But neither is a cure all. At best, they represent a chance and hope. It’s up to the individual addict to make the best of that chance.

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