Many people who walk into a neighborhood facility that offers methadone as well as buprenorphine for opiate addiction has a predetermined idea of which medication they prefer. Generally, this is based on the experiences told to them by friends who have tried medication-assisted treatment (MAT). It’s good to know walking into the program that the ultimate decision which medication is right for you will be made when you are actually seen by the program’s physician. But it’s good to walk into that examining room being prepared to discuss your preference.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published a study titled Toward Optimal Use of Buprenorphine and Methadone in Treatment of Heroin Dependence presented by its clinical director, Mark Heilwig, M.D., Ph.D. His work was based on that of Swedish researcher Dr. Johan Kakko and others whose work was presented at the International Narcotics Research Conference.
First Dr. Heilwig looked at the pros and cons of both methadone and buprenorphine/naloxone, which are the ingredients of Suboxone.
- Partial agonist with limited ceiling effect.
- Better safety—because it is a partial agonist, and because Suboxone comes on a filmstrip, the potential to abuse it is reduced.
- After induction into treatment, the person in treatment can take prescription with him and needs to report only weekly, biweekly, or monthly.
- Deaths per 1000 users: 0.2
- Here’s the negative: Lower retention rate. People on buprenorphine for opiate addiction dropped out at a higher rate than those on methadone.
- More potent medication. This is also a con: Methadone is a full opiate agonist, with a greater potential for abuse.
- Better at reducing cravings
- Higher success rate
- Respiratory suppression
- Deaths per 1000 users: 0.7
- Greater risk of overdose
- Must be controlled by the dispensing program
So then the physicians providing methadone and buprenorphine for opiate addiction asked themselves, what if they began with buprenorphine treatment, and then stepped into methadone treatment as necessary? The person presenting at the neighborhood MAT program would start treatment on buprenorphine/naloxone, and if they continued successfully through the phases of treatment, all would be well and good.
On the other hand, if their drug urine screens show illicit drug use or if the person is skipping their scheduled appointments, either with the doctor or with the counselor, then the person would not be dropped from the program but would instead be offered methadone instead. The Swedish researchers proposed this strategy because they believe it keeps treatment safer with buprenorphine for opiate addiction as a primary consideration. And so the question arose: was there a way to predict ahead of time which people would need to go on methadone?
Swedish Study on Methadone vs Buprenorphine for Opiate Addiction
There were 96 heroin addicts included in the study, 92 of whom were needle users. They were split equally between buprenorphine and methadone. They had to be at least 20 years old, with an addiction history of one year or greater. People were excluded from the study if they had a co-occurring mental health diagnosis; if they were taking anti-epileptic medication or an anti-alcoholism drug called disulfiram, if they were in treatment for HIV/AIDS; or if they were nursing.
The average methadone client was 36.5 years old with a 9.4-year history of heroin abuse. There were 43 men in the study and 5 females. Hepatitis C tests were positive in 42 out of the 48 clients. In the buprenorphine group, the average age was 34.8 with a 10.2 history of heroin addiction. There were a few more women in this group—15 out of the 48—and 39 of the clients tested positive for hepatitis C.
Of the original study group that were screened for participation, only 14 percent of them did not meet criteria. Researchers were excited because this spoke to the general safety of either methadone or buprenorphine for opiate addiction.
After random assignment to either methadone or buprenorphine, all of the study participants completed one month of induction into treatment. Following that, those who requested dose increases were given them only if they had not missed more than two doses during the month, if they did not show signs of sedation—meaning the dose was already too high—and if their urine drug screens showed evidence of illicit drug use. That last criterion was important because it addressed the person’s inability to stay clean rather than drug-seeking behavior asking for a higher dose for no obvious reason.
Ultimately, the study showed that the probability of failure at methadone versus buprenorphine for opiate addiction was less than half of one percent—indicating that no matter which medication you and your doctor choose, you have a very good chance of success at either, as long as you abide by program rules.
So, What Were the Results?
Even so, why were clients slightly more likely to stay in treatment if they were on methadone despite all the advantages offered by buprenorphine? Scientists believe that one of its greatest advantages—the fact that you can take away a prescription with you and see the doctor weekly, then biweekly, and then monthly—is also its downfall. Attendance at counseling is vital for success in opiate treatment, whether you use methadone or buprenorphine. It’s important to meet with your counselor regularly to talk about what areas of your life you want to change and what factors in your life contributed to your addiction.
The methadone clients go to the clinic on a daily basis and so they are there for scheduled group or individual counseling sessions. The buprenorphine clients attend clinic less often and they have a greater propensity to ignore their scheduled counseling sessions. Many neighborhood MAT programs offer not only individual counseling but some also provide group counseling and some allow AA or NA groups to hold 12-step meetings on site, for the convenience of their clients.
Nevertheless, with the results being so close at less than one-half of one percent, the researchers determined that the higher safety associated with buprenorphine outweighed methadone’s very slight advantage. The result of the study was a recommendation to begin buprenorphine for opiate addiction and switch to methadone only if needed.
If you’ve been wondering which medication would be better for you, the best recommendation is to visit your local MAT program and talk to the addiction treatment professionals there. The most important thing, whether you are assigned to methadone or buprenorphine, is to maintain regular visits, participate in counseling and 12-step groups, and explore all the reasons why you want to make changes in your life. After all, your future depends on it!