Methadone or Suboxone? If I have OUD, How Do I Decide?

By Christopher Johnston, MD ABPM-ADM, Chief Medical Officer, Pinnacle Treatment Centers

If you receive a diagnosis for opioid use disorder (OUD) and decide to commit to treatment, you have several options. You can choose a methadone program, you can choose a Suboxone program, or you can choose a different path.

Your options depend on several things, including, but not limited to:

1. The severity of your OUD
2. The duration of your OUD
3. Your simultaneous use of other substances, called polysubstance use
4. Your treatment history:
   • Have you tried to stop opioid use unsuccessfully before?
   • Did you enter professional treatment?
     • If so, what kind of treatment was it?

5. Your medical history:
   • Current conditions
   • Current medications
6. Your psychiatric/mental health history:
   • If you have a mental health disorder as well as a substance use disorder (SUD) such as OUD, you have co-occurring disorder
   • Current psychiatric medications
7. Your goals and motivations for treatment

When you receive a diagnosis from a mental health professional, they’ll ask you detailed questions about all these things before reviewing the pros and cons of different courses of treatment.

Which brings us to this very important disclaimer:

This article is neither a diagnosis nor a treatment recommendation.

Only a licensed and qualified physician, psychiatrist, or mental health professional can give you a accurate diagnosis.

A full biopsychosocial assessment can assist a medical professional to present you with options. The current gold standard for care for people diagnosed with opioid use disorder is an approach called medication-assisted treatment (MAT). MAT most often involves the use of one of the two following medications for opioid use disorder (MOUD):

• Methadone
• Suboxone (buprenorphine)

This article will discuss the differences between these two medications and present their relative benefits and risks. If you’re entering an MAT program and unsure which medication to choose, the following information can help you make an informed choice.

Medication-Assisted Treatment: The Basics

If you’ve already received a diagnosis for OUD, there’s a good chance you know what medication-assisted treatment is. However, there’s also a chance the first time you heard the acronym MAT or the phrase medication-assisted treatment was when you received a diagnosis for OUD and the assessing clinician discussed the various treatment options available to you.

If you know all about MAT already, skip to the next section of this article. If you don’t, please read on: we have important information for you.

Ready?

Here’s how the Substance Abuse and Mental Health Services Administration (SAMHSA), defines MAT:

“MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders. Medications used in MAT are approved by the Food and Drug Administration (FDA) and MAT programs are clinically driven and tailored to meet each patient’s needs.”

We’d like to point out something not everyone realizes about MAT. It includes counseling, therapy, community support, and lifestyle changes. Medication is part of the MAT picture, but it’s not the entire MAT picture.

Here’s what medication – methadone and buprenorphine (Suboxone) – does for people with OUD:

• Blocks the effect of opioids on your brain and body
• Normalizes brain chemistry
• Blocks the euphoric and pleasurable effects of opioids
• Decrease frequency and intensity of opioid cravings
• Reduces the symptoms of withdrawal from opioids

In addition, SAMHSA identifies significant benefits of MAT. For people in MAT programs that administer methadone or buprenorphine (Suboxone), these medications are associated with:

1. Increased time-in-treatment
2. Decreased opioid use
3. Decreased criminal behavior/involvement with justice system
4. Increased ability to find and maintain employment
5. Increased ability to participate in family or school life
6. Decreased overdose risk
7. Decreased overall opioid-related mortality (death)

That’s the big-picture information you need to know about MAT: for people with OUD, it helps them initiate and stay in treatment, reduces overall opioid use, and improves quality of life across a wide range of metrics.

It’s important to understand that these benefits apply to people in MAT programs that administer methadone or buprenorphine. While there are differences between the medications, the benefits are very similar – and most importantly, both are associated with decreased opioid-related mortality.

In other words, both medications save lives.

Now let’s take a look at the differences between methadone and buprenorphine.

Methadone and Buprenorphine (Suboxone): How are They Different?

First, we’ll point out that both methadone and buprenorphine are synthetic opioids approved by the Food and Drug Administration (FDA) for the treatment of opioid use disorder, both medications are safe, effective, and associated with the benefits we list above.

Now let’s look at the differences.

1. How they work:

• • Methadone
    • Methadone is called a full opioid agonist, which means it completely fills opioid receptors in the brain
  • Buprenorphine (Suboxone)
    • Buprenorphine is called a partial opioid agonist, which means it has a ceiling effect on slowing breathing in high doses.
    • Buprenorphine is often administered in a formulation that includes an additional medication called naltrexone. Naltrexone is an opioid antagonist but is inactive when taken orally.
      • This combination medication is called Suboxone.
      • The naltrexone component of Suboxone is intended to be an abuse deterrent

2. How they’re administered:

• • Methadone:
    • Oral liquid
  • Buprenorphine (Suboxone):
    • A sublingual tablet that dissolves under the tongue is the most common method of administration

3. How you start treatment:

• • Methadone
    • You can start immediately upon entering a licensed treatment program
  • Buprenorphine (Suboxone)
    • If you’re treatment for use of short-acting opioids (i.e. heroin or fentanyl), you must wait 12 hours after the last dose of the opioid of misuse before initiation buprenorphine
      • Moderately severe signs of withdrawal must be present like upset stomach and diarrhea.
    • Your initiation depends on clinical presentation, as determined by a qualified medical professional

4. How ongoing treatment works:

• • Methadone:
    • Only federally licensed Opioid Treatment Programs (OTPs) may prescribe and dispense methadone to people with OUD.
    • Methadone is more regulated than buprenorphine
    • Regulations require you to have your dose observed in clinic 6 days a week in many states for the first 3 months.
    • Home dosing increases as progress is made in treatment.
  • Buprenorphine (Suboxone):
  • You can access buprenorphine through federally licensed treatment providers, Office Based Opioid Treatment Programs (OBOTs) and private doctors offices with prescribers who have “waivers.”
  • Once you receive a prescription for buprenorphine, you can refill prescription at your OBOT or at a typical pharmacy
  • Depending on your treatment progress, OBOTs may prescribe enough medication to last a week, two weeks, or a month

Those are the specific differences between methadone and buprenorphine. One thing to keep in mind is that both medications are effective, evidence-based treatments for opioid use disorder. Both work –  but each also has relative risks and benefits, compared to the other.

We’ll discuss those now.

Methadone and Buprenorphine (Suboxone): Comparing Risk and Benefit

There’s something we run into quite often that we need to address.

When we bring up the subject of MAT with people diagnosed with OUD, many people express this sentiment:

“I’m cool with Suboxone, but I don’t want to be on methadone.”

Reminder: Suboxone is the brand name for the most common formulation of buprenorphine. Suboxone contains naloxone, a medication that discourages misuse because when used improperly, it can cause withdrawal – which is one of the things people initiate MAT to avoid.

If that’s your position – you accept the prospect of treatment with Suboxone, but not methadone – we understand. The risks of methadone, as compared to Suboxone, include:

Respiratory Complications:

• Misuse of methadone can cause respiratory depression, which can lead to death
• Suboxone does not cause respiratory depression

Drowsiness:

• Methadone is accompanied by mild sedation, but people do not get “high” from methadone
• Buprenorphine has minimal sedation, which makes it preferable for some people in treatment

Overdose:

• Methadone is an opioid medication which, when diverted or misused, can lead to overdose. This is the reason for daily observed dosing at the beginning of treatment. Once on a stable dose the risk of fatal overdose drops very dramatically.
• Buprenorphine when taken by itself, without sedating medications is impossible for an adult to overdose on.

In addition to those risks – which may make methadone appear, at first, riskier than buprenorphine – you may want to avoid methadone because of the need for daily trips to a methadone clinic, or the stigma attached to methadone clinics themselves.

We understand: the mild sedation may be a dealbreaker, the rules make methadone seem like a hassle, and the association with street heroin users – because of its origin in treating people with heroin use disorder in New York City in the 1970s – may make you question whether methadone is appropriate.

With that said, there are some cases when methadone can lead to better outcomes than buprenorphine.

Advantages of Methadone Treatment

Let’s clarify something: heroin use in New York City in the 1970s stigmatizes methadone treatment for people to this very day. We’re not kidding. The first methadone clinics helped people from low-income neighborhoods address their heroin misuse. These clinics – and the people who received treatment in them – were associated with the kind of criminal behavior common to heroin trafficking and other types of organized crime.

None of that has anything to do with you, today, and the fact you’re seeking treatment for opioid use disorder.

If you receive a diagnosis for OUD and your doctor recommends a methadone program, we encourage you to consider the facts before dismissing the idea of methadone treatment altogether. We also recommend examining the reasons you don’t want to go on methadone. If 50-year-old stigma around heroin use prevents you from engaging in methadone treatment, them we encourage you to reevaluate your position.

It’s true: buprenorphine is more accessible, easier to initiate, and easier to refill. However, the Provider’s Clinical Support System (PCSS), a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), identifies the following advantages of methadone treatment:

• Methadone has been studied and researched more than any other MOUD
• It’s been an approved treatment for OUD since 1973
• Methadone programs have the highest retention rate of any MOUD programs:
  • PCSS data shows 80% of people in methadone programs stay in counseling for at least 6 months
• Methadone is more effective than buprenorphine for mitigating the symptoms of withdrawal

That last bullet point is something anyone with a severe OUD needs to understand with total clarity: because methadone is a full opioid agonist, it can mitigate the discomfort of withdrawal symptoms, and prevent the severity of ongoing cravings, more effectively than buprenorphine.

That’s why clinicians often refer people with severe OUD to methadone maintenance programs:

Your Recovery, Your Choice

If you have OUD, the final decision between about which medication to take – if you do commit to MAT – is a matter of your personal preference. You know yourself, you know your history, and you can make an informed decision in collaboration with your treatment team and with full knowledge of all the information we present above.

Here are additional things to consider when making a choice between methadone and buprenorphine:

• Methadone is easier to start, since you’re not required to be in withdrawal to begin methadone treatment
• Buprenorphine causes side effects in some people that make methadone a preferable way to manage cravings
• If you don’t like methadone – and you give it a fair try – you can switch to buprenorphine
  • In the past, uncomfortable symptoms of withdrawal have made this option less than attractive, but new techniques are available to minimize the discomfort of transition between the two medications, and make switching a realistic option
• If you’re already on buprenorphine and you feel well, you should keep taking it

We understand it’s not an easy decision to make, but in the end, the decision is yours. We’ll close this article with some advice:

“In treatment of any medical condition, individualizing treatment with consideration of side effects is the most appropriate approach.”

That statement applies to OUD: the best way to decide what to do is gather evidence, consult with your treatment provider, and choose a path forward that you think gives you the best chance of achieving sustainable, lifelong recovery.