Methadone Versus Buprenorphine/Naloxone

 

Written by and for people with Lived Experience

Today’s Learning Moment – 09 14 20 Issue:

Methadone Versus Buprenorphine/Naloxone

When people with substance illness – opioid use reach out to begin the healing journey the options usually prescribed are either methadone or buprenorphine/naloxone.

Which of these is better or when should they be used?

In BC the preferred treatment for people with opioid substance illness is Buprenorphine/naloxone (Trade Name - Suboxone). Let’s explore why?

Both methadone and buprenorphine can be considered significantly better options than illicit opioid street drugs. For those people with substance illness that are not ready to stop using opioids, methadone and buprenorphine are known pharmaceuticals which do not have all of the unknown substances including Fentanyl that are in street drugs. In other words, the move to methadone/ buprenorphine can be seen as a significant harm reduction step – hopefully leading to long term opioid abstinence.

NOTE: Naloxone is added into the pill form so that if the pill is dissolved and injected, the Buprenorphine is rendered inert as an opioid.

ADVANTAGES of Each:

Methadone:

·         Potentially people will stay on Methadone - better treatment retention.

·         May be easier to initiate treatment. People with substance illness often see methadone as an ongoing substitute for their opioid where buprenorphine is seen as a reduction treatment and end to their opioid addiction. (people wishing to end opioid use will choose buprenorphine. People wanting to move from illicit opioids but feel then still need the effects of opioids will choose methadone.  

·         No maximum dose.

·         If buprenorphine was unsuccessful in relieving withdrawal symptoms or was associated with severe side effects, methadone is an alternative

·         Approved in Canada for the primary purpose of pain control (as split dose BID (twice a day) or TID (three times a day) dosing; Health Canada exemption to prescribe methadone for analgesia also required).

Buprenorphine/naloxone:

·         Can be started and continued at home

·         Less risk of overdose due to partial agonist effect and ceiling effect for respiratory depression. (in the absence of benzodiazepines or alcohol).

·         Reduced risk of injection, or deviation of use, and overdose due to naloxone if dissolved and injected

·         Milder side effects for most people

·         Easier to rotate from buprenorphine/naloxone to methadone.

·         More flexible take-home dosing schedules may be more cost-effective for patients and patient independence.

·         Shorter time to achieve beneficial dose level (1-3 days).

·         Potentially more effective analgesic for the treatment of concurrent pain (however, see disadvantages).

·         Fewer drug interactions.

·         Milder withdrawal symptoms and easier to discontinue

·         Alternate day dosing schedules (as daily witnessed or take-home doses) are possible.

·         Optimal for rural and remote locations where daily witnessed ingestion at a pharmacy is not possible.

DISADVANTAGES of Each:

Methadone

·         Higher risk of overdose, particularly when treatment is started

·         Generally, requires daily witnessed ingestion. (drug store - pharmacist)

·         More severe side effect profile (e.g., sedation, weight gain, erectile dysfunction, cognitive impairment).

·         More expensive if daily witnessed ingestion required.

·         Longer time to achieve a beneficial dose level.

·         More difficult to transition to buprenorphine once on methadone.

·         Higher potential for adverse drug interactions (e.g., antibiotics, antidepressants, antiretrovirals).

·         Higher risk of non-medical or other problematic use.

·         Increased risk of heart arrhythmias

·         At high doses, may block some of the analgesic effects of other opioid medications administered for pain.

Buprenorphine/naloxone

·         Potentially higher risk of drop-out.

·         If appropriate dose starting schedules are not used, may cause hastened withdrawal symptoms.

·         Doses may be not meet needs for individuals with high opioid tolerance.

·         At high doses, may block the analgesic effect of concurrent opioid medications administered for pain.

·         Reversing effects of an overdose can be challenging. Buprenorphine is very difficult to dislodge from dopamine receptors in the brain. Good news is it’s very difficult to overdose with Buprenorphine

Information is taken from the UBC Addiction Care and Treatment Manual

Families Helping Families is an initiative of the Port Alberni Community Action Team. We send out “Learning Moment” articles regularly to help folks understand substance illness. Knowledge is vital in understanding the illness of our family members. You may copy, distribute or share our articles as long as you retain the attribution. You can be added to our distribution list by dropping us a note to - albernihelp@gmail.com