This page provides general information aimed at patient education and does not reflect the services provided by my practice. I do not prescribe Methadone for opioid addiction.
In the past, there was only one option for outpatient opioid addiction treatment … Methadone.
For the treatment of opioid adddiction, Methadone can only be dispensed by a Methadone Treatment Program … also called Methadone Maintenance Program.
Methadone Treatment Programs are only offered through government contracted facilities, are located only in major cities, and require daily attendance.
The delayed onset of action, the long duration of action, and the low cost, makes Methadone a very good drug for opioid maintenance programs. A single daily dose is enough to keep the person out of withdrawal for 24 hours or longer.
But now there is a better medication, “Suboxone”, and this is available by prescription from a doctor’s office in your community.
Why is Suboxone better?
Because, it has better pharmacological properties, … fast acting, long acting, completely stops withdrawal, and more important … it is available by prescription. (See comparison table below)
You do not have to go to a Methdaone Treatment Program, … everyday, … during certain hours, … to stand in que for your Methadone dose. Instead, you can chose to enroll in an office based Suboxone therapy program, go to a doctors office in your community and receive a prescription for Suboxone or a similar medication, and take the medication in the comfort and privacy of your home.
If taken as prescribed Suboxone does not alter mental status, patients can drive, work with machinery, … students can attend school, and take exams … and if there is any sedation, simply lowering the dose works … and that is still adequate to stop the withdrawal. Another method is to take the dose in the evening instead of the morning … and sleep through the sedation if any.
It is best to start low and understand how the medication affects you and adjust your dose accordingly. Your goal is only to take that much that will stop the withdrawal without having any side effects.
In my practice patients who have experienced both Methadone and Suboxone, have reported that once they are on a stable dose they find Suboxone to be much better … without any significant side effects, or craving … thus helping them to work and lead a normal life.
In USA, Physicians in private practive are not allowed to prescribe Methadone as treatment for addiction, but they are allowed to prescribe Suboxone.
Suboxone is a combination of Buprenorphine and Naloxone. This combination is also available as a generic tablet, and as tablet or film, under the brand names Suboxone, Zubsolv, and Bunavail. An implantable form of Buprenorphine called Probuphine is also available.
Qualified physicians have been granted a waiver by Drug Enforcement Agency to prescribe Suboxone and similar medications from their offices. This has made the outpatient treatment for opioid addiction very affordable and easily accessible … as compared to Methadone programs or inpatient rehab.
The average cost of treatment with Suboxone is $20/day, … much less than the cost of buying street drugs.
A comparison of Methadone Treatment Program and Office Based Suboxone Therapy
|Methadone Program||Suboxone Therapy|
|Only available in major cities.||Available in your community or nearby through a certified provider. Many are Primary Care Providers making this service available through their clinics.|
|Less than 10 Methadone programs available for the entire state of Tennessee.||More than 600 providers in Tennessee with Suboxone waiver are listed on the SAMHSA website.|
|Need to go everyday, during dosing hours.||Not required to go everyday. Need to enroll with a certified provider, and follow their recommendation. Some providers require weekly, or biweekly visits, many prescribe for 30 days.|
|Daily visits at specified dosing hours interfere with work schedule.||Morning and afternoon appointments are available. No matter which shift you are working on, you can get an appointment that is convenient, … and you do not have to go everyday.|
|Methadone is dispensed only during certain times of the day||Suboxone is not dispensed, instead you receive a prescription that you get dispensed from a pharmacy of your choice. You can buy a few days worth of Suboxone at a time … or get the entire prescription.|
|Need reliable transportation and license to drive to go that far everyday.||Transportation is easier to arrange as the Suboxone clinic may be in the same city or nearby. Some clinics may be within walking distance.|
|You have to take the dispensed Methadone at the clinic under direct observation.||You can take Suboxone in the privacy and comfort of your home. You can chose a time according to your convenience and work schedule. You can split your dose to suit your needs as when you are trying to taper to a lower dose.|
|What happens if you have to travel? It is difficult to get Methadone for those days that you will be out of town, and may have to face the possibility of withdrawal.||Because your Suboxone prescription is for two weeks to thirty days, you can plan your travel, and you will not be out of medications, and you do not have to fear withdrawal.|
|What happens if you are sick or are unable to go for Methadone dosing? You will not get the Methadone and may face withdrawal.||Because your Suboxone prescription is dispensed by the pharmacy, you are not affected by temporary sickness, and will not have to worry about withdrawal.|
|Financial assistance and insurance coverage may be available for the Methadone programs; some state Medicaid programs also cover them.||Tenncare covers Suboxone, Bunavail, or Zubsolv, but you have to get it through Tenncare approved providers and there are other limitations. Some providers do accept insurance. Call your insurance for a list of providers. Most providers do not accept insurance. Sometimes only the generic or a particular brand may be covered by your prescription plan.|
|If not covered by insurance or low income provisions then the cost is $10 to $15 per day or about $300 to $450 per month, and includes Methadone. Urine drug screens may be charged extra. Counseling is generally included. Cost of entry into the Methadone program is very low.||Cost of entry into the Suboxone program is high. $300 to $400 for the first visit. Follow up visits are $100 to $300 per visit. Cost of medications are extra and come to $10 to $20 per day. Behavioral therapist/Counselors service is generally extra. Do some research before you enroll with a provider … there is significant difference in fees between programs.|
|Counseling is provided by the counselors employed by the Methadone program, at no extra cost.||You are free to chose your own counselor, however it does cost extra.|
|Methadone is a pure opioid agonist, it maintains the dependence, and is difficult to taper.||Suboxone is an agonist – antagonist, it is easier to taper.|
|If a patient takes other opioids after taking Methdaone the effects are additive and can lead to overdose.||If a patient takes additional opioids after taking Suboxone, the opioid effects are blocked for some time and the risk of overdose is less. However this protection is not absolute, depends on dose of Suboxone, and the blocking effect can be overcome by large amount of opioids, leading to overdose.|
|If a patient takes benzodiazepines, soma, barbiturates, or alcohol, etc., after taking Methdaone the effects are additive and can lead to overdose.||Same with Suboxone. If a patient takes benzodiazepines, soma, barbiturates, or alcohol, etc., after taking Suboxone the effects are additive and can lead to overdose. Suboxone does not provide any protection from overdose.|
|Methadone program upfront costs are low, and daily costs are more manageable.||Upfront costs are high … but overall costs including the cost of transportation, interference with job schedule, daily attendance, convenience of dosing, make office based Suboxone therapy a much better alternative.|
|Most programs have strict policies and procedures. Violation can get you discharged from the program. Methadone programs are more relaxed about tapering, their goal is to get you to the lowest possible maintenance dose.||Most self-pay programs are more flexible and accommodating, however, violations may still get you discharged. Some providers are more strict than others, some write a lower dose, and some require time bound tapering of Suboxone.|
|There is no limit to number of patients that the Methadone program can treat, however they do have limitations based on the resources that the program has.||There is a 100 patient limit per Suboxone provider. These limits have been increased for practices that meet certain criteria; very few do … so for all practical purposes 100 patient limit still stands. Most practices are not full, and there are always a few dropouts.|
Many State contracted Methadone programs also offer Suboxone programs, and have higher patient limits, … so do ask for it.
Transferring from Methadone to Suboxone
Transferring patients who have been taking Methadone to Suboxone poses a special challenge … but can be done as an outpatient. The recommendation is to taper the dose of Methadone to 30mg/day and then go through 48 to 72 hours without any opioids … and then have an in office induction.
Methadone is a long acting drug, with a long half life, thus it accumulates in the body. The 48 to 72 hour period of complete abstinence allows the Methadone level to drop to low enough levels so as to allow for safe Suboxone induction.
Patients are provided with medications like Clonidine (to control heart rate and blood pressure), Benzodiazepine (to reduce anxiety and heart rate), Loperamide (to control excessive diarrhoea), etc., to make this 48 to 72 hour withdrawal period tolerable. These medications have significant side effects of their own and can not be used in certain medical conditions, therefore a medical history and examination is required before these can be prescribed.
Withdrawal is unpleasant, but most users have experienced it at some point and lived through it … so not everyone requires these medications.
I have transferred a few patients from Methadone to Suboxone at higher doses of 40 to 60 mg/day with in-office induction without any significant discomfort or adverse event. It does require some planning and is a two day process.
Suboxone can not be started unless the patient is in withdrawal. If Suboxone is taken while the patient has significant amounts of opioids in their body, then Suboxone will displace those opioids from the receptors and can precipitate a withdrawal that comes on very fast and is quite severe.
Some people have actually done that for the sake of science … and have written elaborate and graphic description of their experience. You can read their experience by searching for “precipitated withdrawal” on Suboxone forums.