Methadone and Suboxone

In response to the comments below about methadone…

I am not aware of the idea that a person’s choice of suboxone vs methadone should be dictated by their tolerance level, and I certainly do not agree with that idea.  I also do not see any advantages of methadone over suboxone when it comes to maintenance treatment of addiction, except for cases where suboxone is problematic– say in people who have frequent surgeries or frequent need to go on and off pain medications.  This may be the case in a person with a relapsing physical illness that causes severe pain, such as severe migraine or cluster headaches, or sickle cell anemia.  Buprenorphine takes forever to leave the body, and until it is mostly gone it is difficult to acheive analgesia even with very high doses of narcotics.  Patients with sickle cell crisis usually require potent narcotic pain medication, and it would be horrible to have to wait for three, four, or even five days in severe pain, waiting for the buprenorphine to dissociate from the receptors and get out of the way of the morphine, oxycodone, or fentanyl.

Methadone is just another opiate agonist.  Agonists are molecules that have a dose-related effect at the receptor, whereas antagonists block receptors without activating them (the classic opiate antagonists are naloxone and naltrexone).  Buprenorphine, the active drug in Suboxone, is a ‘partial agonist’, ‘mixed agonist’, or ‘agonist/antagonist’– it has both a blocking effect and an activating effect.  The dose/response curve for agonists would be a diagonal straight line going upward to the right; for a partial agonist like buprenorphine the graph is similar in low doses, but at about 4 mg or so the line comes off of the diagonal to flatten out– the ‘ceiling effect’. 

I do not see methadone as being better at filling that ‘hole’ that we were talking about (the ‘hole’ was in reference to the chronic empty feeling that many opiate addicts talk about having– sometimes for their entire life, even before opiate use).  Methadone has the same problem that all agonists have– tolerance.  At first, methadone will provide a euphoria… but then tolerance rises and the effect goes away, unless the dose is increased.  And that is how it goes… no matter how high the methadone goes, tolerance will ALWAYS catch up eventually.  That is why there is just no ‘future’ in opiate agonists– no future in using them for chronic pain, and no future in using them to fix ‘emptiness’.  In ALL cases, tolerance will take away any positive effect.  That is why people end up on ridiculously high doses of methadone or oxy if they use long enough.

Bupe is different.  The tolerance is ‘static’– it does not keep changing.  There is an initial change of tolerance– depending on the patient’s tolerance, the suboxone will pull the tolerance down, or push it up, so that it is set at about equal to the tolerance caused by 30 mg of methadone per day.  But once there, the tolerance stays the same even after months and months go by.  Moreover, because of the ‘ceiling effect’ the tolerance doesn’t change much even if the suboxone dose changes, as long as the suboxone dose is above 4 mg.  This is why there is little withdrawal when tapering suboxone until one gets to about 4 mg per day or less. 

We don’t know why cravings go away on suboxone.  The effect seems to be dose related, occurring more as doses increase beyond 8 mg per day.  Cravings are manifest by many different things– depression, irritability, or just plain old desire to use… and so many patients say that on Suboxone they feel happier, less moody, less irritable, etc.

I have treated over 150 people with buprenorphine over several years, and I am still learning more about the medication and about how people respond over time.  It is not a ‘sure thing’– people will still relapse if they don’t make changes in their lives.  The most important thing, in my opinion, is to remember the misery of being trapped by addiction.  People should be told that it is still there waiting for them– it will always be there.  People should also be aware that once they have used on Suboxone they are in deep trouble– the Suboxone seems to represent a commitment to a new life that helps keep people clean, and once a person crosses the line and uses, that commitment goes ‘poof’ and is gone.  Suddenly the person is back to trying to find the ‘will power’ to stop using… and will power simply does not work.  Even worse, residential treatment no longer works well either– residential treatment relies on the patient becoming so desperate that the mind opens to a new way of thinking.  Addicts who ‘know suboxone’ don’t get to that level of desperation– when they get anywhere close to desperation they say they have had enough, and they run from treatment. 

Opiate addiction is a fatal illness– a horrible, fatal illness.  It will wait, dormant, until the addict becomes complacent or thinks he/she is ‘cured’, then become active and take the addict’s career, money, house, family, freedom, and life.  It will change the addict’s thought process to allow rationalization of almost anything.  I encourage people to avoid complacency; use Suboxone as one tool of a recovery program, and make every day another step toward a better life.  Seek out positive experiences.  Take a daily inventory.  Find non-using friends.  Keep busy and always have at least one job.  Read something every day.

  And finally, fear opiates.  Always be afraid of opiates– see the substances for what they are, and what they have done to you.  Fear them and hate them.

If you have a minute check out my hobby of putting together web pages:  http://warmalglobing.com  is one; another is http://dsm-v.com .  And of course my home at http://wisconsinopiates.com .

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