Heavily addicted to opioid pills, Patricia, 60, would spend entire days strung out on her brown leather recliner. Whenever friends or family would invite her out, she’d make excuses. She had just one interest: taking pills to avoid feeling nauseous from withdrawal.
It was only when Patricia’s addiction got too pricey – “I didn’t have enough money for groceries and gas, let alone getting my nails done,” she says — that she sought help from a methadone clinic.
“Methadone made me feel better,” says Patricia, who’s on disability after years of physically demanding factory and supermarket jobs. “But as the dose got higher, I felt sleepy all the time. I was always dozing off.”
Patricia would have stuck with methadone while doctors worked to fine-tune her dosing. But her insurance wouldn’t cover the cost, so after three months, she transitioned to Suboxone, an alternate medication that her insurance did cover.
These days, Patricia says, she has no shortage of energy.
“I take my granddaughter to school and pick her up, and we might get an ice cream or go to the park. I take my mother to the grocery store. I maintain my house and keep busy.”
Patricia rarely sits in that brown recliner. “One of these days,” she says, “I’m going to have a big bonfire and burn it.”
For decades, methadone was the only government-approved medication for opioid addiction. And the medication has served countless addiction patients well — far better than residential treatment programs that offer counseling but no medication.
But in recent years, patients seeking treatment for opioid use disorder (OUD) have had another option: Suboxone (buprenorphine), an approved medication that for many patients has advantages over methadone.
“Both are safe, and each has its role,” says Ken Egli, M.D., Ideal Option’s co-founder and medical director.
Some areas of the country have a shortage of methadone clinics, while other areas have few credentialed Suboxone providers. And much of the country has zero options for medication-assisted treatment. So, for patients who have access to just one of these medications, the decision is easy: you take the medication that’s available.
Studies confirm that without medication — whether methadone or buprenorphine — at least 90% of OUD patients will relapse; medication cuts relapse and overdose rates in half.
However, patients with access to both buprenorphine (Suboxone) and methadone may have good reasons — based on their employment, drug-use history, and level of family support — to select one over the other.
How Suboxone and Methadone Work on the Brain
To some extent, buprenorphine (Suboxone) and methadone work in similar fashion. There are significant differences though. While buprenorphine is a partial opioid agonist, methadone is a full opioid agonist. That means buprenorphine only partially activates opioid receptors while methadone fully activates them, just like heroin or oxycodone.
Both suppress withdrawal symptoms and opioid cravings but buprenorphine is less likely to cause dangerous side effects or euphoria. Methadone, being a full opioid agonist, is more dangerous and can cause euphoria, but it may be more suitable for heavy opioid users than buprenorphine.
Both medications are long-lasting. A single dose will occupy the opioid receptors for over 24 hours. So, taking either medication once a day will keep the brain’s opioid receptors satisfied while staving off the nausea and anxiety that drive users to seek more potent and dangerous opioids.
Chemically speaking, buprenorphine and methadone have different effects on the brain.
“Buprenorphine binds very tightly to the opioid receptors, so if you take heroin on top of it, the heroin won’t get to the receptors,” Dr. Egli explains. In other words, you won’t get high.
Methadone doesn’t bind to opioid receptors as tightly as buprenorphine does.
“You can stack other opiates on top of it, so if you take methadone and then heroin, you will get an additive effect,” says Dr. Egli. This can also cause overdoses.
With both medications, patients typically need treatment for years, maybe even a lifetime — the same way patients with depression may take antidepressants indefinitely or patients with diabetes may take insulin forever.
According to the National Institute on Drug Abuse, “These medications restore balance to the brain circuits affected by addiction, allowing the patient’s brain to heal while working toward recovery.”
But that doesn’t mean Suboxone suits everyone. Some patients with a long history of heavy opioid use feel lethargic on the medication, preferring methadone instead.
As Dr. Egli explains it: “Buprenorphine gets these patients in the zone of not craving the drugs – they feel normal. But the challenge is, they’re not used to feeling normal. Some patients will say, ‘I just don’t have the energy. Methadone gives me more energy.’”
Another difference between the two medications is that Suboxone has a lower potential for abuse and overdose.
Though Suboxone can be dangerous if taken with alcohol, sedatives, or muscle relaxers, high doses of the medication typically will not cause harm. Taking too much methadone, on the other hand, can cause respiratory depression and serious heart problems.
Each year, more than 5,000 people die of overdoses related to methadone. However, Egli points out, only a minority of these deaths result from methadone prescribed at treatment clinics.
“Methadone overdoses are primarily from methadone diverted on the street or bought illegally,” he says.
Indeed, it is not uncommon for people in the throes of opioid addiction to seek out methadone in an attempt to get high or avoid feeling sick from withdrawal.
Ideal Option patient Manasseh, 27, recalls that she’d regularly steal her grandmother’s methadone.
“My grandma was an ‘everything addict,’ and she had methadone lying around,” recalls Manasseh, who began using drugs at age 8.
Many years later, while still mired in addiction, she learned about methadone clinics. “I thought, ‘That’s a free way to get high.’ But I never went and actually did it.”
When Manasseh sought treatment for OUD, at age 25, she chose Suboxone because of her previous addiction to methadone.
Jenna, another Ideal Option patient, actually did go to methadone clinics to sustain her addiction to pills and heroin.
“At the time, I had no plans of recovery — I was just trying to get high,” recalls Jenna, a long-time IV heroin user.
Eventually, after several drug-free months in jail and with the support of her family, Jenna started on Suboxone to maintain her sobriety.
Jenna believes that without Suboxone, she’d have been more tempted to seek out her old drug-using friends when she was released from jail.
“Suboxone is like a safety net,” she says. “It helps with cravings and buys you time to htink about whether you really want to take drugs. It’s like an armor.”
The Convenience of Suboxone
Jenna checks in at Ideal Option every 28 days, to renew her prescription and meet with her provider. Like many patients, she graduated to monthly visits after initially going twice a week, then weekly, and then every two weeks.
The ability to spread out visits over time is a big reason many patients prefer Suboxone over methadone.
By law, methadone patients must come to the clinic frequently and often must be observed taking the medication. While the tight supervision is helpful for patients who don’t have family support and for those who can’t get to both a clinic and a pharmacy, the restrictions can be excessive for patients, like Jenna, who live with family and have stability in their lives.
What’s more, the privacy afforded Suboxone patients helps them avoid the stigma of going to a methadone clinic.
“Methadone has been around for so long, and people think of the classic addict — the person passing out on the street corner with a needle in their arm,” says Dr. Laursen. “That stigma is still there. With Suboxone, you can go into a regular medical office, and nobody has to know it’s an addiction medicine clinic.”
Switching from Methadone to Suboxone
Ultimately, patients need to decide for themselves which medication suits them best.
“Some people just don’t like Suboxone, and some people just don’t like methadone,” says Dr. Laursen. “I do have a number of patients who used to be really heavy users, and they like methadone better.”
Still, for most OUD patients, Dr. Laursen recommends trying Suboxone first. “If that didn’t work, I’d consider methadone, but it’s much easier to start with Suboxone and switch to methadone than the other way around.”
That’s because methadone patients must wait at least a week for the medication to leave their system before they can safely start Suboxone. That week is, to put it mildly, no fun.
Patricia, who made the switch because her insurance wouldn’t cover methadone, endured the misery from her brown recliner.
“I had a lot of methadone in me, and I was really sick,” Patricia recalls. “I had a lot of nausea, diarrhea, and sharp pains in my stomach. I prayed a lot, and I didn’t want anybody around me.”
Her 17-year-old grandson knew what she was going through and would tell her, “I love you. You can do it. You’ll get through it.”
And she did. As soon as she started on Suboxone, Patricia says, all the nausea vanished, and her energy surged. “I even started going to my grandson’s baseball games. I felt like me again.”