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Suboxone or Methadone – what do patients want?

Posted · 11 Comments

Victory in electionsNHS North Lanarkshire asked 90 of their patients to give their viewpoints on what they thought of Suboxone vs. methadone for opioid replacement therapy (ORT). They found that

‘in comparison to methadone, patients receiving buprenorphine–naloxone were highly positive about their treatment experiences and its advantages over methadone, including the “clear-headed response”, improved well-being and concentration, possibility of less social stigma, reduced craving, decreased side effects (especially drowsiness) and easier to withdraw from. As a result, about 57% of patients would consider buprenorphine–naloxone treatment in the near future.’

It’s interesting because the recent Cochrane Review found methadone to be superior (though not enough to say that should be the only option) and last year’s Expert Review on ORT recommended clinicians should stick with national guidelines which quote the National Institute for Clinical Excellence guidance:

If both drugs are equally suitable, methadone should be prescribed as the first choice.” (NICE, 2007a)

The consensus from prescribers and patients does seem to be that patients should have some choice in the matter, but Health Boards are facing mounting prescribing costs due to the fact that Suboxone is much more expensive than methadone. There’s also detoxification to be considered. While methadone, Lofexidine and buprenorphine all have evidence to back them as detox drugs, as the Lanarkshire patients say, buprenorphine does seem to offer the most comfortable detox for most people. In addition, there is doubt  about how easy it is to move on from methadone.

So we have a clash between what the evidence and guidance say and what patients want. Of course to get bogged down in discussions of which drug is better than the other risks missing two arguably more important questions:

  • what clinical and therapeutic set-ups around prescribing help patients move on from ORT to abstinent recovery and
  • how many treatment services and GPs are offering these to patients?

The answer to the question: what do patients want might be ‘neither’. There is evidence that what patients want is not maintenance, but abstinence.

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    11 Responses to "Suboxone or Methadone – what do patients want?"
    1. Jason wallace says:

      Sure suboxone is more expensive for the gross ingredient around £2.46 per 2mg tablet in comparison to methadone but the choice should always be there for clients if you can show me a client who has been on suboxone for 5,10,15 years I might listen to the cost argument but it doesn’t happen anyway offer both is treatment not meant to be Person centred/holistic ?

      • djmac says:

        Agreed. Clients ought to have choice: a full menu of options including Suboxone, methadone and abstinence oriented treatment. They also need to be actively introduced to other recovering people for support; something that doesn’t happen consistently.

    2. Calum Blair says:

      In Forth Valley we offer Methadone / Suboxone and Subutex to anyone at the start of their treatment , we also have had a number of people convert over from Methadone once they have got down to a minimum of 30mg ( most find the transfer over pretty easy but some have found it difficult , mostly people who have been on Methadone for a number of years , but once they have got the first week done they feel a lot better ) . Majority of people who have started or converted to Bupe much prefer it to Methadone . It is also much easier to detox off of and also a bit quicker if that is what the person wants . I only have ever had one person want to transfer back to Methadone

      • djmac says:

        Sounds flexible with regard to prescribing. What’s the retention in treatment like with buprenophine? I guess that was one of the beefs with the Cochrane review.

    3. Akavanagh says:

      Patients should always come first and the facts should always be presented so the patient can make the right choice for them. However, this needs to be changeable because some people do find certain drugs don’t suit them. Another thing to look at is cost. In the long run methadone may not be cheaper in the long fun due to the damages it causes, for example teeth decay and relapses. I have also found a lot of patients who use suboxone respond well to therapy because they have a clearer head and are less likely to relapse.

      • djmac says:

        You are right: patients must come first, but in giving them information to enable solid decisions to be made we need to be clear on what those facts are. The Cochrane review that only higher dose buprenorphine suppressed illicit opiate use and lower dose was no better than placebo. Methadone held clients in treatment better generally.

    4. Ian McNulty says:

      An interesting question, my opinion is, through experience and feed back from service users over a period of a year is as follows; ”Those who have only a small amount of time in active addiction i found generally suited Suboxone, this may be due to a lower psychological dependence and the fact Suboxone has a much less euphoric effect than opposed to Methadone. Where as those in long term addiction responded better to Methadone, again this maybe due to a higher psychological dependence on opiates (Heroin) and Methadone having a much higher euphoric affect and replacing the psychological need for illicit and chaotic heroin use with a much more controlled and structured treatment

      • djmac says:

        Interesting take on it. I know some practitioners are more reluctant to go for methadone in those with shorter histories due to the perception that it’s harder to come off of it.

    5. martin smith says:

      I’m not aware of many other drugs that were developed in the 1930s that are still highlighted as gold standard 1st line treatment in 2014. In other health areas new drugs are being developed all the time. However we are talking drug addiction, people who suffer multiple inequalities and who are, by and large, a group which society cares little for. Methadone is the cheapest form of intervention as Akav says though in the long run it may not be cost effective when you look at length of time in treatment/health conditions/unemployment etc. Whereas Suboxone, by the very nature that it’s less euphoric/clear headedness, the drug is more aspirational as opposed to methadone. Methadone has its place and can take out the chaos, but people are left on it for far too long. The legacy of the last strategy is now being acutely felt and we need new ideas and treatments to offer, we can’t stand by and watch another generation move into their 30s and 40s with illnesses that you would expect to find in people in their 60s and 70s. Suboxone isn’t the wonder drug but it does need to be offerred on a much wider scale than it currently is.

      • djmac says:

        In an ideal world we tell folk the facts about what’s on offer; medication, psychosocial interventions, recovery support and we support them to make their own choices.

    6. Michael ohalloran says:

      I think methadone was and is the wrong drug completely it’s a no brainer
      The feedback. From honest addicts
      Will
      Confirm
      This

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