NHS 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. Perhaps buprenorphine is more recovery-friendly.
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 important questions concerning recovery:
- what clinical and therapeutic set-ups around prescribing help service users, who want to, move on from ORT to abstinent recovery and
- how many treatment services and GPs are offering these to service users?
The answer to the question: what do patients want might be ‘neither’. There is evidence that what many service users want is not maintenance, but abstinence.
[A version of this blog was first published in May 2014]