Studies have shown the combination of Medication Assisted Treatment and counseling has the highest success rate for the treatment of Opioid Use Disorder. But there are a lot of choices in regards to the medication options. How does one choose?
The process of initially coming off opiates is a difficult one. Counterintuitively, studies have shown the easier a patient's withdraw the less likely they are to relapse. An uncomplicated, painless withdraw results in longer term sobriety than a difficult one. As a patient once told me, “withdraw didn’t prevent me from relapsing, it only kept me from wanting to stop the next time I relapsed.”
Stopping a drug and staying stopped are two different things. I believe, as difficult as it is, withdrawing is actually easier than long term sobriety. Life will likely be better off opioids, but there will be triggers, anniversaries, pain, and difficult times ahead. These are unavoidable parts of life. Staying off opiates is a challenge.
After prolonged exposure, the brain becomes dependent on opiates. Brain chemistry is modified and the body adapts to the presence of these substances. When they are withdrawn, the body suffers. We recommend six months to a year of medications that stimulate opioid receptors in a medically monitored setting in order to allow the body to adjust to its new way of life.
The medications used for Medication Assisted Treatment include Suboxone, Subutex, Naltrexone, and Methadone. In this article, I will discuss the two most popular medications for initial therapy: Suboxone and Methadone.
Suboxone is a partial opioid agonist and partial antagonist, it is long acting and binds with high affinity to opioid receptors. The result is partial stimulation of opioid receptors and a milder effect, often without the euphoric effect one usually experiences from opiates. The goal of therapy is to calm the cravings associated with sober life and allow the body to adjust gradually.
Methadone is a stronger agonist at the opioid receptor. It is also extremely long acting. This medication takes days to build up in a patient’s blood stream, and its full effect is not felt immediately. Methadone is often used when Suboxone is ineffective to manage cravings. Doses can be raised higher than those used with Suboxone. There is also no antagonist property to Methadone.
One can still get high on Methadone. Some unfortunate patients who cannot get their cravings under control mix illicit opiates with methadone and over time adapt the mixture of the two. This can be highly detrimental.
The partial antagonist effect of Suboxone and its high affinity for opioid receptors, on the other hand, block the high associated with illicit substances. As long as your taking it every day, Suboxone helps to prevent relapses by making additional opiates ineffective.
There is, unfortunately, the risk of precipitated withdraw with Suboxone. If a patient starts this medication too soon after their last use of other opiates, Suboxone can remove other drugs which fully stimulate receptors from their binding sites. Because Suboxone only partially stimulates these receptors, the result can be instant, severe withdraw.
The good news is that this is avoidable. For this reason and many others, Suboxone is best used under the supervision of a physician. A good Suboxone doctor can help prevent precipitated withdraw by timing the initial dose correctly and prescribing comfort medications to allow a patient to distance themselves from their last use of other opiates.
Methadone does not cause precipitated withdraw. As long as a patient is not actively intoxicated, this medication can be started right away. As mentioned above, methadone takes a few days to build up in a patient’s system, so although it can be started early full effect is not immediately experienced.
A major drawback of Methadone is it’s dosing. In most states, Methadone for Opioid Use Disorder can only be dispensed at a Opioid Treatment Facility. This means patients have to present to a facility every day to be dosed. This can be a major inconvenience. Suboxone, however, can be prescribed and picked up at a pharmacy. Suboxone, therefore, is more convenient for higher functioning patients with busy schedules.
At Hashemi Healthcare, we do not use Methadone. We provide convenient, concierge style Suboxone treatment with same-day and after-hours appointments. Patients do not have to present to our clinic daily and most established patients only speak to our physician via a telemedicine platform once a month. Most people find this highly convenient.
We would recommend trying Suboxone first. If Suboxone is ineffective, Methadone is a good next step. Treatment is not permanent and patients can stop these medications eventually, but we do recommend staying in treatment for some time to allow the body to adjust to life without illicit opiates.