Medication-Assisted Treatment for Opioid Addiction: Suboxone vs Methadone

Poppies

I have a friend (let’s call her Erin) whom I met a few months ago at a detox in Culver City, CA. A long time intravenous heroin user, Erin managed to kick the drug three years ago by adhering to a daily regimen of methadone maintenance. Like the businesswoman stopping in for her Quad Grande Americano at the local Starbucks, Erin would begin every morning with a half shot of pink, viscous, PeptoBismol-like fluid, which she got at the local clinic across the street from where she worked. The methadone, though definitely narcotic and certainly addictive, helped her regain some functionality in her job and social life. It was the lesser of two evils. One shot and she would go from the shivering, bone-aching, stomach-cramping agony of opiate withdrawal to an almost normal, homeostatic state of pain-free equilibrium. Not only did the drug allow her to hold down a job as an accountant for a prestigious firm in the entertainment business, it kept her out of the daily, wheeling-dealing, hustle of the heroin business, which as most junkies will tell you, is a lot of work. And except for the occasional nodding out, methadone is relatively invisible. Hiding it from her employers was a piece of cake. She didn’t have to worry about things like track marks, nausea, fever, and vomiting. One shot in the morning and she was good to go for the rest of the day. At least that’s how it was in the beginning.

What the doctors didn’t tell her was that methadone has a very slow metabolism. For someone built like Erin—tall, skinny, barely weighing a hundred pounds—the half-life was between 48 and 60 hours. That meant that after each morning shot, the concentration of methadone in her blood more than doubled. And there was no ceiling. If she wanted, she could have the dispensary raise her dose from 100 mg to as high as 300! All it took was a little coercing from the dispensers behind the glass window, which wasn’t very difficult, considering the methadone trade, like any other business, cares about one thing and one thing only; profits. Higher doses equal higher profits for both the dispensaries and the pharmaceutical companies that synthesize the drug. And once they have you hooked, you’re trapped for life. Its no wonder methadone is commonly referred to as “liquid handcuffs”. It keeps people locked in a constant state of despair and hopelessness. The only way out is a gradual reduction in dosage, which, for the 300 mg/day user, could take years, even decades. These days, it’s not uncommon to run into the 30 or 40-year methadone user.

Many addicts, including outspoken actor/comedian, Russell Brand, believe the copious administration of methadone is not just unethical, but borderline criminal. In an article in the Observer, Brand states: “We may as well let people carry on taking drugs if they’re going to be on methadone.” He’s got a point. Unlike heroin withdrawal, which lasts 7-14 days tops, methadone withdrawal, due to its snail-pace metabolism, can last as many as 6 to 10 weeks! That’s 10 weeks of the worst pain you can imagine; fever, chills, tremors, nausea, vomiting, diarrhea, lightheadedness, and hyperventilation. Those brave enough to try and go cold turkey might make it the first week or even two, but NO ONE, and I mean NO ONE, makes it through the full ten. According to my friend, Erin, by week 3 you’re so dope sick that you’ll do anything for a reprieve, even if it means purposely breaking a few bones by throwing yourself into oncoming traffic just so you can be prescribed pain medication. Now, that’s desperation.

Fortunately, there’s a new kid on the block in the war against opiate addiction; Suboxone. Approved by the FDA in 2002, Suboxone is composed of two main ingredients: Buprenorphine and Naloxone. Unlike the full opioid agonists (methadone, heroin, Oxycontin, and Vicodin) Buprenorphine is only a partial opioid agonist, which means it produces less of an effect when attaching to an opioid receptor in the brain. According to my friend, Erin, who’s been on Suboxone maintenance now for 8 weeks, there is no euphoric sensation, no nodding out, no numbness, no high…just a feeling of normalcy and only very mild pain relief, if any. And because it’s long acting, meaning it gets stuck in the brain’s opioid receptors for 24 hours, intake of any full opioid, like heroin, less than a day after Suboxone is administered, will not get you high. This gives the addict a 24-hour reprieve, allowing them to reconsider the wisdom of relapsing while on Suboxone maintenance.

The second ingredient, Naloxone, is an opioid antagonist, or opiate “blocker”. When Suboxone is taken correctly, by allowing it to absorb under the tongue, the Naloxone is not absorbed into the bloodstream to any significant degree. However, if the Suboxone is crushed and snorted or dissolved in water and injected, the Naloxone will travel rapidly to the brain and knock any opioids already sitting there off their receptors. This can trigger a rapid and painful withdrawal. Thus, Naloxone’s one and only purpose is to discourage addicts from trying to snort or shoot the Suboxone. And it works. Erin wouldn’t dare try to shoot the entire 2 mg filmstrip, which happens to be not much bigger than the size of a fingernail. Not only would she not get high, she’d have to go through an entire week of withdrawals. Her doctor, appropriately, only gives her enough Suboxone to make it to the next dose. To take it all at once would be a waste and a precursor for a very shitty weekend.

Originally starting on 2 mg/day strips, Erin is now down to 1/8th mg strips. Imagine trying to cut something the size of a fingernail into 8 equal pieces. It’s an exercise in precision that would make even an eye surgeon blush.

Why am I telling you all of this? Well, it’s come to my attention that several members of Erin’s AA group, including her sponsor, have taken it upon themselves to belittle her, by telling her she’s not sober until she’s completely off all drugs, including Suboxone. Needless to say, Erin was very upset. Not only did she not return to that particular meeting, she began to question whether she should continue going to AA at all.

When I heard this I was enraged. I wanted to march right down to that meeting, find those self-righteous assholes, and slap ‘em all in the face. Who did they think they were? Doctors? When did they start handing out medical degrees at AA meetings?

It took a few walks around the block, but I finally cooled off and began to realize that these comments, though insensitive and unbelievably idiotic, weren’t made out of malice, but ignorance. The offenders were, after all, alcoholics. They had little to no real world experience with opiates, or any street drug for that matter. They were simply superimposing their experience with alcohol recovery onto a methadone user, which isn’t fair.  Alcohol is a quick, 3 to 5 day spin-cycle detox with your choice of benzo’s (Valium, Xanax, Paxal, etc) or phenyl-barbiturates to quell the tremors, shaking, and potential seizures. Opiates, however, require several weeks (or months, as in the case of methadone) of carefully constructed, medication-assisted treatment. To tell a former heroin addict that she isn’t really clean unless she stops taking her Suboxone isn’t just stupid, it’s downright dangerous. What if Erin actually listened to these clowns and pitched the rest of her Suboxone? Where would she be then?

I’ll tell you where she’d be. She’d either be back in line at the methadone clinic with all the other zombies or banging on the door of her dealer’s house looking for a speedball and clean syringe. Fortunately, Erin’s got a good head on her shoulders. She wasn’t going to let a few idiotic comments from the peanut gallery destroy eight weeks of hard work. And if you don’t think it’s hard work, try going from 100 mg/day of methadone served up to you each morning on a silver platter to 1/8th of a mg per day of something you have to spend an hour cutting with a scalpel into squares no bigger than a Chicklet. And did I mention, you can’t perspire? If you do, the strip will dissolve on your fingertip before you can even get it under your tongue. Erin says she’s cut pieces so small, she didn’t even know if they got into her mouth. If that’s not a desire to stop using then I don’t know what is.

I don’t know what it says in your Big Book, but in mine it states that the only requirement of AA/NA is a desire to stop drinking/using. The old cliché that “a drug is a drug is a drug” is simply not true. All drugs are not created equal. Each drug—each addict for that matter—comes with it’s own set of unique challenges and obstacles to sobriety. The “one size fits all” program of twelve-step recovery has got to go. What’s needed is a more sophisticated, scientifically based approach to addiction recovery; one tailored to meet an individual’s needs. The fact that 100 people still die from addiction every day in the US alone tells me that something isn’t working. The system is broken. Spirituality based programs, like AA, NA, and CA are great for rallying support and building community, but they are only one small piece of a very complicated puzzle. There’s also medication, therapy, diet, exercise, friends, family, and work to name a few. Throwing your hands up in the air and expecting God to do all this work for you won’t result in any long-term sobriety. You got to roll up your sleeves and do it yourself. It’s hard work, I know, but so is the daily hustle of being a full-fledged heroin junky.

If you want to learn more about the dark side of methadone, I recommend watching Methadonia, a documentary by Michel Negroponte. But be warned, the documentary only covers one subtype of methadone users; the chronic relapsers, who can’t hold down a job and end up living on the streets begging for enough money to buy a few benzo’s that they can use as a chaser after their morning methadone dose. Most patients, like my friend Erin, can actually live somewhat productive lives while on methadone, the only problem being they are still dependent on opioids to get them through the day.

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One comment

  1. I am certainly an advocate of Suboxone. I’ve known two separate men who were able to overcome their addiction to opiates (painkillers) by the use of Suboxone. My only complaint was with the doctor who didn’t seem to fully understand the drug. He initially advised taking 6mg per day and then slowly weaning down. After one week at 6mg (which was working beautifully) he advised that the patient up it to 8mg and then slowly begin reducing by 1/2 mg per month. After researching online the patient dropped it to 4mg w/o doctor’s consent and dropped by 1mg per month. It took approx 6months before he was clean. It can be a dangerous drug when not handled properly but it can also be a great tool for sobriety. I applaud Erin for taking steps toward sobriety and may God be with her. ❤

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