Pros And Cons Of Various Treatments
Helping You Stay Informed
Here at De Novo, located in Salt Lake City, UT, we want to ensure that you get the type of treatment that is right for you, even if it means referring you elsewhere. Methadone has been used as a maintenance treatment for over forty years to assist individuals in ceasing harmful and illegal opioid (narcotic) drug use. Suboxone (buprenorphine) has been approved for use in the United States since 2002 for this same purpose. During this time, both addiction medications have been found to much safer than the ongoing use of illicit opioids/narcotics. However, no medication treatments are entirely risk free. Prior to beginning either of these treatments it is important that you are fully informed of the potential benefits and risks of these treatments, of available alternatives and of the risks of these alternatives.
Note On Terminology
Throughout this document, the term “Suboxone” will be used. Suboxone is a combination of buprenorphine – the active therapeutic ingredient – and naloxone, which will block the effect of the buprenorphine and other opioids, causing immediate withdrawals. When administered in the clinic, generic buprenorphine may occasionally be substituted for Suboxone to reduce patient cost. For the purposes of this informed consent, Suboxone will also be considered to refer to buprenorphine as the benefits and risks are exactly the same for both. Opioids is a term that refers to naturally occurring opiates/narcotics as well as manufactured opiates narcotics.
Potential Benefits of Treatment
Both Methadone and Suboxone can completely eliminate opioid withdrawal symptoms that occur when an individual attempts to stop his use of opioids, including pain killers and heroin. Suboxone is a partial agonist, meaning it may have a ceiling effect, so some individuals with heavy use histories may not find complete relief with Suboxone. Methadone is a full agonist, meaning it has no such ceiling effect and can be increased to a point where withdrawals and cravings will cease. It is relatively simple to transfer from Suboxone to Methadone. It is more difficult to transfer from Methadone to Suboxone – patients must decrease to a low dose of methadone prior to doing so. Both may also block the effects of other opioid use.
Absent cravings and withdrawal symptoms individuals are then able to focus and better benefit from counseling and efforts to repair and rebuild relationships and other aspects of their lives, including pursuing meaningful and gainful employment.
Both medications are legal. This means that you can stop looking over your shoulder while using them. No one can arrest you for using these medications, so long as you are using them and storing them as prescribed.
Both medications are cheaper than illicit drug use, particularly when health, employment and legal consequences are factored in. Methadone is available in generic form for all uses and therefore tends to be a less expensive treatment. This may factor in to your decision about which treatment to choose.
These Medications Will Not:
- Improve your relationships, increase your coping skills, help you get a job. For this, we provide counseling. Research clearly indicates that counseling is critical to help you achieve most of our treatment goals.
- “Cure” you of your addiction. These are maintenance medications. You will continue to have a physical dependence on opioids, including Methadone or Suboxone. Research indicates that Suboxone may be a little easier to withdraw from. If the time comes that you want to withdraw, we will gradually withdraw you from the medication and support you to the best of our ability with counseling and other medications as may be needed to help with any symptoms. Methadone or Suboxone aren’t more difficult to stop using than other opioids, but we can’t guarantee that they will be any easier.
- Provide a quick solution to your problems. Suboxone can be increased to a full therapeutic dose within three days. Methadone may take up to a couple months to get to the point where there are no cravings or withdrawals. However, improvement will be seen day to day. Research indicates that to really achieve full benefit from these medications you should plan on being on them for one to three years. Some individuals find they don’t feel they can function without these and will probably be on them for life – again, it is their initial use of opioids that created this condition, not the medications.
These Medications Can Be Dangerous When:
- You don’t take them exactly as prescribed. They can be very dangerous if you give them to friends who don’t know how they should be taken or used.
- Taken with alcohol, other drugs, or medications. This is particularly true of benzodiazepine use. If you absolutely need benzodiazepines to function because of an anxiety disorder we can safely prescribe methadone or Suboxone if you sign a release that allows us to fully coordinate care with your prescribing physician or if we do the prescribing, but you must then take both medications exactly as prescribed. We can’t provide a full list of all the other medication/drug interactions that might be dangerous when used with methadone or Suboxone, so it is vital for your safety that you provide us with a complete list of medications/drugs you are taking and that you immediately update us of any changes before the changes take effect. Given that it is a partial agonist, Suboxone may be somewhat safer with some of these other medications.
- If you have a family or personal history of heart problems or of fainting you may be at risk for something called a prolonged QT syndrome. This may also occur if you are at high doses of methadone for prolonged periods of time. A prolonged QT interval is an increased time in between the contraction and relaxation of the ventricles of your heart. The good news is that we have developed ways to safeguard your safety with this issue. At intake we will conduct a full physical and medical history. It is vital that you give us honest answers. If it appears that you may be at risk for a prolonged QT interval at intake we will provide you with a free EKG. If you have a prolonged QT interval Suboxone may be a better choice. If you get to a 120 mg. dose of methadone we will also do an EKG, which we will repeat every six months. The good news is that a prolonged QT interval, if it has been caused by the methadone, can be reversed by lowering your methadone dose. However, you do need to be aware of this risk. At its worst a prolonged QT interval may cause a cardiac arrhythmia and death.
Other Drawbacks Of Methadone And Suboxone:
Discrimination – There is still a fair amount of stigma attached to maintenance treatment. This appears to be somewhat less for prescribed Suboxone than for methadone. It is illegal for anyone to discriminate on the basis of your receiving either of these treatments and we will help you defend against any such discrimination, including making referrals to government agencies and attorneys. However, this may not stop employers and others from trying to discriminate against you if they find out you are in treatment.
Cost – As mentioned above, the cost of methadone or Suboxone treatment is much less than many other treatments and is certainly less than the cost of buying drugs on the street. However, given that this is a maintenance treatment of at least one to three years the cost will accrue to a significant amount over time. We will do everything we can to keep costs low, but this is something to consider.
There are a number of alternatives to our methadone or Suboxone maintenance treatments which you should consider in making your decision. In addition, we would note that these can also be used in conjunction with our maintenance treatment.
Self Help Groups
The most well known of these are 12 step based groups. Other self help groups such as SMART and SOS focus on helping changing ways of thinking and seeing the world without the spiritual aspects. The potential benefits of self help groups are that millions of addicted individuals say they have been able to quit using through self help groups alone. They are free. Most are comprised of individuals who have been addicted themselves who may have helpful insights. The potential drawback of self help groups is that their methods have never been tested to prove they are helpful. More worrisome is that there is no quality control over any self help groups. Some are truly committed to help individuals recovery from addictions while others may foster viewpoints or beliefs that can be detrimental to recovery. Finally, self help groups may provide moral support and some suggestions for coping with withdrawal symptoms and cravings but they won’t eliminate these.
Other Outpatient Treatments
These may involve once a week counseling or therapy sessions, which we also provide. Intensive Outpatient Programs (IOP) generally provide groups three times a week for 2-3 hours at a time. They may also involve some individual counseling or therapy. Partial Hospitalization programs (PHP) meet 5-7 times a week for 3-4 hours at a time with a combination of different types of educational and counseling groups. They may also offer some individual therapy. The benefit of these are that they are generally more short term and therefore may be less expensive long-term. IOP and PHP also provide more intensive counseling over this shorter period of time, which may be helpful. Drawbacks are that these are generally time limited and recent research suggest that longer term treatment may be inherently better, given that addiction is a chronic, long term condition. Again, they will offer skills and support for coping with withdrawals and cravings. They may also prescribe some medications to deal with the symptoms of withdrawal but they can’t eliminate these.
These provide a place to live and 24 hour structure and support with day long therapeutic groups and activities with some individual therapy. These are helpful when you are living in an environment where you simply can’t avoid offers to use and where triggers to relapse are present everywhere. They are also helpful if you are battling several addictions and mental health issues at once. We can again provide our treatment in conjunction with a cooperative residential IOP or PHP. The drawback of a PHP is that it is time limited, though it is often followed by an IOP, PHP, or regular outpatient program. As with other programs, it can’t eliminate cravings and withdrawals, though they can keep you from using drugs long enough to get you through the worst of withdrawals.
Some detox programs are outpatient but most are inpatient. They can prescribe medications, including Suboxone, that will soften the withdrawal symptoms. They are often followed by the other levels of care. This is important as they typically don’t provide a great deal of therapy. Drawbacks are that they don’t address the long term cravings.
Rapid Detox And Ibogaine
Ibogaine is not a legal treatment in the United States and has not been supported by solid clinical trials. Rapid detox has been discredited by research, so we don’t consider either of these to be viable alternatives to our treatment.
Many individuals have been able to quit on their own, with no treatment. However, if there are underlying personal or relationship issues or physical/biological issues that keep triggering relapse there is a very real risk that you won’t achieve recovery, defined as achieving your optimal potential.
Informed Consent For Women Of Childbearing Age
Issues To Consider If You May Become Pregnant:
- If you are taking methadone throughout your pregnancy your baby will be born dependent on methadone. Your pediatrician will be able to safely withdraw your infant from the methadone. Breast feeding, which will provide very small amounts of methadone to your baby may help with this.
- Forty years of experience with methadone and nine years of experience with Suboxone haven’t turned up any evidence of long term harm to infants or fetuses. However, because it is not ethical to conduct medical trials on pregnant women, neither medication has been certified safe for pregnant women.
- Research has clearly demonstrated that by far the most harm comes to fetuses from the impurities that are often combined with street drugs and the cycle of highs and withdrawals that mothers go through when they are using regular opioids. Accordingly, there is unanimous agreement among medical professionals that women who may use during pregnancy should be on methadone, though buprenorphine is a possibility as well.
- If you are on methadone while you are pregnant you should not attempt to withdraw from the treatment during your pregnancy – this is particularly true for your first and third trimesters.
- We are committed to safely treating you and will not offer Suboxone or methadone treatment if we believe it will be harmful, given your current circumstances. However, it is important that you consider all of these factors and make your own informed decision as to whether you believe either Suboxone or methadone will be a helpful treatment for you and whether you believe that the benefits outweigh the risks.
Ask Us Anything
Feel free to use the form below if you have any additional questions that you would like to have answered. The staff at De Novo would be happy to clarify or to provide more information about drug maintenance treatments and addiction medication. You are also welcome to contact us directly to learn more about our drug therapy modalities.