What follows is an edited message from a reader in Sweden, and my response.  The original message can be found as a comment to my ‘methadone revisited’ post.  I removed a bit of the writer’s sarcasm and corrected a couple typos; as always nothing was added.

Comment:  Yes, methadone is a ‘pure’ agonist, but to claim no difference between it and morphine and other short acting agonists is really naive. The sole reason methadone is used is because of it’s different pharmacological profile. You claim that tolerance is as much an issue with methadone as with morphine/heroin, how is it then that patients stay on the same dose for decades?

Sweden uses methadone

Response:  There are several reasons that methadone is used for maintenance, not one sole reason.  First, it is easy to manufacture and so is dirt cheap.  Methadone clinics typically mark it up to $10-$15 per day, but when prescribed for pain treatment it is pennies per dose.  It does have some unique properties, and yes, those unique properties make it a good maintenance drug; for example it binds extensively to proteins and so has a long half-life when used for long-term maintenance treatment of addiction. 

Interestingly though, when used for pain treatment it has a shorter ‘effective half-life’ and generally must be given every six hours or so.  In other words the half-life of the drug changes with chronic administration.  This somewhat unique property is one reason that SOME patients can be maintained on a stable dose for long periods of time.  A short exercise will help to understand this point:  Google ‘opiate conversion calculator’ and use it to find the dose of oxycodone that is equi-potent to 40 mg of methadone.  A good conversion program will ask you to differentiate between acute and chronic methadone.  You will see that with chronic use, methadone becomes more potent by a factor of 10 or more.  I see this as the main reason for the APPEARANCE of stability of dose with methadone maintenance. 

Yes, some patients stay on the same dose for years.  But that same dose changes potency over time in ways unique to methadone, so that the patient is actually getting a constantly-increasing opiate potency at the receptor level—even as the oral dosage stays the same.   This does not occur with other agonists, and certainly does not occur with buprenorphine. 

Comment:  To claim that a methadone patient is still an active, using addict but someone on Suboxone is in recovery, that’s the biggest load of BS that I’ve seen in a long time. Sure, buprenorphine is only a partial agonist, but there’s still stimulation of opiate receptors going on. People without tolerance get just as high on buprenorphine as they do methadone, and tolerant users don’t get high with neither buprenorphine nor methadone.

Response:  People without tolerance are not the issue here, but for the record you are wrong—patients cannot get ‘just as high’ on buprenorphine as with methadone.  As an anesthesiologist I used buprenorphine for just that reason—for example, on the labor floor buprenorphine is a safer narcotic because medications given to the mother can cross the placenta and accumulate in the fetus, causing respiratory depression (and arrest) after the birth—a partial agonist like buprenorphine has a maximum effect that preserves respiration, at least as long as no other CNS depressants are present.

Similarly a patient without tolerance will not be able to kill himself using only buprenorphine, as the effect will ‘max out’.  With methadone, on the other hand, it is quite easy to OD and die, simply from taking a few too many tablets.  In fact, a teenager experimenting with methadone for the first time can die from just two or three 10 mg tablets. 

As far as whether methadone users are ‘in recovery’ or are in ‘active addiction’, that is a matter of opinion.  I see a clear difference between taking methadone, a drug that causes progressive tolerance, and buprenorphine, a drug which allows tolerance to remain static.  The ‘shift of tolerance’ is at the heart of addiction—as it shifts upward the addict is high, and as it shifts downward the addict is in withdrawal.  Buprenorphine allows tolerance to increase to a level that eliminates the high, sedation, and other drug effects, but then the tolerance becomes fixed.  And for reasons not understood, doses higher than the ‘ceiling dose’ eliminate subjective cravings. 

For people who consider being on methadone to be ‘in recovery’ I would just ask… why?  What is the difference between being on methadone and being on oxycodone, other than the dosing frequency?  I didn’t intend to take on the entire methadone system, but there are some very intrusive methadone ‘advocates’ out there—they pop into buprenorphine forums and spout opinions, using pseudo-scientific arguments and misquoting articles, causing nothing but confusion and ill will.  I suggest they get a blog of their own—maybe then they would feel less need to flame others.

Comment:  Having been on both substances myself, I can testify that the only difference I find between the two is that methadone has (for me) the ability to take away my cravings completely whereas buprenorphine didn’t quite do so.

Response:  Medication is only part of any recovery program.  In my opinion 16 mg of buprenorphine suppresses cravings sufficiently to allow any patient to remain clean.  Until a few years ago every single opiate addict in recovery (and not on methadone) was doing it without the help of a medication.  The real situation is that a person who uses from ‘cravings while on Suboxone’ is not ready to quit, and (sorry) in my opinion is looking for an excuse to use. 

Nothing is perfect in life—people with opiate addiction must realize they have a fatal illness, for Pete’s sake!!  Cancer patients have to put up with the pain of surgery, severe nausea, hair loss, severe fatigue…  if an addict whines over a few ‘cravings’, I suggest they get real and take a good look at where they are at in life, and start being grateful for being alive. 

In my prison work I frequently come across patients who are intent on fine-tuning their subjective experience using every med they can get.  They think that medication should make them happy, relaxed, content, and filled with self esteem… but in reality medication will do none of those things.  Their expectations are completely out of line.  I get the same impression from patients who always need a bit more of this or that for cravings.  The whole process of that type of ‘treatment’—the focus on symptoms, the need to medicate one’s self, the self-centered demand to feel perfect–  is more consistent with addiction than with recovery!

Comment:  I got annoyed when you’ve written stuff that is twisting the truth, if not lying, about the treatment that has quite literally saved my life. And calling methadone patients active, using addicts (also something many many doctors would disagree with you on).

Response:  There are the ‘many doctors’ again… but seriously, if it works for you, that’s great.

Comment:  Why can’t you accept that our treatments are very similar to each other? I know that you in the US can perceive them to be oh so different, since one can be prescribed in an office-setting and the other can’t. I can see that it can lead to a them-and-us-thing, where suboxone can appear “better” or “more refined” or “less dirty” or whatever.

Response:  The treatments have similarities and differences.  I don’t think one is ‘less dirty’ or ‘more refined’.  But the molecular actions of the drugs differ from each other, and so the subjective effects differ.  Sorry—that is just a fact.

Comment:  I live in Sweden and here we don’t have ‘clinics’ per se, here both buprenorphine and methadone is prescribed in the hospital, and we have to go there to get our meds daily, for the first 6 months and then we get take homes at certain intervals (if we’re clean that is).

Response:  That stinks. You are missing out on one of the biggest advantages of Suboxone. 

Comment:  Here buprenorphine and methadone alike is looked upon with judgment by many many people, since the treatments are so misunderstood. Here buprenorphine (and methadone) patients are called addicts by people who don’t know better.

Response:  They ARE addicts– myself included– And will always be addicts.  Opiate addiction is not ‘curable’—it can only be managed.  I am an addict.  But I am not ashamed of that—although I am ashamed of some of my actions during active addiction.  It bothers me that the whole concept of ‘recovery’ is absent from methadone programs.  A methadone ‘advocate’ made silly remarks a few days ago that showed a complete absence of knowledge of 12 step groups— something that has been an incredible movement throughout the entire world, for almost 100 years! 

Comment:   You seem to have a little of the mentality that if I can do it, so can you. And I find that a bit strange since then you could easily have become sober without medication at all, since other people have been able to do so. Do you see what I mean? I’m just saying that while suboxone works for a lot of people, it doesn’t work for all, and it’s just naive to think so.

Response:  You know what?  A common thing said at NA meetings is that ‘if I can do it, so can you’.   Yes, I do have ‘that mentality’ as you put it… and I don’t get your objection to that mentality.  I don’t understand the rest of that paragraph either—I think we come from totally different perspectives.  I believe that EVERYBODY is capable of getting clean without the use of medication.  Unfortunately, many addicts will not choose to give up their addictions until they have lost everything.  I had to lose a career and a great deal of money before I ‘got it’.  I didn’t ‘get it’ with Suboxone; I went away to residential treatment for over three months.  I didn’t want to do that, but my back was against the wall and finally there was no other place to hide. 

Suboxone was not available at that time—at least not in my area, and I had never heard of it (this was in 2001).  I had the ‘typical miracle’ of AA, NA, etc… I realized I was powerless, and the urge to use went away.  It really is that simple.  Unfortunately, addicts will not usually recognize their powerlessness until they have lost everything—buprenorphine allows people to find some peace without having to go that far. 

The issue isn’t over who is ‘better’; the issue is whether the recovery will last, and whether the person ends up having a rewarding life.  Opiate addiction is a horrible, fatal illness—I have lost friends and patients to it and so the bottom line is that any way that a person keeps clean is OK with me.  And so I usually present the options to the patient and let him/her decide which path they will take. 

Yes I have opinions about methadone—just as others have opinions about Suboxone.  From my perspective, it seems that there are ‘methadone people’ who can’t tolerate the opinions of others.  And I wonder… is that a ‘recovery’ issue?  Part of recovery is learning to accept things we cannot change… like the opinions held by others.  Part of recovery is acceptance—the idea of ‘living life on life’s terms’— including the fact that people are going to disagree on some issues.  And part of recovery is learning to know one’s self, and to know that one is OK regardless of how other people think… like not getting all flustered if some stranger in another state– who doesn’t even know the person– holds the opinion that his choice of medication isn’t the best.  These parts of recovery are what make many people grateful for being an addict.  If things are as I suspect, and methadone maintenance patients are not taught how to find these things… that would be a shame.


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