Where I live, for example, the one methadone clinic often has a waiting list and it takes 1-2 years to get in the clinic!

Sometimes a person can’t make it to a methadone clinic for daily dosing, so the option is closed to them.

Sometimes an opiate dependent person has mental health issues or other life issues that make it unrealistic for them to comply with the rigid rules, structure and rigorous demands of most methadone clinics.

Sometimes a person rules out methadone treatment because of misinformation, or they can’t get past the stigma.

Although I agree with everything you said in your comment, I often see situations where people end up in one treatment instead of the other for a variety of reasons.

Ideally, both medications would be available in a range of settings so that both the medication and the delivery structure would match the needs of the patient!

Patients who need in excess of 60mgs of methadone to stabilize are unlikely to do well on buprenorphine, due to it’s ceiling effect. And, the usual dose of methadone required by most clinic patients is 80-120mgs. Therefore, methadone is targeted at the patient with a more severe opiate addiction, i.e., someone with a longstanding history or very heavy use pattern of either heroin or Rx opiates. Bupe, on the other hand, is targeted at those with a lighter use history–for example, someone who was using 10-20 vicodin a day for 6 months. This would be the main consideration in choosing between the two treatments, because obviously, the advantages of bupe are many (less “red tape”, the ability to Rx a month’s worth at a time right away, getting your treatment from a regular doctor’s office, and so on) and would be wanted by ALL patients. However, bupe is simply unlikely to work well for those with serious, heavy or long term habits.

Good questions. In general, I would not recommend methadone over buprenorphine (Suboxone) or buprenorphine over methadone. We are lucky to have both options.

This is something I will explore in future posts because it’s hard to answer fully in a comment. Some of the factors to consider in choosing between the two options:

1. Which does the client/patient prefer, and why?

2. Is this an informed decision so that the choice is an informed choice based on complete and accurate information (lots of methadone myths out there in particular)?

3. Is the client able to be successful in an office-based treatment setting, or do they need a clinic setting (can they successfully hold their own medication from day one and take it as directed)?

4. Has the client tried medication-assisted treatment in the past and what happened?

5. Are both options available and accessible?

6. How long has the person been opiate dependent, and what is their treatment history?

7. Which does the client prefer (that one bares repeating!)?

Federal law requires that methadone be used to treat opiate dependence only in clinic settings (it can be used to treat pain in office-based settings). Federal law permits buprenorphine to be used to treat opiate dependence in office-based settings.

The two are treated differently for a few reasons:

1. Historical/political reasons

2. Methadone presents a high overdose risk and buprenorphine a low overdose risk to the public if it is diverted (lost, stolen, sold)

3. Methadone is more subject to abuse if it is diverted

Thanks for the questions!