Buprenorphine and methadone have won significant accolades for being effective treatments for opioid use disorder, but they have key differences and concerns about the safest way to use them. When comparing buprenorphine and methadone to find out which is better for you, it is important to look at how they work and what a person’s individual needs are.
The Opioid Connection
As opioids, buprenorphine and methadone are similar in many ways, but there are distinctly different ways in how they are used and to what effect. Methadone is often prescribed for the treatment of chronic pain and opioid addiction treatment, while buprenorphine (as Suboxone) is mainly used for opioid addiction treatment. Both methadone and buprenorphine are equally habit-forming, and they can lead to a patient developing a psychological and physical dependence, culminating in an outright addiction.
As opioids, both medications trigger the opioid receptors on nerve cells in the brain and central nervous system. They are both slow-acting opioids, with long half-lives (the period it takes for a drug to stay in the body before its initial amount is processed by half. The half-life for buprenorphine is between 24 to 60 hours, and the half-life for methadone is between eight to 59 hours, which is why they are both used for opioid maintenance therapy.
Short-term opioids like heroin have much higher peaks, which is how stronger opioids become so addictive. Long-acting opioids, without the strong highs, allow for patients to gradually reduce their dependence on opioids while minimizing the stress of withdrawal.
Full vs. Partial Opioid Agonists
One key area of difference between buprenorphine and methadone is that buprenorphine is a partial opioid agonist, while methadone is a full opioid agonist. They both activate opioid receptor cells, but methadone activates them to their fullest possible degree, producing the maximum painkilling and euphoric effect. Buprenorphine, on the other hand, does not go that far. The chemical effect of buprenorphine on an opioid receptor reaches a plateau, allowing patients to discontinue their use of the opioid without having to go through withdrawal, as would be the case if they were experiencing full opioid agonist activation. Even at moderate doses, buprenorphine reaches its plateau; patients will not feel any increase in effect regardless of whether more buprenorphine is administered.
As with any opioid, there is the risk of respiratory depression with buprenorphine, but even this risk is relatively lower compared to those of full agonists. This is why buprenorphine is so useful in the treatment of opioid addiction. There is a significantly lower risk of misuse, addiction, withdrawal, and side effects compared with full agonists, but patients still experience some of the relief they have gotten accustomed to as a result of their addiction.
Patients who have no dependence on opioids may not notice any differences in how they feel on buprenorphine or methadone. However, Current Neuropharmacology explains that beyond a certain point, partial opioid agonists do not have any effect. While this is good for patients at a specific level of opioid dependence, those who have higher degrees of dependence on opioids might need the full opioid agonist effect of methadone.
Buprenorphine used to be marketed under the brand name Subutex in the form of sublingual tablets (placed under the tongue and allowed to dissolve). Today, buprenorphine is more commonly found as one of the two ingredients in Suboxone; the other is naloxone, an opioid antagonist. Opioid antagonists block opioid receptors and prevent other opioid agonists (either full or partial) from binding to those receptors. Naloxone is often used to reverse opioid overdoses, and it is combined with buprenorphine to prevent buprenorphine from being misused.
Buprenorphine can still be abused on its own. Out of desperation for opioid relief or to get high, people dissolve the film strips in water and inject the solution into their veins. Notwithstanding the belief that abusing buprenorphine is a safe alternative to using heroin or a full opioid agonist, the JAMA journal warns that it is still possible to overdose on the medication in this way.
Administration and Use
Another difference between buprenorphine and methadone is the forms by which they are administered. While buprenorphine is given as a film strip to dissolve under the tongue, methadone can come in an oral tablet, an oral solution, an injectable solution, and an oral dispersible tablet, which has to be dissolved in a liquid before it can be consumed.
Where the two medications come together is in their uses. Methadone and buprenorphine are both used to help patients get through the detoxification period for opioid abuse. The withdrawal symptoms during opioid detox are not fatal, although they can lead to medical complications that can be fatal.
They are, however, very distressing, and can be quite traumatic if a patient does not receive adequate care and support. Methadone and buprenorphine are capable of making the withdrawal symptoms more bearable and, importantly, alleviating the desperate craving for more opioids that is characteristic of the withdrawal process.
How the two medications go about doing this is another difference. With methadone, patients have to go to a certified methadone maintenance clinic, where a medical professional will supervise the person receiving each dose. This is to ensure that the consumption of methadone is legitimate and that the patient is not developing an unhealthy dependence on the methadone itself for their opioid addiction.
When the clinic doctor determines that the methadone treatment is purely legitimate, patients might be allowed to take a small supply of methadone with them, for use between clinic visits. If the doctor believes the use of the methadone at home is recreational, the supply may be limited or discontinued.
Buprenorphine treatment for opioid abuse does not require clinic visits, but the medication nonetheless has to be obtained from a doctor’s office. Patients’ early treatments with buprenorphine are closely monitored, for much the same reason as with methadone. Therapeutic as it may be, buprenorphine can be highly habit-forming, especially for a patient who has demonstrated past dependence on opioids.
If the patient can show their consumption of buprenorphine is within legitimate (medical) guidelines, they might be entrusted with a small supply for home use. Further proper use of buprenorphine could eventually allow a patient to manage their own dosage.
Side Effects and Withdrawal
Both buprenorphine and methadone have their own side effects, but those associated with buprenorphine tend to be on the milder side and are mostly physical in nature. As with most other opioids, they include the following:
- Difficulty concentrating
In extremely rare cases, buprenorphine treatment has been known to cause serious medical complications. The American Journal of Emergency Medicine noted a case where Suboxone treatment led to the development of serotonin syndrome (high body temperatures, tremors, diarrhea, and mood disruptions). However, buprenorphine causing such severe side effects is very rare.
As opioids, both methadone and buprenorphine can induce withdrawal symptoms in patients. Methadone has a higher risk of abuse than buprenorphine (hence its classification as a Schedule II Controlled Substance in the United States), and symptoms of methadone withdrawal can last for six weeks. Buprenorphine’s withdrawal symptoms can continue for longer (up to a few months), but they tend to be less intense and easier to manage than those of methadone.
Buprenorphine and Methadone: Which is Better?
Are there benefits to one medication over the other? Some research has suggested that buprenorphine may be the better alternative. In 2014, the Journal of Community Hospital Internal Medicine Perspectives noted that treatment with Suboxone (the buprenorphine/naloxone combination) was associated with a 45 percent reduction in emergency room visits among test subjects, and researchers concluded that buprenorphine was the primary agent responsible in helping the patients remain abstinent from opioid use.
In 2012, the Journal of Neurosciences in Rural Practice compared the benefits of buprenorphine to those of methadone and summarized that despite buprenorphine being “the safer agent,” methadone remains (in the words of Expert Opinion on Pharmacotherapy) “the gold standard of [opioid dependence] treatment.”
Despite concerns about the stronger addictive potential of methadone, its long history of use as an opioid maintenance therapy makes it a more popular choice than buprenorphine/Suboxone, even though the latter offers greater potential as a more stable addiction medication.