What's the Difference Between Suboxone and Methadone?

If you're ready to kick heroin or another opiate habit and you want to go the harm reduction route, what should you choose?

Know the difference.

Harm reduction is all the rage these days—especially where I come from. For almost a decade, I lived in and around Ithaca, the upstate New York town that’s made national news for wanting to create a safe injection site. Like countless other communities, Ithaca has been rocked by the ongoing heroin epidemic—and there, it’s sparked an increased interest in harm reduction solutions.

But, as this discussion rages on locally—and nationally—I’m finding that there are some questions I’m asked an awful lot. Right now, the most common is: What’s the difference between suboxone and methadone? They’re both important pieces in the harm reduction toolkit, but there are a lot of misconceptions about both drugs. So here’s a shot at breaking down some of the basics.

Suboxone

What Is It?

Suboxone has been an FDA-approved treatment for opioid addiction since the early 2000s. It contains buprenorphine—a partial opioid agonist that helps fight the symptoms of withdrawal—and naloxone, the drug used to reverse opioid overdoses. Buprenorphine acts as a sort of semi-opioid: it attaches to the opioid receptors of the brain, thereby reducing craving and withdrawal, but it does not attach perfectly which means it does not provide the euphoria or respiratory depression of a full opioid. It also prevents other opioids from attaching to those receptors so getting high is impossible. Naloxone is included in suboxone in order to prevent abuse by injection. The idea is that when suboxone is injected, the naloxone becomes active and causes the user to enter into immediate precipitated withdrawal. This effect, however, is not always reported anecdotally. When suboxone is used sublingually, the naloxone remains inert.

What Does It Look Like?

For its first decade on the market, suboxone was primarily found in the form of orange, cloyingly sweet octagonal pills which you let dissolve in your mouth. Now, it’s typically found in the form of water-soluble strips.

How Is It Used?

When it’s legally prescribed for opioid addiction treatment, suboxone is typically used in one of two ways: short-term detox or maintenance treatment. Short-term suboxone use means taking it for up to about two weeks and then stopping. During the time you’re on suboxone, you don’t feel the heroin detox—and by the time you go off the suboxone, the heroin detox is over. It’s not completely painless, but for me it was pretty darn close.

When it’s used for long-term maintenance, the goal is relapse prevention. The basic idea is that if you’re using something else instead—something legal and regulated that avoids the highs and lows of heroin—you can lead a productive life in a way that you probably couldn’t on heroin.

Another common way suboxone is used—but one that is definitely not doctor-approved—is for “bridging the gap.” That is, if a heroin addict knows they’ll be without their drug of choice for a few days, they might fall back on suboxone to avoid full-blown withdrawal.

What Are The Advantages?

The most obvious advantage is that it takes away dope sickness. For me, that meant that instead of spending my first couple weeks of sobriety trying to figure out how to get more drugs to feel less miserable, I could spend some time thinking about whether or not I really wanted drugs in my life anymore.

For maintenance users, one of the big advantages is that it makes it so hard to get high and, for some people, significantly diminishes the urge to get high. Suboxone users who decide to go shoot up heroin anyway won’t really feel the full force of the high because the drug will block it.

That fact can be really important when it comes to relapse prevention.

Also, for some people, suboxone maintenance can help regulate the mood swings of early sobriety. “I would uncontrollably weep over the dumbest thing. My response to things is way off. I get super-angry over the dumbest thing or laugh uncontrollably and suboxone helped me fix my head,” a former heroin user who asked to be identified as DJ told The Fix.

What Are the Disadvantages?

It’s addictive. That’s a huge disadvantage. If it’s used for short-term detox, that’s not long enough to get addicted so it doesn’t matter. But, if you’re taking it for long-term maintenance, you will eventually become addicted to it and if you ever decide to go off, you will have to taper down and detox. According to some anecdotal reports, the withdrawal off of suboxone can be worse than withdrawal from a full agonist such as heroin. With a sensible taper schedule, however, withdrawal symptoms are reduced.

Suboxone can be hard to get because most doctors don’t prescribe it. It requires additional qualifications to prescribe and there’s a federally mandated limit on the number of patients each suboxone prescriber can have.

Also, it can be abused. In my experience, it’s pretty much impossible to get high on suboxone if you currently have any sort of opioid habit. But, if you’re a couple months sober—and not taking suboxone, methadone, or other opioids—it is entirely possible to get high on suboxone.

Finally, suboxone can cause a hellish precipitated withdrawal if you take it while you are dependent on other opioids. For this reason, patients must already be experiencing symptoms of withdrawal before starting the drug. Doctors will frequently judge their patients' withdrawal symptoms based on the COWS rating system and create a supervised induction period in which to introduce suboxone.

Methadone

What Is It?

Methadone has a much longer history than suboxone. It’s been used for treating opioid addiction since at least the 1960s, though it was developed a few decades earlier in Germany. It is a synthetic opioid and, unlike suboxone, does not contain naloxone or any other opioid antagonist.

What Does It Look Like?

Methadone typically comes in pill or liquid form. The pills are usually white and either circular or rectangular, depending on the maker.

How Is It Used?

Like suboxone, methadone can be used for short-term detox, maintenance, and bridging the gap.

What Are The Advantages?

Methadone eases the detox process when used in the short-term—and it’s okay to take it earlier in the detox process than suboxone. As mentioned above, if you take suboxone while there’s still a decent amount of opioids in your system, you’ll immediately go into major withdrawal. So with suboxone it’s necessary to wait—sometimes until withdrawal is already setting in—before taking any. But with methadone that’s not necessary.

As with suboxone, it provides a regulated alternative that avoids some of the legal and health risks associated with illicit drug use.

What Are The Disadvantages?

Like suboxone, methadone is addictive. For short-term use that’s not a problem, but for maintenance users there’s a long taper-down process.

Since methadone is a full opioid agonist, it’s easier to abuse. It does not have the partial agonist properties of buprenorphine so if you already have a habit, you’ll still get a bit of a high from taking methadone. It also does not prevent other opioids from affecting you. Since you can use other opioids while on methadone and still feel their effect, overdose is more likely.

Also, some people have unpleasant side effects. DJ, who took methadone for about five years—before suboxone was on the market—said the side effects were almost intolerable.

“When I first started methadone it was just like being without dope—I was incoherent, I was crying all the time. My bones got brittle, my teeth started rotting, I gained weight,” he said. “To me, it feels like the treatment of heroin with methadone is like treating someone with an addiction to a 12-pack of beer with Everclear—but some people thrive on it.” For some people, he added, suboxone can have unpleasant side effects, too.

Finally, the process of getting methadone can be hugely inconvenient. When it’s used for maintenance—as opposed to treating chronic pain—methadone is given out at clinics. Instead of getting a month's prescription and coming back for a refill, methadone maintenance typically requires going to the clinic every day to pick up that day’s dose. In some cases, with enough clean time it’s possible to get take-home doses to avoid a few trips, but it still requires regular clinic visits.