I have experience with buprenorphine/Naloxone (Suboxone). It is well tolerated by patients, safe because of its ceiling effect and secondary effects are milder than those of methadone. Naloxone avoids intravenous administration, but has no effect orally. I consider Suboxone a good option for opioid dependent patients with some degree of stability. In my view, Methadone is a good option for patients with which harm reduction is the main therapeutic objective.

I use both methadone and buprenorphine to treat opioid dependance and both work well for different groups of patients. If you are in the US, patients can only get methadone in Opioid Treatment Centers, in contrast to buprenorphine which can be prescribed by community physicians. Some considerations in choosing the right medicine:

A partial agonist, bupe is not as "strong" as methadone. Patients who are very opioid tolerant (using >8 bags heroin daily approx) will not have their withdrawal relived by bupe.

Buprenorphine is much more expensive than methadone. I discuss this with patients who are without stable health insurance. If they lose it, more will be able to pay for meth than bupe.

For patients who are new to treatment or actively using drugs, simply having the bupe tablets (or films) is too tempting and they end up selling most of it to fund illicit drug use.

Methadone programs (should) provide other services which can be helpful to patients with opioid dependance and the many other problems which frequently accompany it. At a minimum there should be some counseling and social work services, I am thrilled to work in a clinic which also provides primary medical care, HIV care, eval and treatment of HCV, vocational services, GED classes and a weekly creative writing group!

Excellent responses above.

However I must point out that the naloxone content in Suboxone is clinically irrelevant.

Despite Reckitt-Benckiser marketing Suboxone as having less abuse potential than Subutex (or generic buprenorphine products) buprenorphine out-competes naloxone. There is simply not enough naloxone in each Suboxone film or wafer to block the bupe.

Some people who inject Subutex report slightly blunted onset and reduced effect when switched to Suboxone, but the majority report that the only difference is the lemon taste you get in your mouth after injecting the latter product.

If someone is dependent on heroin, oxycodone or other opioids and they inject Suboxone the naloxone will precipitate withdrawal. The antagonist effect of the naloxone will last 30 to 90 minutes. However in this scenario, the buprenorphine would also precipitate withdrawals, and the antagonism would last considerably longer- 24 to 48 hours or so.

Subutex (or generic buprenorphine) is just as effective at deterring in injecting use in this population as Suboxone.

If someone only injects opioids occasionally, has been withdrawing from dependent use of other opioids for a few days, or only injects buprenorphine, then the naloxone has no significant effect at all.

In the state where I live there is a very enthusiastic Doctor who almost exclusively uses naltrexone implants to treat opiate dependence. I see a disproportionate number of people who misuse Suboxone intravenously, because they have received a naltrexone implant, and bupe is the only opioid that will over ride the blockade.

I believe it is reasonable to suggest that RB produced Suboxone for political reasons, and to maintain market-share, not because there was any strong evidence of it being safer or more effective than a plain buprenorphine product.

PLEASE NOTE This is not an argument against using Suboxone or any other buprenorphine product in detoxification or maintenance treatment. Like methadone, the vast majority of people prescribed buprenorphine do not misuse it. Buprenorphine is safe, well-tolerated, and very effective. The ceiling effect makes overdose much less likely, and most patients report less unwanted side effects from bupe than from methadone.

Regards,

Paul.

Both the Cochrane reviews on the subject and personal prescribing experience for these two agents (both available as office based therapies in Australia) finds that methadone is a little more effective at stabilising the chaotic patient. However both are very dose dependent and require accurate counselling to identify and treat side effects and manage the lifestyle impact of supervised dosing. Some pharmacists in Australia have refused new patients of burp endorphins / Suboxone because there is a least anecdotal evidence of instability and frequent program interruptions compared with methadone. The black market in diverted Suboxone tabs remains important despite the addition of Naloxone.

I agree with Paul Dessauer above, and in my practice use only pure buprenorphine.

There are reports of increased endovenous use of sublingual tablets in the transition from pure buprenorphine to the association buprenorphine-naloxone, and some suggestions of increased mortality. Plus, there is no real barrier to the intravenous use of the association in a naturalistic environment.