Buprenorphine with naloxone (also known as Suboxone) and methadone are two of the most widely used medications prescribed as opioid agonist therapy (OAT) to treat opioid use disorders in Canada. The aim of OAT is to replace the use of unregulated opioids with a safe and legal therapeutic medication that can prevent opioid cravings and withdrawal symptoms. This can in turn reduce the risk of overdose and other potential harms of opioid use disorder but it is not meant for everyone. In addition to these treatments, we also need greater access to safe supply, which is defined as a legal and regulated supply of drugs with mind/body altering properties that traditionally have only been accessible through the illegal drug market. Safe supply medications include opioids such as injectable hydromorphone and diaceltymorphine, slow release oral morphine, as well as oral instant release and slow release hydromorphone.
I know how life-changing OAT can be. I have personally been on methadone, buprenorphine, and hydromorphone, but I experienced lots of difficulties maintaining any kind of abstinence from other drugs while taking these medications. It was almost like being on medication psychologically woke up a strong craving in me to continue using either stimulants, benzodiazepines, or more opioids. Craving is characterized as a strong urge to consume a substance, which is a central component of addiction. For me, being on OAT was like that feeling after you drink a beer: you want another one. That’s the way these medications made me feel, but nonetheless they saved my life multiple times.
What’s the difference between methadone and buprenorphine with naloxone?
Methadone is a full opioid agonist which means it has similar effects as other opioids such as heroin and fentanyl. A full opioid agonist means the drug fully binds to the opioid receptors, reducing opioid cravings and withdrawal symptoms. Methadone can be prescribed in various forms such as a liquid or a tablet and has different formulations such as Metadol-D and Methadose. The most regularly prescribed type of methadone is liquid, whereas tablets are mainly prescribed for people with chronic pain.
Buprenorphine with naloxone is a partial opioid agonist. Partial opioid agonists activate the opioid receptors in the brain, but to a much lesser degree than a full agonist. That means they are not as strong as full opioid agonists and don’t produce the same euphoric feelings as drugs like heroin and fentanyl. Buprenorphine with naloxone does reduce uncomfortable withdrawal symptoms for most people, but it doesn’t work fully for everyone.
The way that these medications are delivered is vastly different. Methadone is typically prescribed under strict supervision, whereas buprenorphine with naloxone is typically deemed safer so providers feel more comfortable prescribing it for take-home doses. These are the standard models of care for each but are subject to change according to provincial and national guidelines.
How effective are these medications at reducing cravings?
There is literature examining the effects that these drugs have in treating opioid use disorder, but as we know, opioids are very strong and become addictive to people who injest them for a long period of time. Opioids also lead to physical dependence – when people stop using they experience withdrawal symptoms such as insomnia, hot-and-cold spells, sweats, vomiting, runny nose and diarrhea. The current opioid supply is made up of extremely strong opioids such as fentanyl and carfentanil, which are potent, yet short-acting. The consequence of using these strong but short-acting opioids is a powerful urge and desire to continue to use more opioids, regardless of being on medication for opioid use disorder. This is the phenomenon of craving.
A randomized control trial called OPTIMA was conducted to measure the effectiveness of two different OAT delivery models. Study participants were randomized to receive either the regular methadone standard of care under supervised consumption or buprenorphine with naloxone, allowing more flexible take-home options. A secondary measure of the study looked at how successful each medication was at reducing cravings in the context of the delivery model. OPTIMA collected data from people in four Canadian provinces (British Columbia, Alberta, Ontario and Quebec) between 2017 and 2020. Participants were followed for 24 weeks.
In October 2022, OPTIMA published findings on the effectiveness of these OAT medications and delivery models on reducing cravings. The study looked at various different measures related to craving, including their intensity, frequency, and length. The study found that buprenorphine with naloxone reduced opioid craving more than methadone, especially in the first couple weeks of the trial. This finding is in contrast with previous literature which found that methadone was superior or equivalent to buprenorphine with naloxone at reducing cravings.
The researchers noted several different reasons why buprenorphine with naloxone may have been more effective in reducing cravings:
- People can be “titrated” onto buprenorphine with naloxone much quicker than methadone. This means that they can find a dose that best meets their needs sooner than with methadone. By rapidly starting someone on buprenorphine with naloxone, it allows cravings to be controlled more easily.
- Buprenorphine with naloxone was consumed orally as a tablet and take-home doses became possible as early as two weeks after treatment initiation. This reduces the stigma, stress, shame, anxiety, and hassle that come with the supervised consumption of liquid substances like methadone, which could lead to a reduction in cravings.
- Buprenorphine with naloxone is a partial opioid agonist, which makes it harder to feel the effects of other opioids taken in addition to OAT treatment, so people may be less likely to have a strong urge to use opioids.
Learning from the experiences of people who use drugs is critical
It’s imperative to challenge the norms surrounding the strict and regulated delivery of these medications. Moreover, patient-centred approaches to OAT can reduce hepatitis C transmission. By examining the effects of how OAT is delivered, we can change the way healthcare for people who use drugs is designed and delivered. This challenges the system and provides a more person-centred approach. We need to create safer and more effective models of care for people who use drugs, rather than force people to participate in patronizing healthcare practices, such as the supervised consumption of OAT medication, daily appointments with healthcare professionals, and witnessed urine drug screen tests.
Ongoing research should look at the implications of different OAT medications on cravings and stress, as well as their overall effectiveness. The OPTIMA study offers one good example of how quantitative data can be pulled from a national trial to explore the different impacts of methadone and buprenorphine with naloxone on cravings.
People on OAT need to be involved in the research about the medications they take and the way their therapy is delivered. Examining data sets through a research lens is critical, but unless it’s backed up by real-life experiences, it’s sure to miss important elements that only people who use drugs can identify. It’s crucial to have people with lived/living expertise involved in research projects that directly impact their lives. We need to advocate within academic bodies to include people with lived/living expertise in every aspect of the research process. This is extremely important for producing effective, evidence-based research that meets the needs of people who are using OAT or could benefit from it.
OAT is just one tool used to combat the overdose crisis from a therapeutic approach. It must be understood that we are in this apocalyptic nightmare because policy-makers thought OAT was enough and if people didn’t succeed on OAT, then that was simply too bad for them. OAT should not be the first-line approach, it should be offered once patients actually want to give it a chance.
Anyone who uses drugs and wants to access patient-centred safe supply programs should be offered that option in addition to other harm reduction services. If they want to transition to OAT and only if the decision to transition is truly their own, that approach should be available. People shouldn’t have to fail on OAT before they are offered safe supply.
The system is backwards and broken.
Matthew Bonn is the program manager with the Canadian Association of People Who Use Drugs. He’s also an international board member with the International Network of Health and Hepatitis in Substance Users, and a knowledge translator for the Dr. Peter Centre. His freelance writing has appeared in many publications, including Filter-Mag, The Blackwood Gallery at the University of Toronto, The Conversation, Doctors Nova Scotia, Policy Options and The Coast. Matthew was also on the 64th Canadian delegation to the Commission on Narcotic Drugs. He is a current drug user and a formerly incarcerated person.
- Patient-centred care in opioid agonist treatment could improve outcomes: https://www.cmaj.ca/content/191/17/E460.short
- Buprenorphine/naloxone and methadone effectiveness for reducing craving in individuals with prescription opioid use disorder: Exploratory results from an open-label, pragmatic randomized controlled trial: https://www.sciencedirect.com/science/article/pii/S0376871622003416
- The OPTIMA Trial: https://www.optima-trial.com
- Flexible buprenorphine/naloxone model of care for reducing opioid use in individuals with prescription-type opioid use disorder: an open-label, pragmatic, noninferiority randomized controlled trial: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.21090964
- National Guideline for the Clinical Management of Opioid Use Disorder: https://crism.ca/wp-content/uploads/2018/03/CRISM_NationalGuideline_OUD-ENG.pdf