‘Opiate detox: methadone or suboxone’ by Peapod

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

This is the third part of Peapod’s Guide to Recovery, a series of articles written by Wired In To Recovery’s most visited blogger.

‘I don’t like stand alone detoxes, mostly because they almost always fail to deliver. Relapse is the norm if all you are offered is detoxification. I’ve written about this before in Detoxification: the nuts and the bolts so won’t go over old ground, but I will say again that success depends on the stuff that goes on around the detox and in the days, weeks and months afterwards.

This rough guide is written for those of you (or your clients) who might be thinking about detoxification.

Getting ready
Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.

Let’s assume you have a package of treatment and support set up and detoxification is an early part in your journey. If you are coming off opiates then you may be offered some choices around the nature of your detoxification plan. On the agenda may be discussions around whether you should use methadone, Suboxone (or subutex) or even lofexidine to help you withdraw.

What should you choose?
NICE is an organisation which makes recommendations to the NHS based on research findings. There are many recommendations and considerations in their guidance. This blog is not an in-depth guide. It’s important that things are kept safe so speak with your prescriber.

In the NICE Opiate Detoxification Guidelines, they suggest that if you are prescribed methadone or subutex/suboxone on a maintenance basis, then you normally ought to detox on the same drug. Research indicates that neither drug is better than the other though withdrawals are over faster with Suboxone than methadone.

In practice, you’ll almost certainly get some choice around what drug to use for detox, but there’s more to think about than the drug alone. Here’s what NICE say:

“In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks, including:

  • the physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms, and how these may be managed
  • the use of non-pharmacological approaches to manage or cope with opioid withdrawal symptoms
  • the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use that may be potentiated by the use of alcohol or benzodiazepines
  • the importance of continued support, as well as psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of adverse outcomes (including death).”

How long will it take?
That depends on what sort of level of methadone or heroin or suboxone you are starting out from and also on the setting. In an in-patient unit, a detox will take less than a month generally (sometimes much faster).

In the community, it could be much longer though the guidance suggests that around three months would be reasonable. If you are doing it in the community you’ll probably have to pick your medication up daily from the pharmacy.

Methadone
Many folk have successfully completed detoxes on methadone. Withdrawals are generally not too uncomfortable with reductions at higher levels, but begin to bite a bit below thirty milligrammes. The NHS Orange Book Guidelines suggest reducing methadone at 5mg every one or two weeks. The last few mls can be problematic for many.

Methadone is generally more sedating than Suboxone but it has the advantage to many of familiarity and you don’t have to worry about moving onto a drug you’ve not tried before.

Suboxone/subutex (buprenorphine)
The main player here is buprenorphine. When naloxone, an opiate blocker is added in to reduce abuse, the combination is called Suboxone. Buprenorphine is a newer drug than methadone and it has some advantages and one or two tricky points.

The most important thing to remember is that you can’t start Suboxone when you still have significant amounts of methadone or heroin (or any other opiate) in your system because it can cause withdrawal to suddenly occur and when that happens it’s horrible. This is because opiate receptors in the body love buprenorphine and give up their methadone and heroin molecules at the drop of a hat to accommodate the buprenorphine. The sudden loss of the other opiates causes this withdrawal and there’s not much you can do about it, so it’s best to avoid the situation where it might occur.

The bottom line is that you need to have allowed at least 24 hours (often more) after the last methadone dose or eight hours after the last heroin dose before you can start subutex and the prescriber will want to see some evidence of early withdrawal just to make sure.

It’s also difficult to convert to Suboxone when you are on higher amounts of methadone. Generally prescribers like you to be under 30mls, so you will have to detox on methadone down to that kind of amount.

In some people, Suboxone causes a headache and for everyone it tastes a bit bitter (it’s absorbed from under the tongue). People commonly report a “clear head” on Suboxone compared to methadone.

The Orange Book Guidelines suggest reducing by 2mg every two weeks to start with and slowing down to reductions of 400 microgrammes towards the end. Withdrawals from Suboxone peak a few days after the last dose and get better rapidly afterwards.

Lofexidine (Britlofex)
Not an opiate, but works on a body system that turns the dial down on some opiate withdrawal symptoms. In some centres, you may be offered this alone to help with withdrawals, though it is most often added in to a methadone or Suboxone detox, usually towards the end.

It can drop your blood pressure, give you a dry mouth and make you feel a bit drowsy, but it’s quite good at taking the edge off withdrawals. Lofexidine is usually only prescribed for about a week, starting at a low dose, building up rapidly and then tailing off again. Not a good idea to stop it suddenly as your blood pressure can jump. Ask your prescriber about whether it might be helpful at some point. I don’t think it’s available in the USA.

Complicated detoxes
Where there are a few drugs in the mix, e.g. benzodiazepines and opiates or alcohol and opiates, then it’s often wise to be attending a specialist service and there’s more likely to be an in-patient admission involved.

The same might be true if you’ve had complications on detoxing before (e.g. seizures or mental health problems). If you have other medical problems or complex social issues, then a residential detox may well be best.

Down to you
Ultimately, the choice is yours. I would suggest when speaking with the prescriber or clinical staff that you ask them what they would choose in your position.

If you are asking me, it would generally be Suboxone though there would be some exceptions to this; I think people are more comfortable on it and the discomfort is over faster.

If you don’t fancy the (usually minor) discomfort of converting to Suboxone from methadone, that might be a reason to go down the methadone route.

I can’t stress enough that what goes with the detox will determine how successful you are at achieving your goals of a drug-free recovery. So many people think of the detox as being the important part. If recovery is the train journey from London to Aberdeen, then detox is the time taken to call the taxi. You need to think about the rest of the journey.

Being in an intensive treatment setting, attending mutual aid and being engaged with peer support services will increase the odds of success. The more support you have the better.

Don’t forget those harm reduction messages of loss of tolerance and risk of overdose on relapse. If you do go back to using: use less; don’t inject; don’t use alone and don’t mix drugs.

Being informed will empower you. Don’t be afraid to ask questions – remember it’s your detox. The prescriber is there to be your guide and supporter, not to dictate. Good luck!’

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Comments

  1. Angie Sparrowhawk says:

    I totally agree that stand alone detoxes are not helpful. Detox is the beginning of recovery and should be followed by further treatment whether it be ongoing counselling or a spell in rehab. I feel that people are very vulnerable post detox. I find that clients are often now offered detox as a treatment and not part of a treatment package. If further support is offered it is not always a continuation of detox, it is not joined up and not consistent. I really do not understand that short treatments – 2 weeks detox with further short-term support can ‘cure’ [not a word I like!] years of addictive behaviour. Time is necessary and lots of it! It is like all current thinking, very short-term – to be seen to be dealing with an issue rather than addressing the underlying issues and the struggle recovery so often represents.

    • David Clark says:

      It amazes me that we have a system where parts of it have such little understanding. How on earth can a detox be treatment, rather than part of a treatment package? And how on earth are people making such decisions working in this field? Thanks for highlighting this Angie. Hope you are well.

      • Angie Sparrowhawk says:

        Thanks David – I am well, recovering from a minor operation and feeling good. I am enjoying the posts and learning all the time.

  2. Hi folks I am currently on methadone & have been heroin free for 9 years but sadly on the methadone for 9 years too, I Thanks Helen recently had enough and last july2012 told doc I wanted to detox I was on 95mls daily I am now on 10 mls daily its now july 2013 but I am struggling severly to get past this I got to 7mls and had to go back up, I am scared to death as cant sleep (4.18am now & just had a bought of cramps & on the toilet :( its driving me crazy ), eat constantly on the toilet & having leg & stomach cramps , I cannot be a proper mum & wife my business is suffering as I have 0% energy for anything or any one, they plan to put me on lofexidine but I am feeling stuck even the 10mls does not even give me more than 2hrs “slight” relief what can I do?

    • David Clark says:

      Hi Helen, It’s David here all the way from Australia. I’m sorry to hear that you are struggling at the moment. There are several things I’ll say which I hope will help in some way.

      Firstly, there is nothing wrong in going back up in dose on your medication. You have to feel comfortable in yourself and you certainly should not be feeling ‘scared to death’ and worried that you cannot be a ‘proper mum’. Feeling safe and being able to feel good about yourself are key elements of recovery, yours or anyone else’s.

      There is nothing wrong in having difficulty in detoxing off methadone. Some people do it more easily than others – we are all different! And again I say there is nothing wrong in experiencing difficulties. Don’t beat yourself. Get yourself back on a dose that you feel comfortable at and feel good about yourself. You can always try and reduce your dose again in the future if you want to try.

      Secondly, what other support do you have around you? Are you connected to other recovering people? How are you getting on with the treatment team? Do you have supportive family and friends? Support is key?

      Thirdly, have a look at the other Peapod blogs in the Resources section to see if anything he has to say helps you. You might also like to read the Stories by Matthew, Sapphire (may be particularly relevant), Iain and Simon.

      Fourthly, remember you can do this. Recovery is a process that takes time, but you can get there. Just take little steps, and accept that sometimes you go back a little before moving forward.

      Fifthly, keep in touch on the website. I can also be contacted at profdavidclark1@gmail.com.

      I hope this helps. Got to dash out now but will be back later. Thinking of you and remember, you can do this.

      • Hiya Helen here again,
        Thank you for your quick reply.
        I have been attending a basic doctor up until I moved & now attend a clinic picking up weekly as been clean so long but I feel they just want me off the methadone FAST and were bringing me down 2 mls every 7 days, I was ok until I reached the 9 mls felt a bit iffy but still went down to 7mls(1ml/1mg oral liquid meth) but that was just too fast & I had to beg to be put back up again & how kind of them I am now on 10mls(mg) I try to tell myself that I was on 95ml(mg) last June so should be proud of myself but I am feeling so depressed lately and cant seem to shift the fear factor. The clinic is bringing me down to 8mls again in 2 weeks & tbh the 10 is barely holding me I took my dose at 6am this morning as I woke up in bits at 4am now its 2.30pm & back to square one feeling crap just no energy at all. They have promised me the earth for my detox but nothing has actually materialized no sleeping tablets they said they would give me zopiclone(zimovane)which is non addictive, & also nearer the last few mls lofexadine.
        I dont know if its due to being on a very high dose for 9 years that its taking its toll on my body, I would never ever use again got past all that years ago thanks to God! But I just dont want to be tied to a bloody chemist 24/7 I want to teach English in Kurdistan Iraq (no meth there lol) so I need to be done with this & before March 2014& atm it just feels like I am going to be stuck on this crap forever. As for contact with any recovering addicts no not really tbh my Husband does not even know what I go to docs for he is Kurdish & doesn’t have a clue about any of this I was ashamed to tell him :( So really I only have my worker who is like 20 years old I am 30 & tbh shes not the brightest bulb in the box either bless her.
        I just want to feel comfortable again & normal but also I want off it I supose I will have to just put up with all the withdrawals. Thank you for your advice its much appreciated more that you can know. Take care Helen.

        • David Clark says:

          Hi Helen,

          You must remain in control of your reduction and decided whether it needs going up if you are not coping. You have done fantastically well so far, so don’t beat yourself up about it being difficult at present. You need to learn NOT be fearful. I know that’s easier said then done, but it can be worked upon.

          It sounds to me that you need some support from people who can appreciate what you are going through. Have you tried NA? That may not be viable given you family situation, but it could be of real value. You are suffering in isolation and there is nothing worse than that. Where are you based? Maybe there is a place I know.

          Please keep in touch.

          David xx

    • Iain Donald says:

      Hi Helen I can completely relate to where you are at.
      When I was going through my own detox over three and a half years ago the point where you find yourself just now is looking back where I realise now I was at my most vulnerable. The reason are got past it was largely due to unplanned timing.
      Just at the point where I was coming to finish my methadone detox a place in a recovery day project became available for myself, this played a pivitol role in not only keeping me busy during the week but also educating me in the best techniques of avoiding trigger situations and how best to cope with them if they became unavoidable.
      From the day I started that recovery day project in the south side of Glasgow Scotland I made sure that I got involved in anything and everything that had a connection to recovery in the south of Glasgow, this took the shape of years of volunteering with worthwhile recovery events and doing as much as I could to help others who were also travelling down their own recovery path, alongside all this I went back to college for two years studying Social Care and now find myself working with people who find themselves homeless with chaotic substance misuse. I find everything I have done since that first day going into the day project extremely fulfilling and get great satisfaction helping others, I know have a settled young family to keep me on my toes.
      Basically what I am saying is at the point you find yourself at at present get as much positive support around you as possible follow this on with giving a good amount of thought as to your future and where you see yourself in 5 years time both in your personal and business, this may involve drastic changes such as a career change which may seem far too scary to be attempted. All I can say is if you give it enough thought it will be scary initially but will benefit you and your recovery in the long run, remember what FEAR stands for:
      False.
      Evidence.
      Appears.
      Real.
      Also just to say don`t loose sight of the overall goal “A SUBSTANCE FREE LIFE”
      One last word cause it feels like I am starting to babble a wee bit!
      DON`T DWELL ON THE PAST LEAVE IT WHERE IT BELONGS, IN THE PAST, CONCENTRATE ON YOUR FUTURE CAUSE THAT`S WHERE YOUR HEADING.
      Good Luck & Take Care.
      Iain

  3. Hi, David, I am in the UK Liverpool area, I have managed to wait to take my dose today as its pick up so far so good its 11.15am & still not great but keeping busy with my Daughter, I know I should not be scared but I think I am going to speak with my worker Monday morning as its too fast & I am suffering badly for it I think I need to go back up to 20ml/mg to feel some sort of normality, I have just been trying to tell myself dont go back up as you are so close, but if I am feeling like this 24/7 for the past 2 months how much worse will I feel in another month ? I know I have to suck it up & expect I cant get out of this with no wothdrawals, I remember before I went to prison & had to cold turkey off the meth they gave me valium & dihydracodien )dfs) and then tapered you off them & it was a 2 week detox & either I was completely out of it due to the withdrawals that I cant rem them or it wasn’t half as bad as this but then again I had not been on such a high doese for as long as I have now 9 years what did I expect really. Thank you David I have a place nearby my clinic who do NA I just never considered myself to need that but maybe I do, thanks again you have really made me feel so much better especially yesterday when I felt at my worst.
    Take care Helen xx

    • David Clark says:

      Hi Helen, Excellent that you are in Liverpool, which is a good recovery city. Please give me a day or so to think through this and make contact with people I know there. Now, I want you to try and relax this weekend and enjoy your time with your Daughter. I don’t want you worrying about the withdrawals and the dose for the next day or so. (Sorry if I sound bossy, don’t mean to). I know its uncomfortable just now, but you can get the dose increased. Then you need to think about other forms of support (bossy again!). I’ll help you there.

      We can talk by email from now if you wish (profdavidclark1@gmail.com). Whatever, I am here to help if you wish. I am seven hours ahead of you – it’s 7.00pm here (and I am watching Australian football) and midday for you. No need to thank me. x

  4. Thats great thank you David, AND I AM GOING TO THANKYOU! lol :) I am just off to the canal with my Daughter then will cook for my Husband when he returns home from work. I think my dose was just dropped way too fast & thats not given my body time to adjust, Monday I shall sort that out, but like you say I will enjoy my time with my family this weekend.
    Bossy I like lol kind of makes me realise there is no point dwelling when I cannot do anything till monday.
    I have family in Austrailia in Victoria :) We visited 4 years ago & hope to once again……..as a drug free person :)
    I will email you privately as thats much better. again thanks. Enjoy your football, its only 2.22pm here , so i’ll say good night & god bless.
    Helenxx

    • David Clark says:

      Footie finished… and then watched some rugby. You know what, the tone of your latest comment is different – you sound more upbeat! Will be back tomorrow by email xxxxx

  5. Hi Helen,

    Just some more support from Scotland. :-)

    I am in recovery from opiate addiction and found it impossible to remain drug free without lots of help & support. My journey has been through a treatment centre for 3 months and then immersion within a 12 step fellowship, engaging with all the recovery opportunities that have come my way.

    I spent 15 years fighting and struggling with opiates and to now be over 3 years substance free seems like a miracle to me. I don’t have the experience of being on methadone maintenance but I have seen many other people benefit from its use. I have also seen people struggle to come off methadone.

    I believe that when I became substance free (illicit or prescribed) I was very vulnerable initially. I felt raw, on an emotional rollercoaster and my thinking was speeding / dark / negative. I was full of fear about the future and lots of unresolved anger / regrets /shame about my past. It was difficult to get any enjoyment in anything, there were no simple pleasures, everything seemed grey and lifeless. Every day seemed a grind, hard work. The physical symptoms remained for only a week or so but as described it was the psychological pain that was most challenging.

    The way I felt initially was never going to be a long term option. I don’t feel like that anymore. It passed. However it required action on my part, even when I had little motivation or energy. Becoming connected with other recovering addicts and alcoholics was what changed things for me. Simple human connections.

    I believe if I hadn’t become immersed in recovery circles I would probably have relapsed. How long would I have been able to tolerate feeling terrible for? I have a default physical and emotional need for opiates, this yearning had to be replaced with something more powerful, I’m grateful I found that something.

    I hope you find the support you want and need in Liverpool on your own recovery journey.

    Love,

    Ian

  6. Hi Helen

    Sorry to hear that things are not too good.

    I really do think that the drug service that you are attending are reducing your methadone far too quickly. 2mg every 7 days is ridiculous, especially given the low dose that you are on.

    When a person is reducing, each reduction must not exceed more than 10% of the initial dose.

    For example, if you are on 10mg, you should not be reduced by more than 1mg. I just cannot reiterate how important that is to a successful and comfortable reduction.

    Also, as methadone has such a long half life, doing reductions every week is far too fast. You body will not be acclimatised to the 1st reduction by the time they are making you do the 2nd, 3rd, etc.

    It is dangerous for your drug service to put you I the position that you feel that you have no say or control over the speed or rate of your reduction.

    As the Orange Book and NICE guidelines say, any treatment done without the patient being happy with it is unlikely to be successful.

    Personally my worry for you would be that as you are in withdrawal, and feel you cannot speak to your service about getting a dose increase to get you back on an even keel, that you are very susceptible to relapse.

    I moderate a website in the UK that advocates for patients in methadone and buprenorphine treatment. If you would like some more advice as to how to approach your drug service about getting this all sorted out, please feel free to contact us.

    If necessary, we can intervene and speak directly with your service and come to an arrangement that suits everyone.

    Our website is http://www.m-alliance.org.uk/forum/index.php

    In the mean time, exercise can help as it increases endorphins (the brain’s opiates) and can help with the restless legs etc. Try to hang in there until you can speak to your service about coming up with a more realistic and achievable reduction/detox plan.

    For instance, have they spoken to you about using Lofexidine when you get near to stopping the methadone? Or any other support meds?

  7. David Clark says:

    Great comments, Ian, Sapphire and Iain. Hope they help, Helen.

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