‘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.

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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