Generally speaking, there are currently three types of medications that are U.S. Food and Drug Administration approved to combat opioid addiction: Methadone, Suboxone and Vivitrol. These medications come in different forms: pills, dissolvable films and liquids. Studies have shown that these forms of medication-assisted treatment when used in conjunction with addiction recovery treatment can raise the one-year sobriety rates to as high 45 to 60%. This is a great improvement over the 20 to 30% percent average rate we typically see with treatment alone. However, relapse rates appear to be similar for the medications in the long run, but there has been no true head-to-head comparison testing done as of yet. Doctors agree that these medications work best when they’re paired with treatment and support (ex. rehab, intensive outpatient program (IOP), and sober living. Given the derivatives, the discussion really boils down to a comparison of suboxone vs methadone.
What We Know About These MAT Medications
While not new, Vivitrol is an injectable version of naltrexone, a generic drug which has been used in the treatment of opioid addiction since the mid-1980s. Vivitrol is an antagonist that blocks receptors in the brain so they can’t be activated by opioids. That prevents a person from feeling euphoria, or the “high” produced by taking opioid-based pain pills or heroin. Initially available as a pill, oral naltrexone, wasn’t a huge success because it didn’t completely reduce cravings for opioids and it was hard to get addicts to adhere to taking it daily. In 2006, an injectable version of naltrexone – first called Vivitrex but later branded Vivitrol — was approved to treat alcohol dependence. In 2010, the FDA approved the Vivitrol shot to help prevent relapse in opioid addicts, though it noted several warnings regarding its use. (See more about the warnings below.)
Suboxone vs Methadone vs Vivitrol
Buprenorphine is a semi-synthetic opioid that partially activates receptors in the brain that crave opioids. Doses are set to give addicts enough medication not to feel the symptoms of withdraw but also not enough to feel high. The medications, called agonists, have been studied for decades and found to be effective when used in conjunction with treatment. Suboxone, a brand of the medication, also includes naloxone to prevent tampering and abuse. It is among the most-prescribed versions of this medication in the country. First approved by the FDA for use to treat opioid addiction in 2002, buprenorphine-based medications are most often taken as pills or films that dissolve under the tongue or inside the cheek. Recently, the FDA cautiously approved a longer-acting version of buprenorphine that can be placed under the skin to release a steady dose of the medication for up to six months for patients who have done well and have been put on smaller doses of the medication.
In the treatment world, the discussion of suboxone vs methadone is raised often. There are some differences worthy of consideration. First, methadone is the oldest and most proven opioid addiction treatment medication. The opioid-based medication helps a person to maintain a safer level of opioids in their body to prevent the shock of withdrawal or incessant cravings. Methadone is shown to work best when used for long periods of time, often years. Patients are generally weaned off the medication slowly over time and this process must be carefully monitored. Methadone can be addictive, so it is the most highly regulated. Again, strict regulation and careful monitoring speak to the risks associate with abuse. For this reason, pharmaceutical companies explored other options.
Vivitrol is the most expensive medication per dose, though it is often prescribed for shorter period of time than buprenorphine or methadone. It can cost anywhere from $1,000 to $1,400 per shot, not including a facility fee for administering the injection. Medicaid pays a slightly lower negotiated price, though the exact amount is confidential. In a recent report, Ohio Medicaid paid more than $38 million dollars for Vivitrol prescriptions to treat opioid addiction. The pill version of naltrexone is far less costly, at roughly $70 a month. It has to be taken daily and is most use for those with addictions very motivated to be sober.
Suboxone and Buprenorphine: Costs
Costs for Suboxone or generic buprenorphine prescriptions vary significantly based on the dose prescribed, from $100 a month to $800 a month, far less for generics. In one state, Medicaid paid more than $60 million for for Suboxone prescriptions in 2016 and close to $11 million for generic or other branded formulations that include buprenorphine. In some states, prescribers and clinics have drawn criticism for charging Suboxone patients for the weekly or monthly appointments required to get the prescriptions. Prescribers cite the high administrative costs to manage patients on Suboxone (because of the monthly pre-authorizations required by Medicaid and other insurance coverage) as a reason for these fees. In order to prescribe buprenorphine or Suboxone, doctors must undergo eight hours of training. Under federal rules, doctors are limited to offering only prescriptions to 275 patients. The limits used to be lower, and were either 30 or 100 patients.
Methadone’s cost is low, generally a few dollars per dose. However, the costs of daily visits to receive the medicine, additional case management and counseling bumps the cost to between $10 and $20 per day. In one state, Medicaid paid $21 million in 2016 for treatment with methadone to the state’s certified programs. Often, individuals not covered by insurance pay cash for daily visits.
Vivitrol: Pros and Cons
Vivitrol is favored, especially in criminal justice circles, because it is not an opioid and can’t be abused. It can also be prescribed by any doctor and administered by nurses and other medical professionals, without specialized training. Patients must be fully detoxed from opioids to avoid severe withdrawals when receiving the shot. One concern with Vivitrol is that patients on the drug could be at increased risk for overdoses when they stop using the medication. Smaller studies on closely-watched patients involved with the criminal justice system have not shown increased deaths, though noone has carefully studied overdose deaths after the medication is discontinued. One study in Australia in Vivitrol found patients on oral naltrexone were 44 percent more likely to die from an overdose after discontinuing use of the drug. Although that study is a decade old, it speaks to the sensitivity of a person’s body to relapsing after being weaned from the drug with Vivitrol. The consequences of relapsing while on Vivitrol are extremely dire. There’ a high risk of death. The medication carries a warning about the increased overdose risk along with health risks for patients with severe liver issues.
Suboxone: Pros and Cons
Proponents of buprenorphine-based medications, like Suboxone, said they are proven to work as evidenced by hundreds of carefully managed studies. So much so, that the World Health Organization, the Centers for Disease Control and Prevention, and the Department of Veterans Affairs have all endorsed buprenorphine as their preferred method as the first line of treatment for opioid addiction. But these endorsements are not the last word in the battle, and the suboxone vs methadone argument continues. Buprenorphine-based medications however, are not popular in criminal justice circles because defendants have used them to avoid positive drug tests. Further, there have been problems with this drug finding its way into prison systems. In some cases, this drug is being sold on the streets. With this drug, careful monitoring of patients is necessary while using the medication to ensure the appropriate dose is being given. Some also complain that not enough doctors are trained and willing to prescribe the buprenorphine, and that some who do charge cash for visits must hassle with burdensome pre-authorization requirements from insurance.
Methadone: Pros and cons
Since it is a powerful opioid, methadone is tightly controlled because of the potential for abuse. It also is the most well-researched of the opioid addiction treatment and is proven safe when used properly.
Collectively, there are options that increase the chances of success in recovery treatment. Medications can play a role in the recovery process, but tricking the brain through the use of medication is only one approach. Training the brain through a comprehensive addiction treatment program is another way. The two treatments, working together, have shown to increase the chances of success. While the suboxone vs methadone debate continues, recovering addicts would be well advised to examine all options and speak to their treatment professionals. Each person must do a self-assessment at regular intervals. You’re not thinking clearly before rehab, and you’re not thinking clearly while in rehab. Post-rehab is a good time to self-assess, initially. Then again as you enter outpatient treatment or sober living. Only you know best as to how close you are to relapse. Being serious about fending off triggers will help ensure the best possible outcome.