Although either methadone or buprenorphine can treat opioid use disorders effectively, patients may have good reasons to prefer one or the other. Giving patients a choice, when possible, can lead to better outcomes.
But patients don’t always have a choice about treatment—and even when they do, they may not realize it. The availability of a given medication varies among drug plans, and some plans fail to make it clear what medications they cover. Even patients who understand their options don’t always make the best choice, either for lack of time or because their desires conflict with evidence-based treatment recommendations.
These findings are among those reported in “Methadone, Buprenorphine and Preferences for Opioid Agonist Treatment: A Qualitative Analysis,” published in Drug and Alcohol Dependence.
The article’s authors conducted semi-structured interviews exploring patients’ backgrounds in several areas: experiences with the medications, knowledge of medication options, treatment preferences, and experiences with treatment for chronic pain in the context of opioid misuse.
(See published study for additional details)
Barriers to Treatment
Methadone treatment. Methadone must be administered through federally approved opioid treatment programs that inhibit access to care, especially in rural areas; the requirement for onsite dosing competes with work and family obligations; and the goals of treatment programs and patients often differ on issues such as abstinence.
Buprenorphine treatment. Buprenorphine can be prescribed in a variety of settings, and patients can take their doses at home; but the Drug Addiction Treatment Act of 2000 (DATA 2000) has limited the number of potential patients and the type of prescribers.
As would be expected, some barriers are more important to patients than others, influencing patients’ medication preferences. Patients who find barriers especially vexing may discontinue treatment.
The authors found several factors that help empower patients to make better treatment decisions:
- Better clinician-patient communication
- Improved patient education
- Better collaboration and partnership between clinician and patient
The authors also identified seven key themes influencing decisions:
|Themes Influencing Patients’ Treatment Decisions
Themes 3, 5, and 6 were especially important in decision-making, and “provided further evidence of the general favorability of buprenorphine over methadone.” Another finding: “treating pain with co-occurring substance use remains a challenge both for patients and clinicians.”
(Theme 1) Many patients were unaware that they had options:
Patient: “Like the first time I went into treatment, I think more or less they just put me on Suboxone. I mean, I didn’t even really know of any options. I didn’t know I could have done the methadone . . . it would have been nice to have that option.”
Another patient (given buprenorphine as a detox medication, then asked about her interest in maintenance treatment): “You can do that? I was never told that you could continue using [buprenorphine].”
(Theme 3) Prior unsuccessful experience with buprenorphine or methadone influenced patients’ decisions:
Patient, after several tries of buprenorphine: “. . . so I brought it up to one of the addiction specialists here and wanted to know if I could go on a methadone program. That’s how I got on it.”
(Theme 4) Some patients realized they needed more accountability and structure than buprenorphine offers:
Patient, after having struggled to maintain abstinence when given a 30-day supply of buprenorphine, and subsequently leaving urine samples that tested positive for opioids: “I just kind of felt that I needed more structure . . . And then [they said], you’re probably better off going onto the methadone . . . and . . . they were right.”
(Theme 4) But for other patients, even those who would otherwise prefer methadone, requiring daily dosing visits was too strong a negative:
“I don’t think it would actually work with my schedule . . . my job should be at the top of my list of importance.”
(Theme 5) Desire to avoid methadone clinics, or to avoid stigma, was an issue with some:
“When you take [buprenorphine], it’s in the privacy of your own home. You don’t have to go to some public clinic . . . what I would consider a finishing school for drug junkies . . . It was practical because I didn’t have to get up at 5:00 AM and go to a methadone clinic.”
(Theme 7) A patient with chronic pain leaned toward buprenorphine—until a counselor explained that buprenorphine doesn’t take care of chronic pain:
“I thought about what she had said as far as the pain . . . [and] decided to try the methadone.”
The authors note that having medication options increases the need “for clear communication between clinicians and patients, for additional patient education,” and for collaboration and patient influence over choices in treatment decision-making. They also point to the rise in prescription opioid misuse, especially among people with chronic pain, as increasing the need for offering flexible treatment options.
The authors emphasize that patients do not necessarily view methadone and buprenorphine as interchangeable, for reasons mentioned above. “Our results show that access to both opioid agonists will increase appropriate treatment options. Patient choice, when supported in the context of shared decision-making, may lead to better adherence and better outcomes.”
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Yarborough BJ, Stumbo SP, McCarty D, Mertens J, Weisner C, Green CA. Methadone, buprenorphine and preferences for opioid agonist treatment: A qualitative analysis [Epub ahead of print January 6 2016]. Drug Alcohol Depend. PMCID: PMC4767611. Accessed April 20, 2016.
Drug Addiction Treatment Act of 2000. http://buprenorphine.samhsa.gov/data.html. Accessed April 20, 2016.