Besides more structured care, how do patients benefit from methadone vs buprenorphine for OUD?
While the structure of daily supervised dosing is important, some patients simply feel better on methadone than buprenorphine. Some patients continue to crave (and use) opioids at even high doses of buprenorphine (e.g. ~32mg/day). Patients with more extensive histories of opioid use (higher doses, longer years, particularly if a longer history of heroin use), may be more successful on methadone than buprenorphine. The most common adverse effects of buprenorphine, for which patients in my clinic seek to transition from bupe to methadone are persistent nausea, and/or a sense of dysphoria.
Is there a special license or certificate required to “prescribe” methadone? Can an NP or PA “prescribe” methadone?
No. Although methadone is a full mu agonist, with multiple medication interactions, and thus has a much narrower therapeutic index than buprenorphine, there is no special training required to “prescribe” methadone. To be specific, any provider with a DEA license can prescribe methadone for pain (which can be very problematic, see discussion below about methadone as an analgesic). However:
- Methadone for the treatment of opioid use disorder is administered in a specialized, licensed clinic, and is thus “ordered” by the clinician. No special license is required to “order” methadone in such a clinic (but getting the appropriate training/mentoring is highly advisable).
- A methadone clinic, also known as an Opioid Treatment Program, or “OTP,” (an antiquated title, as referenced in federal statutes), is required to have a physician present for a face-to-face evaluation at the time of induction into methadone treatment (but can, under certain conditions, be performed via telemedicine).
- After the induction orders are placed, NPs and PAs can order dosing adjustments without the physician present, but the clinic medical director (physician), must co-sign dosing adjustment orders.
Does every patient need a screening EKG before beginning MAT with methadone?
No. It is impractical in the setting of most methadone clinics, and unnecessary to get an EKG at the time of induction for all patients. I refer to the AATOD QTc Interval Screening – Policy and Guidance Statement (2012) guidelines for EKG screening, which AATOD recommends the following for management of cardiac conduction risk in methadone maintained patients:
- Consider a baseline and follow-up 12-lead ECG for patients with “a history of arrhythmia, prolonged QTc, a family history of premature death, and/or other significant arrhythmia risk factors” on admission or for suspected arrhythmia risks in ongoing methadone maintained patients.
- Referral should be made for cardiac consultation for “known or detected cardiac conditions affecting heart rhythm, unexplained syncope or seizures or a significant increase in QTc from the baseline if known.”
- Patients at-risk should be educated on cardiac symptoms to watch for e.g. “racing” heartbeat, dizziness, seizures, or fainting spells and encouraged to contact the clinic” and medical provider and/or emergency services immediately.
How do you transition from methadone to buprenorphine? Do patients have to be titrated down to a dose of 30mg first?
This is not well studied, and as discussed in a very thorough review article, by Mannelli, et al (Curr Drug Abuse Rev. 2012 Mar;5(1):52-63), published guidelines are based on small studies, mostly uncontrolled investigations, and mostly on patients on low to moderate methadone doses (60-70mg daily). Furthermore, “due to differences in design and individual variability, a single protocol cannot be formulated.” Unfortunately, approximately “70% of patients receive more than 60 mg per day of methadone in the USA. Lowering the dose of methadone and/or increasing the interval between the last dose of methadone and buprenorphine may be less acceptable in this case, as it exposes patients to relapse.” There is much less data on transitioning patients at higher doses. That said, I have transitioned many patients from methadone to buprenorphine, including several patients at higher doses of methadone, for a variety of reasons. [Although more often I transition patients from bupe to methadone], By far the most common reasons for switching a patient form higher dose methadone to bupe was due to an upcoming move to an area where there was no methadone program; change in insurance status (transitioning from Medicaid to Medicare, or from Medicaid to a commercial payer); or adverse effects of decreased libido, excessive weight gain, or somnolence. [The vast majority of patients on methadone tolerate it well]. These are my overall observations and suggestions:
- Methadone is a very good medicine for treating OUD, with a longer track record than buprenorphine, and overall higher rates of patient retention than buprenorphine.
- Due to logistics, and/or patient preference/tolerance, and sometimes for compliance issues is makes sense to switch patients from methadone to bupe (particularly if planning to eventually switch the patient to an injectable form of bupe, or if transportation to a methadone clinic is an insurmountable challenge).
- In the promotion of buprenorphine (which is also an outstanding medication) sometimes methadone incorrectly gets labeled as a problematic, inferior medication, and providers seek to transition patients from methadone to bupe, even though methadone is a more appropriate medication for many patients.
- Thus, however, if the transition from methadone to bupe must proceed, from my experience I would note the following:
- Consistent with common guidelines, the patient must achieve a state of moderate opioid withdrawal (e.g. a COWS of at least 13), before administering bupe, to avoid incurring buprenorphine precipitated withdrawal (BPW). [I have made this mistake, and have incurred substantial misery, which can last a day or more.]
- The decision to rapidly titrate the dose downward first, vs. abruptly stopping the methadone, should be a shared decision with the patient, addressing the need for a sense of control. An example of rapidly titrating down would be dropping from 100mg of methadone daily, and dropping to 60mg on day 1, then 30mg on day 2, and 0mg on day 3, then assessing a COWS on days 4 and 5, and then dosing when moderate withdrawal is achieved. Some patients feel as sense of greater control with this type of taper. However, while some patients find this step-wise drop comforting, others find this painfully prolongs the withdrawal.
- Plan the stop date and set realistic expectations of duration of withdrawal symptoms. Coordinate around the patient’s schedule, and the patient’s desire to withdraw either during the week, or on the weekend.
- The primary goal is to prevent relapse during the withdrawal period, and secondarily to not prolong the withdrawal period unnecessarily.
- Prescribe anti-emetics, and other symptomatic relief medications if possible.
- Some protocols (particularly if involving higher risk patients – e.g. pregnant patients) even include using short half-life immediate release opioids or fentanyl transdermal patches.
- Some patients may require a brief hospital stay to avoid a relapse during the transition (if that is an available option).
- Plan an appropriate dose of buprenorphine to match the patient’s opioid use history and methadone dosing, to adequately relieve withdrawal.
- Regardless of the patient’s current methadone dose (whether that is 15mg or 200mg), patients stable on methadone are going to withdraw during abstinence (and some will supplement with heroin or other short acting opioids).
- Get to a COWS of at least 13, then administer bupe.
- Gradually weaning down the patient’s methadone dose over many weeks (e.g. by 1-3%/week), working towards an opioid free sobriety is not applicable to this discussion.
