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Methadone Alternatives: Which One Is Right for You?

April 18, 2022

Table of Contents

Over two million people in the US suffer from opioid use disorder (OUD). [1-3] One of the primary ways to combat this complex, chronic disease is with Medication for Addiction Treatment (MAT), which uses an individualized combination of both medication and behavioral therapy. 

There are three primary medications used in MAT: 

  • Methadone
  • Naltrexone
  • Buprenorphine

Although they all work with the opioid receptors in the brain, there are important differences to know about before starting treatment. Each individual should work with their healthcare team to decide which option is best for them. 

Using Methadone to Treat Opioid Use Disorder

The first medication that was available for OUD treatment was methadone.[2,3] It has been around for decades, taking favor as an OUD treatment option in the 1970s. 

Methadone is an opioid used to treat pain and OUD.[1-3] It is a full opioid agonist, which means it works by binding directly to and activating the opioid receptors. 

This medication is an effective OUD treatment option because it can outcompete other opioids for the opioid receptors. It also does not cause the same euphoric effects as other opioids and can reduce cravings and withdrawal symptoms. 

Methadone is available orally and is long-acting. Dosing starts low and is slowly increased over several weeks as directed.[1,2] 

Common side effects are similar to other opioids: 

  • Constipation
  • Dry mouth
  • Headache
  • Nausea
  • Slowed breathing 
  • Trouble falling asleep or staying asleep 

Methadone also has multiple drug-drug interactions, so it is important to let your healthcare team know what other medications you are taking before starting treatment. 

Methadone is a highly-regulated medication available only through specially certified opioid treatment programs (OTP). Through OTP, doses are individualized and adjusted over time. 

Even though methadone is a safe and effective option for OUD treatment, several other medications have emerged as methadone alternatives in recent years that may be more desirable. 

Learn more about methadone

- Methadone During Pregnancy

- Suboxone vs Methadone: Differences and Similarities

- The Dangers of Methadone Misuse

Naltrexone as a Methadone Alternative

Naltrexone is an opioid antagonist, meaning it blocks the opioid receptors so that other opioids cannot bind.[2] 

This medication does not cause an opioid response like methadone, but due to the potential of causing withdrawal symptoms, you need to be opioid-free before beginning treatment. 

  • 7-10 days for short-acting opioids
  • 10-14 days for long-acting opioids 

Naltrexone is not a controlled substance nor is it heavily regulated as other OUD medications.[2] 

It is available in oral and long-acting injection formulations, but the oral option has fallen out of favor.[2,3]

The FDA approved injectable naltrexone (Vivitrol) in 2010 to prevent the return of opioid dependence after medically supervised tapering-off. 

Vivitrol is an extended-release intramuscular injectable suspension that is administered by a licensed healthcare provider once every four weeks. 

Common side effects of Vivitrol include:[5]

  • Anxiety
  • Headache
  • Insomnia
  • Muscle joint pain 
  • Nausea
  • Sexual dysfunction

It is required to be administered by a healthcare professional due to the risk of serious injection site reactions. You should immediately report any of the following signs/symptoms at any of your injection sites:[5] 

  • Any open wound or a dark scab
  • The area feels hard, or any lumps
  • Blisters
  • Intense pain
  • A large area of swelling

Should You Use Naltrexone as a Methadone Alternative?  

Long-acting injectable naltrexone (Vivitrol) may be right for you as a methadone alternative if you are not currently physically dependent on opioids, meaning you can remain opioid-free for a period of time (1-2 weeks) before starting treatment.[2] 

Vivitrol may also be an option if you have trouble staying on other therapies, such as a daily pill since it is only given once per month. 

Naltrexone may also be a good option if access to OTP or buprenorphine treatment options are not readily available to you – as any physician can prescribe it since it is not a controlled substance.  

Buprenorphine as a Methadone Alternative

Another popular methadone alternative is buprenorphine. It is a partial opioid agonist, which means it binds to opioid receptors preferentially over other competing opioids.[2] 

By taking over these receptors, buprenorphine reduces withdrawal and cravings and blunts the effects of other illegal opioids such as heroin. 

Buprenorphine can be safely administered at various dose ranges, allowing for improved treatment individualization. It also does not have slow breathing effects like full agonist OUD treatment (i.e., methadone).

Buprenorphine products are controlled substances and may only be prescribed by specially certified providers.

However, over the past 20 years, many buprenorphine formulations have come to market, allowing for more tailored treatment for people with OUD. 

Learn about the most widely used buprenorphine-containing medications:

Buprenorphine is available alone or in combination with an opioid antagonist called naloxone.[3] 

These formulations include:[2,4]

  • Sublingual (under the tongue) film and tablet
  • Buccal (cheek) film and tablet
  • Injection (once monthly)
  • Implant (once every six months)

Because buprenorphine is a partial, rather than full, agonist, it tends to have fewer drug-drug interactions and side effects comparatively.[2] However, since it still acts on opioid receptors, side effects are similar to other opioids: 

  • Constipation
  • Dry mouth
  • Headache
  • Nausea
  • Slowed breathing 
  • Trouble falling asleep or staying asleep 

Should You Use Buprenorphine as a Methadone Alternative?

Buprenorphine may be the right methadone alternative for you if you are physically dependent on opioids, have issues with the side effects or drug-drug interactions of methadone, or want something other than a daily oral pill.[2] 

Although buprenorphine products are controlled and still require specially certified providers, they are generally more accessible than methadone. 

How Bicycle Health Can Help with Opioid Use Disorder

If you or someone you know is struggling to overcome opioid use disorder, reach out to Bicycle Health to find out more about telemedicine treatment options. Call us at (844)943-2514 or schedule an appointment here.

Audrey Kostrzewa, PharmD, MPH, BCPS

Audrey Kostrzewa, PharmD, MPH, BCPS completed a pharmacy residency at Froedtert & The Medical College of Wisconsin focusing on ambulatory care and community practice and is also a Board Certified Pharmacotherapy Specialist.

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Citations

1. Medication-Assisted Treatment (MAT). U.S. Department of Health & Human Services Substance Abuse and Mental Health Services Administration (SAMHSA). Updated November 29, 2021. Accessed December 13, 2021. https://www.samhsa.gov/medication-assisted-treatment

2. TIP 63: Medications for Opioid Use Disorder. U.S. Department of Health & Human Services Substance Abuse and Mental Health Services Administration (SAMHSA). Updated July 2021. Accessed December 13, 2021. https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document/PEP21-02-01-002

3. Opioids. National Institute on Drug Abuse (NIDA). Accessed December 13, 2021. https://www.drugabuse.gov/drug-topics/opioids

4. Information about Medication-Assisted Treatment (MAT). U.S. Food & Drug Administration (FDA). Updated February 14, 2019. Accessed December 13, 2021. https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat

5. Vivitrol [Naltrexone] Prescribing Information. Alkermes, Inc; 2021. Accessed December 14, 2021. https://od.vivitrol.com/content/pdfs/prescribing-information.pdf

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