Substitute prescribing or Opioid Substitution Therapy (OST) is defined as the administration of a prescribed (daily) dosage of opioid medicines to patients with opioid dependence problems. Two main medications used are methadone and buprenorphine (Subutex/subbies/suboxone). Some people are able to achieve abstinence quickly with OST; many others need long-term support and long-term opioid substitute prescribing. The main reason that OST is part of guidelines is that it has been shown to reduce harms of opioid misuse. Some people want to pursue this kind of treatment and others are interested in abstinence. Choice is very important.
About substitute prescribing usage
The two main prescription medications used in the UK to replace opioids are methadone and buprenorphine.
Methadone is very well known. It might pose an excess risk of death from overdose at the start of treatment if the initial doses are too high or if there is illicit opioid use alongside the methadone.
Buprenorphine is more modern than methadone but may be less effective in keeping patients in treatment* but studies show it has lower risk of death from overdose than methadone (or illicit opioids).
Buprenorphine (‘Subutex’ or ‘Suboxone’) is from the opioid family but it has both opioid-like effects (“agonist”) but also opioid blocking effects (“antagonist”). It is therefore an “agonist-antagonist” of opioid receptors in the brain and has been used in opioid drug misuse treatment since the 1970s, usually for heroin.
Because of this mixed “agonist-antagonist” effect, buprenorphine use is associated with significantly lower risks of fatal overdose. When prescribed, it is administered under the tongue. Some users find its lack of euphoric effect frustrating, just like methadone, and there is often use of heroin ‘on top’.
Methadone is prescribed to people who are misusing opioids, usually heroin. It is usually a green liquid that is taken orally, sometimes under the supervision of a pharmacist. Methadone is a manufactured ‘synthetic’ opioid that is almost exclusively used in the UK to treat opioid misuse. It is used as a substitute for the opioid (most commonly heroin) and hence is called “opioid substitute therapy” or “OST”. It has similar effects on the brain as heroin and other strong opioids but doesn’t give the same high . Therefore it is seen as a safer alternative to heroin and can reduce some of the massive harms from heroin misuse such as risks to the patient’s mental and physical health, damage to the patient’s family, and damage to society such as crime. It can either be prescribed as a long-term substitute or as a planned long term detox to come off opioids where the dose of methadone is slowly reduced over weeks, months, or years.
- A feeling of lethargy or slowing down of body functioning and thinking
- Reducing pain
- Reducing psychological distress or anxiety
- Feelings of relaxation and detachment
- Taking more than intended and feeling drowsy
- Nausea or vomiting
- Overdose and death
- ‘Boosted’ effects when mixed with other addictive substances such as benzodiazepines, fentanyl, or even “fillers” which bulk up the liquid but don’t have an opioid-life effect. Sometimes these added chemicals can cause allergic reactions.
Methadone and buprenorphine are opioids, so they share signs of misuse with other opioids, such as:
- Fatigue, followed by patterns of alertness
- Shallow or laboured breathing
- Nausea & vomiting
- Small, constricted pupils
- Appearance of “distant” gazing eyes
- Lack of motivation
- Distance from old friends and family members
- Disorientation or dizziness
- Difficulty speaking, slurred speech
- Lack of memory, forgetting things or not remembering important events or matters
- Lack of interest in the future or what comes next
- Unkempt self-image, lack of hygiene, loss of self-discipline
- Sometimes injection wounds if they are injected
- Infections on the skin and deeper tissue from injecting
Withdrawal from methadone or buprenorphine
Withdrawal symptoms from methadone or buprenorphine usually occur a bit more slowly than for heroin. Withdrawal produces flu-like symptoms and can include:
- Tremors / shakes
- Muscle spasms causing jerks/kicking
- Widespread pains
- Tummy cramps
- Runny nose
These physical symptoms peak in a few days but the cravings can last long term.
We try hard to control the withdrawal symptoms from methadone and buprenorphine during a detox and we are proud of the feedback that our patients give us on the Bonds protocol detox process. We specialise in detox usually over 1-2 weeks using non-addictive medication to make it as comfortable as possible. Published evidence shows that even an early version of the Bonds protocol was very well tolerated in opioid detox, for example, and opioid detox is notoriously unpleasant, often worse than a detox for amphetamines or cocaine. 97% of patients* did not report pain during a Bonds protocol detox from opioids. (ref Beaini AY et al (2000, October). A compressed opiate detoxification regime with naltrexone maintenance: patient tolerance, risk assessment and abstinence rates. Addiction Biology, 1;5(4):451-62 ).
Once the drugs are out of your system, you can then have naltrexone which can reduce cravings for substitute medicines and a wide range of other substances, thus supporting long term abstinence.
*Outcome measures recorded at a time in previous years when Dr Amal Beaini was previously providing the BONDS protocols from the Detox5 service, not The New Life Centre at Broughton. These BONDS protocols are now part of The New Life Centre at Broughton and Detox5 has closed a few years ago. Abstinence data at 12 months did not include those patients who could not be contacted or lost to follow up.
Our programme model is tailored to the individual’s needs. Our detox varies depending on whether the substance is a lone problem or is accompanied by misuse of other substances, the amount the patient is using, and if there any underlying mental health issues. The internal audits of the BONDS treatment protocols of many years have shown that approximately 70% of patients with alcohol or substance misuse also have an underlying mental health disorder. This combination of addiction and a mental health disorder is called Dual Diagnosis.