The DORN experience:

We have had a great deal of experience with opiate dependant patients that are either undergoing or have undergone methadone treatment. A large percent of the patients have then subsequently "switched" to Buprenorphine using a protocol that is far different than the current published protocol. The results to date have been universally excellent. Patients have a much improved sense of physical wellness associated with markedly improved thought processes (cognition). Most importantly, as opposed to methadone, buprenorphine patients tolerate incremental progressive dose reductions over time.

From Wikipedia:

Buprenorphine and methadone are both used for short-term and long-term opioid maintenance therapy. Each agent has its relative advantages and disadvantages.

In terms of efficacy (i.e. treatment retention, negative urine samples), high-dose buprenorphine (such as that commonly found with Subutex/Suboxone treatment; 8-16 mg typically) has been found to be superior to 20-40 mg of methadone/day (low dose) and equatable anywhere between 50 mg-70 mg (moderate dose)[12] to up to 100 mg (high dose)[13] methadone/day. (Methadone, however, can continue to increase in effectiveness over 100 mg, although it is a debatable topic, but this would constitute "very high dose" in this measurement commonly used by studies, including those quoted). In all cases, high-dose buprenorphine has been found to be far superior to placebo and an effective treatment for opioid addiction, with retention rates of 50% as a minimum.

Buprenorphine sublingual tablets (Suboxone and Subutex for opioid addiction) have a long duration of action which may allow for dosing every two or three days, as tolerated by the patient, compared with the daily dosing required to prevent withdrawals with methadone. In the United States, following initial management, a patient is typically prescribed up to a one month supply for self-administration. It is often misunderstood that the patient has to receive other therapy in this situation, but the law simply states that the prescribing physician needs to be capable of referring the patient to other addiction treatment (i.e. psychotherapy or support groups,) and many (but not all) physicians are aware of this and simply recommend therapy, or as they deem fit have therapy required.

Buprenorphine may be more convenient for some users because patients can be given a 30 day take home dose relatively soon after starting treatment, hence making them more compliant relative to those who need to visit a methadone dispensing facility daily to receive their methadone. The facilities, which are regulated at the state and federal level, initially only allow patients to take home weekend and holiday doses and after months of compliance without missing a day, they are given a week or more worth of methadone to take home. However, at many clinics, patients are given enough methadone to last for 2 weeks or 1 month, after significant time in treatment. At some US clinics, patients may get enough methadone to last 3 months. Therefore, buprenorphine does not have an advantage in terms of convenience for patients who have access to relatively liberal clinics, stay free of other drugs, and who stay on methadone long enough to earn the take-homes. In fact, users who are taking home a supply of methadone which lasts 3 months, 1 month, or even 2 weeks at a time may have difficulty finding a buprenorphine doctor who would offer equally convenient accommodations in some areas. There are also many professionals who are advocating for office-based methadone treatment, like office-based buprenorphine treatment, in the US and elsewhere. Such treatment with full opiate agonists is already available in the UK, and has been ever since heroin was made illegal, with an interruption of a few decades which occurred, likely under pressure from the United States, during the worldwide escalation of the War on Drugs which occurred during the 1960's and 1970's. In fact, in the UK a doctor may prescribe any opiate to a person, regardless of their complaint. In practice, methadone is most often used, although morphine and heroin are also frequently prescribed. The UK has a smaller number of opiate users, per capita, than the United States, which many attribute to the availability of full opiate agonist prescriptions to users, which reduces the amount of opiates sold illicitly and, in turn, the number of users of other drugs who encounter and begin using the opiates. Therefore, buprenorphine holds no advantage in convenience over methadone for users in the UK, and elsewhere in the world where prescriptions of full opiate agonists to opiate users are not discouraged.

Buprenorphine may and is generally viewed to have a lower dependence-liability than methadone. In other words, withdrawal from buprenorphine is less difficult. Buprenorphine treatment can last anywhere from several days (for detoxification purposes) to several months (sometimes for only a few weeks or up to two or three years) or longer. While not the general goal, and often not intentional with buprenorphine, it can sometimes but rarely be used in an indefinite, often life-long regimen just as methadone can be. The choice of buprenorphine vs. methadone in the mentioned situation (by the patient) is usually due to the benefits of the less-restrictive outpatient treatment; prescriptions for take-home doses for up to a month vs. the heavy restrictions for take-home methadone doses and frequent visits to the clinic, as well as the stigma of going to a methadone clinic.

The usually less-severe withdrawal effects make it usually much easier to discontinue use as opposed to methadone, but no evidence thus far exists that sustaining abstinence post-buprenorphine maintenance is any more likely than post-methadone maintenance, or post-heroin withdrawal. On the other side, going from heroin/other potent opioids to buprenorphine is generally harder than going from the same to methadone. For patients making decisions about whether to use buprenorphine or methadone, avoiding withdrawal symptoms is very important -- the discomfort which is more likely to occur while switching to buprenorphine from illicit opiates may interfere with daily life, whereas withdrawal symptoms while getting on methadone are less likely, and more easily remedied by increasing dosage. Many doctors believe buprenorphine has a ceiling, and further increases in buprenorphine dose will not ease the discomfort of a person switching from illicit opiates to buprenorphine, whereas methadone has no ceiling, and even the heaviest users' withdrawal symptoms can be stopped by an appropriate methadone dose.

Buprenorphine, as a partial μ-opioid receptor agonist, has been claimed and is generally viewed to have a less euphoric effect compared to the full agonist methadone, and was therefore predicted less likely to be diverted to the black market (as reflected by its CIII status vs. methadone's more restrictive CII status), as well as that buprenorphine is generally accepted as unable to be abused (for euphoria) by those with a heroin or other potent opioid habit (however neither drug is supposed to have a euphoric effect when used long-term). However, in at least one study in which opiate users who were currently not using were given buprenorphine, several other opioids, and placebo intramuscularly, subjects identified the drug they were injected with as heroin when it was actually buprenorphine.[16] This evidence tends to support the contentions of those who reject the notion that buprenorphine, when injected, is only marginally euphoric, or significantly less euphoric than other opiates. It should be noted that, in an effort to prevent injection of the drug, the Suboxone formulation includes naloxone in addition to the buprenorphine. When naloxone is injected, it precipitates opiate withdrawal and blocks the effects of any opiate, thus making "getting high" on Suboxone an impossibility. (The naloxone does not precipitate withdrawal or block the effect of the buprenorphine when taken sublingually.) However, the Subutex formulation does not include naloxone and may thus be injected by users to achieve the effect which was sufficiently heroin-like as to fool experienced users. Methadone, on the other hand, is given to patients at clinics in solution, with large amounts of water. This makes injection difficult without evaporating the liquid and taking other measures. Therefore, injection of buprenorphine as found in the preparations provided to opiate users simpler than injection of methadone, although data on the relative incidence is not currently available. Thus far in the United States buprenorphine is far less often found on the black market vs. methadone, but most street heroin addicts don't even know it exists, and its (legitimate) usage is far less than methadone (and according to many newspapers "underused"). It should also be noted that the vast majority of the black market methadone does not come from prescriptions to opiate users, but rather from prescriptions of methadone for pain. Since buprenorphine is used rarely for this purpose in the United States due to its comparatively poor efficacy in pain management, this is not surprising. In France where it is used more often than methadone there is more black market availability, although this and the apparent attraction is possibly due to a heroin dry-spell. Evidence indicates buprenorphine is often combined with benzodiazepines for more of an effect.

Blockade Effect

The Suboxone preparation contains the μ-opioid receptor antagonist naloxone which is intended only to prevent abuse (i.e. injection) of the buprenorphine, not, as is commonly misunderstood, to block the effects of other opiates. Buprenorphine itself is mixed agonist/antagonist, and, as such, buprenorphine blocks the activity of other opiates and induces withdrawal in opiate dependent individuals who are currently physically dependent on another opiate. This is why users must wait until they are in withdrawal before beginning treatment with buprenorphine.

Buprenorphine itself binds more strongly to receptors in the brain than do other opioids, making it more difficult to become intoxicated via other opioids when buprenorphine is in the system, regardless of the presence of the naloxone. (Measurable, but small, amounts of naloxone can be absorbed and detected via the sublingual route, and while this is insignificant and has no subjective effect, there are anecdotal reports of hypersensitivity to naloxone in rare cases. These reports are not fully substantiated.) If enough buprenorphine is in the system, however, it has the same type of effect as naloxone, i.e. it completely or nearly completely blocks or reverses opiate effects from other opioids. 0.3 mg of buprenorphine parenterally is equivalent in antagonistic effect to between 0.4 and 2.0 mg of naloxone parenterally, but with a much longer half-life. Methadone also blocks the effects of other opioids, and at commonly used methadone maintenance doses, the degree of blockade is similar. Unlike buprenorphine, however, this is not due to any opiate antagonist-like action of methadone. Instead, daily use of methadone, like daily use of all opiate agonists, results in tolerance to all opiates, called "cross-tolerance". However, it is still possible to abuse other opioids on either treatment regime, although many people find "getting high" to be impossible. In the case of pregnancy, buprenorphine causes milder neo-natal withdrawals than methadone.[17] (and is one of the few cases where Subutex is likely to be used over Suboxone in the United States.) Thus, buprenorphine is preferable during pregnancy, although methadone and the common opiate agonists are safe.

Switching to buprenorphine from methadone is often difficult and withdrawals lasting several days or more are often encountered mostly when the methadone dose is any higher than 30 mg/day (the suggested and usual dose for switching to buprenorphine). A 30 mg dose of methadone is relatively low, and some patients have difficulty reaching that dose, for a variety of reasons.[citation needed] Healthy users of methadone who commit to a slow taper, however, frequently find success in tapering to 30 mg in order to switch to buprenorphine, as well as in tapering off of methadone completely without the use of buprenorphine. Switching to buprenorphine at higher doses of methadone may be uncomfortable for the user. One reason is that users must be in withdrawal before switching to buprenorphine, and users of opiates with long half-lives, like methadone, may need to wait several days after their last dose of methadone before they are fully in withdrawal and ready to begin buprenorphine. User of heroin, hydrocodone, oxycodone, and morphine, as well as most other common opiates, only need to wait a maximum of 24 hours before they are fully in withdrawal and ready to begin buprenorphine. For this reason, some doctors switch methadone users to a shorter acting opiate, such as morphine, before allowing withdrawal to occur and beginning buprenorphine. Unfortunately, due to the unique qualities of both methadone and buprenorphine, switching to and using buprenorphine during pregnancy instead of methadone is unlikely to be helpful, since the strain of withdrawal on the body is far more dangerous for a fetus than the use of an opiate such as methadone. Also, data regarding buprenorphine's safety during pregnancy is less available than data on methadone during pregnancy -- data which has established the safety of methadone during pregnancy and the lack of lasting effects on children of mothers on methadone during pregnancy. On the other hand, switching from buprenorphine to methadone is relatively easy as methadone is a full opiate agonist which does not have a ceiling, and can stop the withdrawal symptoms of users at any dosage of other opiates, including buprenorphine.