see attachments below1 page summary of these articles.

http://informahealthcare.com/jsu ISSN: 1465-9891 (print), 1475-9942 (electronic) J Subst Use, 2015; 20(3): 168–177 !2014 Informa UK Ltd. DOI: 10.3109/14659891.2014.894589 ORIGINAL ARTICLE A comparison of methadone and buprenorphine–naloxone as opioid substitution therapy: the patient perspective in NHS Lanarkshire Duncan R. Hill 1, Stephen Conroy 2, Afreen Afzal 3, Debbie Lang 3, Siobhan Steele 3, and Derna Campbell 3 1NHS Lanarkshire, Lanarkshire, Scotland, 2Drug and Alcohol Services, c/o Airbles Road Centre, NHS Lanarkshire, Lanarkshire, Scotland, and 3Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK Abstract This article was designed to assess the viewpoint of patients in NHS North Lanarkshire, on the use of buprenorphine–naloxone versus methadone for opioid substitution. Ninety patients from NHS Lanarkshire were questioned on comparing methadone and buprenorphine– naloxone treatment. Only one significant comparison was obtained from statistical analysis conducted (p50.05). This was evident for drug (methadone/buprenorphine–naloxone) and patient preference. The article finds that in comparison to methadone, patients receiving buprenorphine–naloxone were highly positive about their treatment experiences and its advantages over methadone, including the ‘‘clear-headed response’’, improved well-being and concentration, possibility of less social stigma, reduced craving, decreased side effects (especially drowsiness) and easier to withdraw from. As a result, about 57% of patients would consider buprenorphine–naloxone treatment in the near future.Keywords Addiction, buprenorphine naloxone, methadone, treatment History Received 18 October 2013 Revised 27 January 2014 Accepted 10 February 2014 Published online 10 March 2014 Introduction Substance misuse refers to drug use for a purpose not consistent with legal or medical guidelines, e.g. recreational use, which can lead a person to become dependent. It is a major health problem in Scotland which significantly impacts families, communities and society as a whole, including the individual. This problem can negatively affect a person’s health, education, employment potential and their relation- ships with others. As a result, it can prevent individuals from contributing positively to society and the economy (Scottish Government, 2008).

Scotland has an estimated 52 000 problem drug users; 40–60 000 children are affected by their parent’s drug abuse (Scottish Government, 2008). In 2010, Government drug statistics showed that 66% of those surveyed were recorded using heroin (5340 patients), the next most common sub- stances reported are diazepam (34%, 2758 patients), cannabis (30%, 2459 patients) and cocaine (9%, 758 patients). Patients can record more than one drug of misuse on this from, hence the total is over 100%. Of the total number of individuals using heroin (5340), 95% (5049) of them reported it as their main drug of misuse, with the other most common substances reported as the main drug of misuse: cannabis (48.5%, 1193 patients) and diazepam (22.5%, 622 patients). Furthermore,half of the total number of heroin users reported that they injected the drug (NHS National Services Scotland, 2010).

Heroin is one of the most widely abused drugs in Scotland (National Institute for Health and Clinical Excellence, 2007).

Pharmacological treatments are in themselves not the solution to the addiction, and should always be prescribed as part of a comprehensive care package which is more holistic including psychosocial interventions to improve success rates. Methadone Methadone is the most prevalent opioid substitution therapy (OST) in Scotland from the numbers of patients in treatment.

It is a long acting, synthetic opioid with full agonist activity on the Mu (m) and Kappa (k) opioid receptors. Methadone helps to reduce cravings and prevent symptoms of withdrawal such as yawning, goose flesh (piloerection), runny nose (rhinorrea), watery eyes (lachrymation), pupil dilation, diar- rhoea, anxiety, restlessness and troubled sleep (Department of Health, 2007).

Methadone maintenance treatment has been proven to have many benefits. These include: reduced criminal behaviour, reduced mortality, reduced illicit drug use, improved physical and mental health, improved employment potential, decreased cost to society and reduced risk of transmitting diseases such as HCV, HIV and sexually transmitted diseases (Department of Health and Human Services, 2002).

Evidence shows that higher doses of methadone (between 60 mg and 120 mg daily (Department of Health, 2007) are much more effective at optimising outcomes and reducing Correspondence: Duncan R. Hill, BSc (Hons) Pharmacy, Specialist Pharmacist in Substance Misuse, NHS Lanarkshire, Airbles Road Centre, 49–59 Airbles Road, Motherwell, Lanarkshire ML1 2TP, Scoltland. Tel: 01698 266717. Fax: 01698 210033. E-mail:

[email protected] heroin use, than moderate or low doses (National Treatment Agency for Substance Misuse, 2003). Doses of methadone in the range of 60–120 mg daily have been shown to produce a blockade of the euphoric response from other opioids, therefore reducing illicit consumption/injecting and associated risks such as Blood Borne Virus transmission and overdose.

Research published by NICE (2007) as a technology appraisal commented that methadone in high doses (greater than 60 mg daily) may be more effective in retaining patients in treatment than high-dose buprenorphine treatment.

Methadone is not always suitable for every individual, e.g. drug interactions, patients with prolonged QTc intervals; therefore, other alternatives may need to be considered.

Buprenorphine Buprenorphine (a partial agonist at themreceptor and an antagonist at thekreceptor with high affinity for and slow dissociation from themreceptor) is a well-established alterna- tive to methadone. Buprenorphine was licensed in the UK in 1996 (although licensed in France in 1995) for maintenance and detoxification (NICE guideline, 2008) as a solo prepar- ation and the combined product buprenorphine/naloxone ((an opioid antagonist at themreceptor) at a ratio of 4:1) was approved by the European Medicine Agency in 2006.

Due to the high affinity and intrinsic activity on the receptors, a number of properties may be beneficial to patients such as it was more effective in blocking heroin, reducing craving and easier to reduce and cease taking (Pinto et al., 2008), and buprenorphine–naloxone is safer in overdose compared to full agonists (e.g. methadone) as it causes less respiratory depression due to the ceiling effect as a result of the partial activity at themreceptors (Ford et al., 2004) and a lower overdose potential at higher doses and also has a milder degree of physical dependence (Department of Health, 1999). Furthermore, many patients reported it is less euphoric and less sedating compared to methadone.

In areas of the UK, buprenorphine became increasingly abused by drug misusers who were injecting it intravenously (Department of Health, 1999), to overcome this issue buprenorphine–naloxone (Suboxone) was licensed (Ford et al., 2011).

The combination treatment is the preferred choice of medication for treatment providers due to the inclusion of naloxone in the formulation, which is intended to act as a deterrent for patients who are tempted to misuse their medication. Naloxone has poor bioavailability when taken sublingually, therefore has no clinical effect and will not precipitate withdrawal. However, if misused by injecting or snorting, the naloxone component becomes active, causing acute withdrawal symptoms, making the drug undesirable for misuse (Yokell et al., 2011). Buprenorphine is again not suited for all patients and situations, e.g. patients with current severe mental illness.

Previous comparison studies Buprenorphine–naloxone is a relatively new substitute therapy and, consequently, there are very few clinical studies which have compared treatment by assessing patients’ opinions regarding their treatment on both substances.A previous study conducted in Lanarkshire (Tanner et al., 2011) compared methadone and buprenorphine–naloxone by gathering the opinions of patients to evaluate the strengths and weaknesses of both drugs. Participants reported an increased clarity of thinking while on buprenorphine–nalox- one, allowing them to do more and focus more on their lives, whereas methadone was associated with mental clouding.

The greater clarity of thought with buprenorphine– naloxone for some requires more psychosocial support compared to methadone, and not all participants perceived this as an advantage.

Interviews revealed some clients felt that buprenorphine– naloxone was associated with increased confidence and lower stigma when switching from methadone to buprenorphine– naloxone.

Another trial (Rapeli et al., 2007) assessed the attention, working memory, and verbal memory of patients starting opiate substitution therapy on methadone or buprenorphine– naloxone by carrying out cognitive tests which involved alertness tasks, letter-number sequencing tasks and list learning tasks. The results were compared to the performance of healthy control participants and revealed that both metha- done and buprenorphine–naloxone patients showed deficits in working and verbal memory in the early stages of OST.

However, verbal memory defects may be more evident in methadone treated. Attention deterioration may only be seen in methadone-treated patients and it may be dose-dependent.

Furthermore, it discussed that methadone-treated patients were slower in reflecting alertness and attention, when patients used benzodiazepines along with OST. Therefore, when benzodi- azepines or any other psychoactive medications are taken in early stages of OST, buprenorphine may possibly protect cognitive activity better than methadone, as well as being a safer treatment to use due to the previously mentioned reduction in risk from overdose.

A research study (McKeganey et al., 2013), compared the impact of methadone and buprenorphine–naloxone on two samples of opioid users. Over the 90 days of the study, results illustrated that 62.5% of the methadone sample users had taken heroin compared to 26.4% of the buprenorphine– naloxone group. Additionally, on the last 3 days it recorded that 37.5% of the methadone users reported having used heroin compared to 1.9% of the buprenorphine–naloxone group. These results prove that the buprenorphine–naloxone users are less likely to use heroin with OST. In comparison to the methadone group, buprenorphine–naloxone-treated patients reported an improved sleep pattern and an enhanced self-assessment of health which is interesting as it is converse to the rationale that methadone is more sedating, therefore it would be expected to provide an improved sleep pattern.

Some patients expressed a preference in taking buprenor- phine–naloxone because it was easier to consume a tablet and less recognisable to others as treatment for opioid addiction.

NICE guidance (2007) recommends when both metha- done and buprenorphine–naloxone are apparently equally effective; methadone should be the first choice of treatment.

Financially, buprenorphine–naloxone has a disadvantage as it is more expensive than methadone (Scottish Government, 2011).

DOI: 10.3109/14659891.2014.894589 A comparison of methadone and buprenorphine–naloxone169 Overall previous studies on buprenorphine–naloxone have recognised several benefits, these include: having a positive effect on drug users cognitive function compared to metha- done; fewer side effects; quicker stabilisation; improved drug user decision making; greater levels of patient satisfaction, less adverse effects on respiratory function compared to methadone; reduced heroin use and fewer drug interactions in comparison to methadone (McKeganey et al., 2013). The road to recovery The ‘‘Road to Recovery’’ is the strategy published by the Scottish Government. It proposes key priorities for action and outlines new strategies to tackle problem drug use in Scotland (Scottish Government, 2008). An estimated £2.6 billion is spent annually to prevent drug misuse and treat patients.

It primarily focuses on the concept of recovery; the progression of an individual moving towards a drug-free life, thus, helping them become an active and successful member of society.

NHS Lanarkshire situation In 2006, it was estimated that there were 5084 problem drug users in Lanarkshire, which is 1.36% of the population. This value is marginally below the national prevalence rate of 1.62%. A local audit (January 2010) revealed that in Lanarkshire there was approximately 2036 people receiving OST (e.g. methadone, buprenorphine–naloxone), a significant fall from the previous estimate of 3806 in 2003 (Lanarkshire Alcohol and Drug Action Team, 2008). The main substances involved were heroin or alcohol, although many drug users use more than one substance, e.g. consume heroin with alcohol and benzodiazepines.

Aim To assess the viewpoint of patients in NHS North Lanarkshire, on the use of buprenorphine–naloxone versus methadone for OST.

Methods A questionnaire was developed to ascertain patient views of the methadone and buprenorphine/naloxone, Appendix 1. The study was conducted on patients attending North Lanarkshire Integrated Addictions Service (NLIAS) clinics in the areas six largest towns. Quantitative data were entered into the Statistical Package for Social Sciences version 18.0 (SPSSv.18, Chicago, IL) and into Microsoft Office Excel 2007 (Redmond, Washington). These databases were used to calculate descriptive statistics which were used to construct figures, including graphs and tables, to demonstrate the results obtained from the questionnaires. Qualitative data were taken from each questionnaire and collated using Microsoft Word 2007.

Results Quotes from patients are shown in Appendix 2.

Demographics Of the 90 patients, 71(79%) were male and 19(21%) were female. The average age was 37 years, with a minimum of23 and a maximum of 54. There were no participants under the age of 20 years old. Sixty patients (67%) were under 40 years, only 30 patients (33%) were 40 years. At-test compared the average age and sex for those prescribed methadone or buprenorphine–naloxone. It revealed there was no significant correlation between drug and patient age or sex (pvalue40.05).

Employment status Eighty-one (90.1%) patients were unemployed. 64(71.1%) of these patients were receiving methadone treatment and 17 (19%) patients were receiving buprenorphine–naloxone treatment. Only nine (10%) patients were employed. Six of these patients (6.6%) had a part-time job, four being buprenorphine–naloxone patients. Only three patients (3.3%) were in full-time employment, of which one was a buprenorphine–naloxone patient. There was no significant relationship between drug and employment status.

Patients receiving methadone/buprenorphine– naloxone treatment currently Sixty-eight patients (75.6%), who participated in the ques- tionnaire were currently receiving methadone, the remainder were on buprenorphine–naloxone.

Duration of current opioid substitution treatment was collected and no patients had been on buprenorphine/ buprenorphine–naloxone for longer than 5 years, but 28 patients reported to have been on methadone for 5 years or longer.

Current dose of methadone/buprenorphine–naloxone Results revealed that 50 ml was the most common dose for methadone. Ten patients (15%) received this dose. The most common dose for buprenorphine–naloxone was 16 mg, as eight patients (36%) reported having this dose. In contrast to methadone, buprenorphine–naloxone dose ranges were not as wide.

Of the 68 were methadone patients interviewed nearly half of these patients (n¼30(44%)) were receiving methadone for the first time. 44% of patients had attempted methadone treatment more than once. The remaining methadone patients (n¼8(12%)) had previously been prescribed buprenorphine– naloxone; however, they were switched back on to methadone as it was not tolerated well.

There were 22 buprenorphine–naloxone participants in the study. As might be expected the majority of buprenorphine– naloxone respondents, 20 (91%), had been prescribed methadone at some point during their past drug treatment.

Two patients (9%) had been prescribed buprenorphine– naloxone as first-line treatment.

Table 1 shows comments made by patients in response to questions compared to previous methadone treatment, (a) 24 of the 31(26.7%) patients reported improved concen- tration with buprenorphine–naloxone.

(b) 22 of the 31 patients (71%) experienced improved well-being with buprenorphine–naloxone treatment.

(c) 23 of the 31 patients (74%) felt that buprenorphine– naloxone treatment helped them to think more clearly.

170D. R. Hill et al. J Subst Use, 2015; 20(3): 168–177 (d) 19 of the 31 patients (61%) reported that buprenorphine– naloxone treatment changed their life in another way.

Table 2 revealed that 25 patients (27.8%) preferred this drug, whereas methadone was only favoured by 7 patients (7.8%). Fifty-eight respondents (64.4%) showed no preference between methadone and buprenorphine–naloxone. Apvalue of less than 0.05 was obtained; therefore, a significant correlation exists between drug and patient preference.

In Table 3, 39 methadone patients (43.3%) reported they would consider trying buprenorphine–naloxone in the future and 25 methadone patients (27.8%) would not like to try it.

Discussion The purpose of this study was to gather and compare the views of patients in North Lanarkshire, on the use of buprenorphine– naloxone versus methadone as substitution therapy. Qualitative interviews allowed a more in-depth understanding of how buprenorphine–naloxone and methadone was seen from the perspective of those prescribed the medication.

Effectiveness of treatment Patients were highly positive in describing their overall buprenorphine–naloxone experience. All 22 buprenorphine– naloxone patients found their treatment to be successful.

The first major theme to emerge was that participants felt‘‘cloudy headed’’ and ‘‘drowsy’’ when receiving methadone, whereas with buprenorphine–naloxone, patients felt ‘‘clearer headed’’. Patient responses included:

Methadone made me feel cloudy headed. Now I feel awake and aware...there’s no dunt with Suboxone.

Methadone is worse than heroin. Suboxone makes me feel the same as I was when I was drug free...there’s no fuzz.

Seven patients felt buprenorphine–naloxone did not improve their clarity of thinking compared to methadone.

Two patients viewed the ‘‘clear headed’’ response as a disadvantage:

I think a lot at times.

Methadone makes you feel better in a way because with Suboxone, you feel the lows and the highs.

These findings were similar to those in previous studies (Egan et al., 2011; Tanner et al., 2011). Thus, drug users who find it difficult to control their thoughts and emotions may require extra counselling with buprenorphine–naloxone treat- ment to help cope with the new levels of clarity. Although it could also be argued that the patients receiving methadone treatment may require more psychosocial input due to the sedative properties.

Table 1. Patient comments on buprenorphine–naloxone changes.

Question Positive Negative Why has buprenorphine–naloxone improved your concentration or ability to do more?‘‘Suboxone make me think more clearly and gives me better clarity’’ ‘‘I am working again...’’ ‘‘it helps me to think more clearly so I can concentrate better’’ ‘‘...able to be a lot more focused’’ Why has buprenorphine–naloxone helped improve the way you feel?‘‘it’s less depressive and I feel more awake’’ ‘‘my overall health feels better’’ ‘‘its allowed me to get my life back’’ ‘‘I feel more confident in my appearance’’‘‘...not really, I still feel depressed’’ ‘‘Methadone make you feel better in a way because with Suboxone, you feel the lows and the highs’’ Why has buprenorphine–naloxone helped you think more clearly?‘‘...make me more aware of what’s going on and I know what I am doing’’ ‘‘I have better clarity’’ ‘‘I was very forgetful, but now my memory is better’’ ‘‘...just able to think better about decisions’’ Why had buprenorphine–naloxone changed you life in any other way?‘‘my depression has improved’’ ‘‘I am a much happier person’’ ‘‘...able to keep a relationship – easier to come off it when you get that support, now have goals in life’’ ‘‘...got a job, before couldn’t have managed to do this’’ Table 2. Reasons why patients prefer methadone/buprenorphine– naloxone.

Treatment option Comments Methadone ‘‘...I am stable’’ ‘‘I am stabilised on it and I’m drug free’’ ‘‘I prefer methadone as when I took Suboxone I just lost lots of weight and couldn’t keep it up’’ Buprenorphine– naloxone‘‘...prefer Suboxone because it makes me more aware and I have a better quality of life’’ ‘‘...it has no fuzz or cloud’’ ‘‘...I can think straight but methadone just made me numb’’ Table 3. Reasons patients would/would not consider transferring to buprenorphine–naloxone in the future.

Comments Positive ‘‘I’ve heard it’s easier to come off than methadone’’ ‘‘I know other people who have had it and they are settled’’ ‘‘Methadone sometimes gives you a sleepy side effect.

I’ve heard with Suboxone you get all your feelings back’’ Negative ‘‘I wouldn’t consider Suboxone in the future as I am happy on methadone’’ ‘‘I wouldn’t consider trying Suboxone as I am happy reducing my dose of methadone’’ DOI: 10.3109/14659891.2014.894589 A comparison of methadone and buprenorphine–naloxone171 Clients compared their current buprenorphine–naloxone treatment with previous methadone treatment, noting several advantages, including reduction in cravings, effectiveness in blocking the euphoric effects of other opioid drugs, increased concentration, improved well-being and absence of side effects (especially sedation).

The majority of the patients who had only been on methadone treatment reported it as successful, but nearly every respondent felt it was a very poor substitute drug.

Many stated it was just like ‘‘another drug addiction’’ and ‘‘worse than heroin’’.

Impact of treatment on health and quality of life Several buprenorphine–naloxone patients reported significant improvements in their health and quality of life, in compari- son to their previous methadone treatment:

It’s improved my life as it’s allowed me to get my life back to normality, the way I was before I took drugs.

Suboxone has improved my life, my asthma and back pain is better.

Respondents described other changes like increased motiv- ation, confidence and generally feeling more positive about life:

I feel more confident in my appearance.

This re-engagement with life involved changes in daily activities such as: reading more often, a return to a stable job and renewed relationships with family and friends.

Although some patients experienced no differences with the switch from methadone to buprenorphine–naloxone:

...I still feel depressed.

Duration of treatment The duration of current treatment for methadone patients ranged from less than 1 year to 15 years, whereas current treatment length for buprenorphine–naloxone patients ranged from only less than 1 year to 5 years. Results showed that most buprenorphine–naloxone patients, 18 of the 22 (82%), had received their current treatment for less than 1 year, but current treatment length for the majority of methadone patients (n¼33(49%)) was between 1 and 5 years. These findings showed that those on methadone have remained in current treatment longer than those on buprenorphine– naloxone. However, no significant correlation was found between drug and length of current treatment.

Stigma Another theme was the social stigma attached to collect- ing methadone prescriptions at the pharmacy. One patient responded:

There is a lot of stigma associated with taking methadone.In comparison, patients felt there was less stigma associated with buprenorphine–naloxone:

I don’t feel there is as much stigma attached to taking Suboxone as there is with methadone.

These findings were similar to a previous study which investigated heroin user views’ on substitute prescribing (James & Clark, 2011). The majority of participants in this study stated that the stigma with heroin addiction was evident in their worker’s view of the clients and many felt this deterred their progress. To enhance effectiveness of treatment, staff should be educated about the nature of heroin addiction and efforts should be made to make all clients feel at ease.

Drug preference A significant correlation (p50.05) was seen between drug (methadone/buprenorphine–naloxone) and patient preference to OST of choice. Although 57 of the 68 (84%) methadone patients expressed no preference buprenorphine patients expressed a preference to it over methadone. Most of the methadone-treated patients had only ever been prescribed methadone. Buprenorphine–naloxone was preferred over methadone among buprenorphine–naloxone users, main reason being the increased clarity of thinking and being able to do more in their daily life.

Some clients reported to preferring methadone, having tried both medications, stating:

I prefer methadone because Suboxone made me sick.

I couldn’t take Suboxone, just didn’t agree with me.

Thirty-nine of the 68 methadone patients (57%) would consider trying buprenorphine–naloxone in the future. Most of these patients had heard positive results from other drug users receiving treatment; therefore, they viewed buprenor- phine–naloxone to be an alternative substitute with some advantages compared to methadone:

I’ve heard it is a lot easier to come off, whereas with methadone it is a lot harder.

A recent study emphasized the need to improve education about opioid dependence and treatments to drug users.

Patients’ knowledge and understanding about all the treatment options available may lead to improved treatment outcomes, better engagement and treatment adherence (Alves & Winstock, 2011).

Additional counselling/support Previous research indicates that mental health/psychiatric problems may be expected in opioid-dependent individuals.

Concurrent counselling and support services are important components of an individual’s recovery process and can significantly improve treatment outcomes by focusing on behaviour modification, motivation, coping skills, interper- sonal relationships and social reintegration (Fiellin et al., 172D. R. Hill et al. J Subst Use, 2015; 20(3): 168–177 2006). Many of the respondents in the study had led chaotic lifestyles and had a number of co-morbidites, including mental health issues. These included childhood trauma, personal struggles with stress, depression, anxiety, suicide attempts and major losses. Less than half (41%) of the total number of participants in the study received counselling, the majority of these finding it beneficial. Some patients highlighted that successful treatment outcomes can be influenced by positive relationships with workers. This theme was found to be evident in a similar study (Tanner et al., 2011). One patient stated:

I feel more at ease and I have a good relationship with my counsellor.

Limitations The largest limitation lies in the fact that all 90 respondents were from the same geographical area. The sample size may have been too small as there were no statistically significant results (p40.05) to be found between drug choice and demographics. Other limitations were that most of the participants were male and there were no patients under the age group of 20.

The number of methadone patients (68) in the study was not equal to the number of buprenorphine–naloxone patients (22), but this is representative of the service which currently prescribes 3:1 ratio of the treatment options.

In addition, there were eight methadone patients in the study who had been prescribed buprenorphine–naloxone on a single occasion, then switched back to methadone. Some of these patients responded to noticing differences between treatments. Due to the limited duration of treatment on buprenorphine–naloxone their answers may not be truly reliable. Due to the above reasons, the comparison of patient views on each drug may not be extremely accurate. Some participants may not have been truthful when answering some of the questions, although overall participants freely disclosed their concerns.

Future research A study such as this one should be done over a longer duration, with a larger sample size of diverse clients from different areas, ensuring opinions gathered are representative.

Exploration of the views of pharmacists and prescribers in order to gain an understanding of their perspective of dispensing/prescribing buprenorphine–naloxone and metha- done would potentially be of interest.

Conclusion In comparison to methadone, patients receiving buprenor- phine–naloxone were highly positive about their treatment experiences and the advantage over methadone, including the ‘‘clear-headed response’’, improved well-being and concen- tration, possibility of less social stigma, reduced craving, decreased side effects (especially drowsiness) and easier to withdraw from.

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Appendix 1. Questionnaire This questionnaire is being carried out by pharmacy students, at the University of Strathclyde. The information is anonymous and completely confidential and the answers given will not be reported back to the addiction worker.

174D. R. Hill et al. J Subst Use, 2015; 20(3): 168–177 DOI: 10.3109/14659891.2014.894589 A comparison of methadone and buprenorphine–naloxone175 Appendix 2 – Patient responses Why has Buprenorphine–naloxone improved your concentration or ability to do more?

5. ‘‘Buprenorphine–naloxone make me think more clearly and gives me better clarity’’ 9. ‘‘its improved my life as it’s allowed me to get my life back to normality, the way I was before I took drugs’’ 25. ‘‘it helps me to think more clearly so I can concentrate better’’ 45. ‘‘now I enjoy reading’’ 46. ‘‘I am working again’’ 62. ‘‘able to be a lot more focused’’ Why has Buprenorphine–naloxone helped improve the way you feel?

5. ‘‘its allowed me to get my life back’’ 9. ‘‘it’s less depressive and I feel more awake’’ 11. ‘‘its made me feel better because I no longer need to take illicit drugs’’ 25. ‘‘my overall health feels better’’ 30. ‘‘I don’t feel there is as much stigma attached to taking suboxoneas there is with methadone’’ 31. ‘‘not really, I still feel depressed’’ 45. ‘‘I feel more confident in my appearance’’ 46. ‘‘I feel more positive about life’’ 55. ‘‘Methadone make you feel better in a way because with suboxone, you feel the lows and the highs’’ 61. ‘‘no need to look for other drugs’’ 71. ‘‘have a clearer head’’ Why has Buprenorphine–naloxone helped you think more clearly?

5.‘‘yes, it’s given me better clarity of mind and I don’t need to wear glasses anymore’’ 9. ‘‘make me more aware of what’s going on and I know what I am doing’’ 25. ‘‘I have better clarity’’ 39. ‘‘I was very forgetful, but now my memory is better’’ 62.‘‘don’t feel groggy’’ 71. ‘‘just able to think better about decisions’’ Why has Buprenorphine–naloxone changed your life in any other way?

5. ‘‘its improved my love life’’ 31. ‘‘you can’t take anything on top of suboxone’’ 42. ‘‘my depression has improved’’ 45. ‘‘I now have better take home arrangements’’ 46. ‘‘I am a much happier person’’ 62. ‘‘it works in just half an hour and you know you’ll get no effects from opiates’’ 72. ‘‘applying for jobs’’ 82. ‘‘was able to get a flat’’ 83. ‘‘able to keep a relationship – easier to come off it when you get that support, now have goals in life’’ 84. ‘‘got a job, before couldn’t have managed to do this’’ Why do prefer methadone/buprenorphine–naloxone?

9. ‘‘prefer Suboxone because it makes me more aware and I have a better quality of life’’ 11. ‘‘I prefer Suboxone as methadone is just covering up another problem, it doesn’t help you to get rid of it’’ 14. ‘‘I prefer methadone as Suboxone made me sick’’ 30. ‘‘I prefer Suboxone as its easier to deal with as people don’t judge you the same’’ 33. ‘‘I prefer methadone because I’m constant at it’’ 35. ‘‘Methadone: because I am stable’’ 36. ‘‘Suboxone: it’s a lot easier to come off’’ 39. ‘‘suboxone: I am fine with the dose’’ 40. ‘‘Suboxone: I am more alert’’ 43. ‘‘methadone: its faster working’’ 55. ‘‘suboxone: no fuzz or cloud’’ 57. ‘‘methadone: I am stabilised on it and I’m drug free’’ 60. ‘‘suboxone: I have a clearer head’’ 71. ‘‘I prefer Suboxone as I think I can come off it’’ 75. ‘‘I prefer methadone as when I took Suboxone I just lost lots of weight and couldn’t keep it up’’ 79. ‘‘I prefer methadone as Suboxone just made me feel terrible’’ 82. ‘‘I prefer Suboxone as I can think better and I want to come off it’’ 83. ‘‘I prefer Suboxone as I can think straight and have normality’’ 86. ‘‘I prefer Suboxone as I can think straight but methadone just made me numb’’ Why would you/wouldn’t you consider trying buprenorphine–naloxone in the future?

1. ‘‘I’ve heard it’s easier to come off than methadone’’ 2. ‘‘I want to achieve abstinence and I’ve heard it’s easier to come off than methadone’’ 3. ‘‘It’s easier to come off’’ 4. ‘‘It’s easier to withdraw from and there is less supervision required’’ 5. ‘‘it’s something different, would try anything’’ 7. ‘‘it’s easier to come off and allows you to think more clearly’’ 8. ‘‘It’s easier to come off’’ 10. ‘‘It’s easier to come off and I want to achieve abstinence soon’’ (continued) 176D. R. Hill et al. J Subst Use, 2015; 20(3): 168–177 15. ‘‘it may be a better drug’’ 16. ‘‘it’s a different drug, I would be willing to try any drug’’ 17. ‘‘It’s easier to come off’’ 18. ‘‘I wouldn’t consider Suboxone in the future as I am happy on methadone’’ 19. ‘‘I have been told it’s easier to come off’’ 20. ‘‘its something different, it may help’’ 21. ‘‘I wouldn’t consider trying it as I am happy on methadone’’ 22. ‘‘I would consider it in the future but I’d need more information about it first’’ 23. ‘‘I wouldn’t consider trying Suboxone as I am happy reducing my dose of methadone’’ 24. ‘‘I wouldn’t consider trying Suboxone as I am happy reducing my dose of methadone’’ 25. ‘‘it’s easier to come off and easier to take’’ 29. ‘‘I wouldn’t consider trying it in the future as I would be frightened to stop methadone as I have achieved stability on it and I wouldn’t want to waste it’’ 32. ‘‘I see a difference in my partner, and I’ve heard it give you a clearer mind’’ 33. ‘‘Methadone makes you nauseous’’ 36. ‘‘Suboxone is a lot easier to come off’’ 37. ‘‘its a lot easier to come off’’ 38. ‘‘I’ve heard a lot of good results with suboxone’’ 44. ‘‘I’ve heard it’s a lot easier to detox’’ 46. ‘‘It is a tablet form’’ 49. ‘‘I would not consider it, a friend of mine in prison died from it’’ 50. ‘‘I’ve heard it is a lot easier to come off, whereas with methadone it is a lot harder’’ 52. ‘‘methadone sometimes gives you a sleepy side effect. I’ve heard with suboxone you get all your feelings back’’ 53. ‘‘I know people who have been taking it and heard good reports about it. People have been happy with suboxone.’’ 54. ‘‘I know other people who have had it and they are settled’’ 56. ‘‘I have heard it is better from people’’ 57. ‘‘I would not consider it because I am stabilised on my methadone and hopefully I can come off that’’ 58. ‘‘methadone isn’t working. I feel like a prisoner because I have to go to the chemist’’ 63. ‘‘I wouldn’t want to change to anything as I’m settled on the methadone’’ 64. ‘‘I’m happy on the methadone, don’t want to change in case I upset how I’m doing’’ 67. ‘‘I’m coming off everything so won’t need to try anything’’ 68 ‘‘I’m doing fine with methadone but maybe if I knew more about it might be better for me’’ 69. ‘‘I’ve heard it’s better to come off’’ 70. ‘‘happy just to stick to methadone’’ 73. I’d rather just stick to what I know since I know I’m doing alright with it’’ 74. ‘‘I’m happy with the methadone, I’ve heard bad things about Suboxone ’’ 76. ‘‘I’d like to try it, I’ve heard people function better on it’’ 78. ‘‘I’ve heard Suboxone is harder to come off than methadone’’ 80. ‘‘don’t want to change, the methadone is keeping me off drugs and the tablets might not’’ 81. ‘‘happy with being on methadone, been on it too long to change’’ 84. ‘‘wouldn’t want to change as methadone is working well this time since I’ve got newfriends and I’m getting counselling’’ 85. ‘‘I’m happy with my methadone, it works fine if you mean it’’ 87. ‘‘happy just sticking with what I’m on, tried enough drugs in my life already’’ 88. ‘‘I’m coming off methadone so I won’t be needing anything anyway soon’’ 89. ‘‘happy sticking to methadone just now’’ 90. ‘‘I don’t want to change’’ DOI: 10.3109/14659891.2014.894589 A comparison of methadone and buprenorphine–naloxone177 Copyright ofJournal ofSubstance Useisthe property ofTaylor &Francis Ltdand itscontent may notbecopied oremailed tomultiple sitesorposted toalistserv without thecopyright holder's expresswrittenpermission. However,usersmayprint, download, oremail articles for individual use.