TOXICOLOGY ASSOCIATES

PHYSICIAN GUIDE TO INITIAL METHADONE DOSE

Having determined from history and physical examination that a patient is physiologically dependent on opiate drugs and eligible for admission to Methadone maintenance treatment, an initial dose between 0 and 30 mg must be ordered.

INITIAL DOSE 0 MG:

The patient may have used his last available dose of opiate just prior to presenting for admission, with or without physical evidence of use, and appearing “stoned.” The patient should be asked to return when he is off his “high” before administering the initial dose of Methadone.

The patient may qualify by history of opiate drug use by oral route, nasal insufflation or smoking and have no physical evidence substantiating drug use, and appear normal on examination. Initial administration of Methadone should be deferred until substantiating evidence is available. Useful information includes old prescriptions, prescription drug bottles, pharmacy records, confirmation by a treating physician of excessive opiate prescriptions and/or drug seeking behavior, statements signed by significant others concerning patient’s drug use, and a positive urine for opiates. It is unexpected but not impossible that an opiate dependent patient could present with a normal physical appearance and urinalysis negative for opiates. Initial Methadone dose should be deferred until additional data is collected.

INITIAL DOSE 10 MG:

The patient qualifies for admission to Methadone maintenance treatment for opiate dependence but the frequency or dose is in question. Physical signs of recent drug use are identified but symptoms and signs of withdrawal are not manifest. Examples are episodic use during the past year, or use two to three times a week.

The patient has been on Methadone maintenance treatment and was discharged after reducing his dose to 0. He returns to the program within two years with the urge to fix but not dependent currently.

The patient presents within six months of release from prison having been convicted of a drug-related crime and is qualified at the time of incarceration from Methadone maintenance treatment but not dependent currently.

The patient is pregnant and currently using opiate drugs but does not otherwise qualify for Methadone maintenance.

INITIAL DOSE 20 MG:

Twenty milligrams is an intermediate dose which will result in significant signs and symptoms of opiate excess in patients who are not tolerant of opiate drugs but may be adequate as an initial dose for entry into the titration protocol for those whose intensity of opiate use is moderate.

INITIAL DOSE 30 MG:

Thirty milligrams of Methadone is the maximum first dose permissible. This dose usually is inadequate to control withdrawal symptoms in a patient who qualifies for Methadone maintenance treatment but will reduce intensity and delay onset of symptoms.

INITIAL DOSE 30 MG WITH ADDITIONAL 10 MG:

The patient presenting with disabling withdrawal symptoms that are not attenuated one hour after the first dose of 30 mg may be administered an additional 10 mg under direct supervision, for a total of 40 mg for the first day.

TITRATION PROTOCOL:

Titration is a dose-finding procedure which permits determination of the appropriate maintenance dose. A probable maintenance dose may be determined by stepwise increase of 5 to 10 mg daily while monitoring for signs and symptoms of opiate drug effects 24 hours after each dose. Further increases are stopped after signs and symptoms of withdrawal have been controlled. Continuing the same dose will result in an increase in the blood level of Methadone over several days. At this point, the titration protocol is complete.

REFER TO THE TITRATION PROTOCOL.