TOXICOLOGY ASSOCIATES

TITRATION FOR DETERMINATION OF APPROPRIATE METHADONE MAINTENANCE DOSE

25,000 PATIENTS SINCE 1976, USING STANDING ORDERS AND PERSONALLY TRAINED STAFF

(NOTE: THIS PROCEDURE PRECEDE THE MANDATE THAT STANDING ORDERS ARE PROHIBITED BY FEDERAL REGULATIONS)

The titration procedure is both dose-finding and an objective measure of tolerance.

Before initiation of the titration procedure, the patient should understand clearly that the purpose is to determine the dose of Methadone which will prevent withdrawal symptoms while not resulting in impairment from excessive dose. It should be explained that the initial doses of Methadone might not completely relieve symptoms of withdrawal. It is vital that the patient understand that using additional opiates other than dispensed by the clinic will prevent the treatment from working and could be life-endangering. Treatment during the first two or three days may not completely relieve symptoms but will reduce their severity. The patient should note any symptoms and the time of day that they occur so that they may be reported to the nurse the following day. The patient will be seen by both the counselor and the nurse, and signs and symptoms recorded on the forms provided in the chart.

Titration is a method for determining the appropriate daily dose of Methadone based upon the generally accepted pharmacologic principle that physiologic dependence on a drug cannot occur without frequent use causing the body chemistry to change to accommodate the constant presence of the drug. As a result of change in body chemistry, tolerance to the drug occurs. Tolerance causes increasing amounts of the drug to be required in order to achieve the same effect. The titration procedure measures the existence of tolerance or lack of tolerance to the drug. A patient who is not tolerant of the drug is not dependent and therefore not addicted. A person who is addicted will be tolerant of many times the usual therapeutic dose. The titration procedure permits a determination of drug dependence independent of any drug history related by the patient. A patient who is not using opiate drugs will experience significant sedation from a single dose of 20 mg. A patient who is a frequent user of opiate drugs will experience no sedation and only modest reduction of withdrawal symptoms when 30 mg of Methadone are administered.

INITIAL DOSE:

The initial dose administered will be selected by the physician (See Physician Guide to Initial Methadone Dose). The effectiveness of each dose is determined by observation of objective response as well as subjective symptoms reported by the patient and the time after administration of the first dose that the symptoms were manifest. If the patient has symptoms and objective signs of opiate withdrawal which persist after one hour of observation on the first day, an additional 10 mg of Methadone may be administered. Under these circumstances, the dose of Methadone administered on the first day may be as much as 40 mg. The first dose of Methadone may be 10, 20 or 30 mg.

The first day total dose should never exceed 40 mg.

On the second day, the dose of Methadone may be increased, remain the same, or decreased depending upon symptoms. If the patient appears sedated, the dose should be decreased by 5 or 10 mg depending upon the degree of sedation. If such a patient received a low starting on the first day, the staff should discuss alternative treatments with the patient.

The interim use of non-opiate sedative hypnotic or tranquilizer drugs also should be considered. If the patient has experienced withdrawal distress within 12 to 24 hours of the first dose, the second dose should be increased by 10 mg. If the patient has no complaints when presenting on the second day, the dose of Methadone should not be changed. Subsequent doses of Methadone may be increased or decreased by five or

10 mg depending upon the patient’s clinical status when presenting for medication after 24 hours. The dose of Methadone administered to the patient should not be increased on any day when a visit to the clinic is not scheduled for the day following.

During the titration period, the counselor should see the patient on each day and record in the chart on the appropriate form available to the nurse the events occurring during the preceding 24 hours. This information will assist the nurse and the doctor in the decision to modify the dose of Methadone.

At least two different types of dysfunctional behavior commonly occur. One is the patient who is determined to obtain as much Methadone as possible and underreport symptoms of sedation. Another is the patient who underreports symptoms of withdrawal in the belief that more Methadone will be more addictive. The patient should be encouraged to accept whatever dose is required for a symptom-free state.

During the titration period, the dose of Methadone is adjusted daily by 5 or 10 mg up to 60 mg per day. Between 60 and 80 mg, standing orders allow the dose to be adjusted as required in 10 mg steps up to 80 mg, with a minimum of two days on each dose.

For example, the patient must have been on 60 mg for two days prior to consideration of an increase to 70 mg, and the same procedure prevails in a change from 70 mg to 80 mg.

If the clinical response to 80 mg per day is not adequate, then a “REQUEST FOR DOSE CHANGE” form must be completed and approved by the program physician before further increases are given.

Both staff and patient should be mindful that any change in dose requires about three days for the maximum effect to be realized. The target dose is the amount that prevents withdrawal, reduces drug craving, and helps block effects of other opiates without causing sedation or any other interference with normal functioning.