Methadone dosing

Detoxification is more successful when the patient is transitioned from a stable methadone dose with the support of ongoing therapy than when the patient comes directly from the street for detoxification from heroin. Some practitioners believe that detoxification with clonidine can be more rapid than with methadone, at least on an outpatient basis. One important hmitation of clonidine is that, although it suppresses autonomic signs of withdrawal, subject-reported symptoms, such as lethargy, restlessness, insomnia, and craving, are not well relieved (Charney et al. 1981 Jasinski et al. 1985). Anxiety may... 

LAAM (L-a-acetylmethadol or levomethadyl acetate) is a full agonist at the i opioid receptor with pharmacologic properties similar to those of methadone. A number of studies have demonstrated that treatment with LAAM results in reduction of opioid use and beneficial effects comparable to those achieved with methadone (Ling et al. 1978 Tennant et al. 1986 Zangwell et al. 1986). However, retention rates are higher in patients who take methadone doses of 80—100 mg/day. 

The initial dose of buprenorphine should be given at least 12-24 hours after the last heroin dose, 24 hours after the last methadone dose, or 48 hours after the last LAAM dose (see Table 2-3). The methadone dosage of methadone maintenance patients should be reduced to 30 mg/day before the transfer to buprenorphine is attempted. Ideally patients should show clear evidence of opiate withdrawal before receiving the first dose of buprenorphine, to avoid the risk that buprenorphine will precipitate more severe withdrawal. For the first day, sublingual buprenorphine/naloxone doses of 2/0.5-4/1 mg can be given every 2-4 hours, up to a maximum total dose of 8/2 mg/day. On the... 

Shi J, Hui L, Xu Y, et al Sequence variations in the mu-opioid receptor gene (OPRM1) associated with human addiction to heroin. Hum Mutat 19 459 60, 2002 Shinderman M, Maxwell S, Brawand-Arney M, etal Cytochrome P4503A4 metabolic activity, methadone blood concentrations, and methadone doses. Drug Alcohol Dependence 69 205-211, 2003... 

Tenore PL Guidance on optimal methadone dosing. Addiction Treatment Forum 12(2) Spring, 2003, p 3... 

Carbamazepine is an inducer of CYP3A4 and methadone is primarily metabolized via CYP3A4 if carbamazepine is added to a drug regimen containing methadone, the methadone dose will probably need to be adjusted upward to avoid withdrawal. 

Nervirapine is an HIV drug that is a CYP3A4 inducer in a small sample, nevirapine caused a 50% reduction in methadone blood levels, resulting in complaints of methadone withdrawal symptoms in patients receiving methadone maintenance may need to increase methadone dose in patients who have nevirapine added to their drug regimen. 

An inducer of many CYP450 enzymes may result in complaints of withdrawal symptoms in methadone maintenance patients when added to their drug regimen may need to increase methadone dose. ... 

Phenytoin Similar to phenobarbital may need to increase methadone dose when phenytoin is added to a methadone maintenance drug regimen to avoid withdrawal symptoms. 

If L-methadyl acetate hydrochloride is used instead of methadone dosing is three times weekly. 

Methadone is not a tranquilizer patients may react to problems and stresses with the same anxiety symptoms as others do. Do not confuse such symptoms with narcotic abstinence do not treat anxiety by increasing the methadone dose. 

Patients taking methadone or other long-acting opioids Withdrawal appears more likely in patients maintained on higher doses of methadone (more than 30 mg) and when the first buprenorphine dose is administered shortly after the last methadone dose. 

Methadone Coadministration increased oral methadone clearance by 22%. An increased methadone dose may be required in a small number of patients. 

The inclination to rely on the caring capacities of a ten year old was unusual. However, the drive to contain the situation was not. The first response was most likely to be one of finding a means of ameliorating the present situation (contact the extended family, review the methadone dose, put in some home support), and, then to review the situation ... 

Prescribers often worried about the risk of increasing methadone dose in combined usage, but overall high-dose methadone reduces both such use and mortality... 

Even in a short-term detoxification, an initial stabilizing period on the same methadone dose is often desirable, so that the user gains confidence in the treatment, and the effects of cessation of other drugs can be gauged before dose reduction. Further counselling on the withdrawal process can be done in this period, as typically some aspects do not sink in while negotiation to secure methadone treatment is still under way. 

Donny EC, Brasser SM, Bigelow GE, Stitzer ML Walsh SL (2005). Methadone doses of 100 mg or greater are more effective than lower doses at suppressing heroin selfadministration in opioid-dependent volunteers. Addiction, 100, 1496-1509... 

Hartel DM, Schoenbaum EE, Selwyn PA, Khne J, Davenny K, Klein RS Friedland GH (1995). Heroin use during methadone maintenance treatment the importance of methadone dose and cocaine use. American Journal of Public Health, 85, 83-8 Hartnoll RL, Mitcheson MC, Battersby A, Brown G, Elhs M, Fleming P Hedley N (1980). Evaluation of heroin maintenance in controlled trial. Archives of General Psychiatry, 37, 877-84... 

Preston KL, Umhricht A Epstein DH (2000). Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance. Archives of General Psychiatry, 57, 395-404... 

Once the client has been assessed and is stable on their prescribed methadone dose, the attention should then be placed on arranging an appointment to include the rest of the family. It is sometimes necessary to hold several preliminary sessions with the client individually, in order to gain their final acceptance and co-operation when inviting the family to attend. Throughout these preliminary sessions the therapist should avoid engaging the client in discussion about treatment issues. This is necessary if the therapist is to avoid becoming alienated from the rest of the family. Our experience suggests that the therapist contact the parents directly rather than leave it to the user. It can be useful to telephone the parents at a time when the addict is with the therapist. If this is not possible, a letter... 

A 31-year-old white man with depression, hepatitis C, and cirrhosis of the liver was hospitalized for alcohol detoxification. He had taken methadone 50 mg bd for opium dependence for 6 months. He developed bilateral pedal edema and 27 kg weight gain. There was no ascites, portal hypertension, or congestive heart failure. Most of his laboratory tests were within the reference ranges, except for reduced prothrombin time and platelet count. After stopping alcohol, his methadone dose was reduced to 60 mg/day his edema resolved 15 days later. When the dose of methadone was increased to 70 mg/day there was a progressive increase in the edema. When methadone was withdrawn his edema completely resolved and he lost 8 kg in 2 weeks. 

Methadone maintenance treatment was established in 1964 in New York City by Vincent Dole and Marie Nyswander. In the initial studies, subjects who were heavily addicted to heroin were evaluated and stabilized on daily methadone doses as inpatients before transfer to an outpatient clinic for continued treatment. With further experience, it was feasible to drop the inpatient phase (65). 

---