Methadone Dosing in Opioid Treatment Programs: Use the Evidence

The most successful opioid treatment programs and the most successful patients in those programs use evidence-based dosing of methadone. Many studies over the last 40 years show patients do better on adequate doses of methadone. They have better outcomes when they’re on enough methadone to block physical withdrawal signs and symptoms than when they’re on insufficient doses.

In the past, methadone clinics often had dose caps. Some clinics told their patients they didn’t need any more than 60 or 70mg of methadone per day.  But over the last 40 years, we have multiple studies showing poorer outcomes at clinics with these low dose caps, as opposed to individualized dose determination. Numerous studies show higher drop-out rates in patients on doses less than 60mg, as well as more illicit opioid use and higher rates of HIV infection, as compared to patients on 100mg or more. For most patients, the blocking effect is seen in the neighborhood of 80 to 120mg of methadone per day.

However, there’s a great deal of difference between how patients metabolize methadone. A patient with slow methadone metabolism may do best on 30mg of methadone per day, and a fast metabolizer may need much more than 120mg per day. This rate of methadone metabolism is probably determined by our genetics. When patients ask me how much methadone they should be taking, my answer is, “Enough.” I’m not advocating taking doses higher than they need to be, but if the patient looks like they’re in withdrawal, and they feel like they’re in withdrawal, it’s best to take the dose up. We want to use the lowest effective dose.                                                                                                                                 

There are still misguided opioid treatment programs that try to keep methadone doses low. Sometimes clinic staff can send shaming verbal or nonverbal messages, and imply patients who ask for an increase in their dose are somehow trying to get one over on the clinic. Staff shouldn’t shame patients who ask for a dose increase; staff should defer decisions about methadone dosing to their medical personnel.

Sometimes patients don’t want to increase their dose of methadone because they have mixed feelings about their treatment. If they feel guilty about being in a methadone program, they may want to keep their dose low. Sometimes family members, with the best of intentions, will demand the patient stay on a low dose, not understanding that their loved one is less likely to do well on an inadequate dose.

Frequently I see patients who are feeling bad, not sleeping, and achy all over in the mornings, and dosing at 40mg. I ask them if we can increase their dose, and they say something like, “No, I promised myself I wouldn’t go higher than 40mg.” Too often, patients don’t increase their dose for fear that coming off methadone will be harder to do at higher doses. This is partly true. It may not be harder to come off of, but it does take longer to taper off a higher dose. But the patient won’t do as well while they’re in treatment, so what’s the point?

Some patients prefer low doses because they want to have just enough methadone per day to keep them out of terrible opioid withdrawal, but not so much to block the euphoria they get from using an illicit opioid later in the day.

I tell patients that methadone is a little like chemotherapy. For chemo to work, you have to take a big enough dose to do the job. It’s the same way with methadone. It’s not a perfect analogy but patients get what I’m saying.

Let’s turn to the other side of dosing. I’ve seen some clinics with many patients on what I would consider very high methadone dosing. It’s hard to criticize, because I do think there are some patients who need doses higher than 250mg, particularly if they’re on certain medications, or are pregnant. But that’s rare, and at some clinics, many patients seem to be on these big doses. Since these patients have their dose increased slowly, they build a tolerance to the methadone, so such patients aren’t sedated. There’s no long-term damage to the body with very high dose methadone, but higher doses can cause some problems.

It may be hard for a patient on a very high dose to transfer to another clinic. Some methadone clinic medical directors are hesitant to accept a patient in transfer if they’re on 200-plus milligrams of methadone, unless there’s evidence that this dose is required. For example, I was looking over the records of a patient on 290mg, in preparation for transfer. This man was on no other medications and otherwise healthy. When I saw the peak and trough data, I was puzzled, because they were both high, and this was done at 200mg of methadone. So why was the patient taken to 290 milligrams? I know peak and trough levels aren’t the only factor to be considered when determining the right methadone dose, but there was scant information about why the doctor decided to raise the dose, or even if the patient had even seen the doctor recently. I wasn’t particularly concerned the patient would be sedated, because the dose had been raised slowly, over months. But I was concerned that the patient was on more methadone than he needed, especially since many of the patients at this clinic were on doses of more than 200mg per day.

Some studies have shown higher doses of methadone affect the way electrical impulses are transmitted through the heart. In some studies, higher methadone doses are more likely to produce prolongation of the QT interval than lower doses. (2) This QT prolongation does put patients at risk for a potentially fatal heart rhythm problem. The medical literature at present suggests that periodic EKG screening of patients on doses above 100mg is probably a good idea, but there’s still disagreement on this issue.

There is another factor to be considered. This may offend some readers, but we need to acknowledge the nature of addiction. It’s a disease who tells its sufferers, “More is better!”  I think it’s important to acknowledge this point, and discuss it openly, but not in a shaming way. This psychological part of addiction doesn’t always go away within the first few weeks.

My approach to a patient on a relatively high dose, who desires an increase in methadone, is to meet with the patient, preferable prior to dosing. Sometimes I like to meet the patient two hours post-dose if I’m worried about sedation. I ask about withdrawal symptoms and check for pupil size and reaction, and other signs. I check the last drug screen. If the patient doesn’t describe withdrawal symptoms, and I don’t see objective signs of withdrawal, I’ll ask the patient how they expect to feel on an ideal dose of methadone, and if it’s possible their addiction is driving the desire to increase. I’m surprised that most patients aren’t offended, but welcome the opportunity to talk openly. Some patients say they honestly can’t tell if they are in withdrawal, or if their addiction tells them they are in withdrawal. My job is to help decide which it is.

Some patients feel “high” for the first few days after a dose increase, but tolerance builds quickly to this feeling. Some patients mistakenly believe they should always get that high after dosing. If the addiction is driving the patient’s way of thinking, the dose may never be “enough.” When I explain this to patients, most understand.

I could be wrong, but I have an impression that very high doses are seen more frequently in patients enrolled in large, for-profit methadone clinic chains, with numerous facilities scattered across the country. I wonder if the doctors working there talk often with their patients, examine them, and talk about their symptoms and expectations.

I’d like to hear feedback from patients at opioid treatment centers. What do you think? Are clinic doctors too reluctant to order dose increases? Or too quick to increase doses, without talking to the patient?

 

  1. http://international.drugabuse.gov/sites/default/files/pdf/methadoneresearchwebguide.pdf

      2. Krantz, Lewkowlez, Hays, et.al., “Torsade de Pointes Associated with Very-High Dose Methadone, Annals of Internal Medicine, Sept. 17, 2002, Vol 137(6) pp 501-505.

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11 responses to this post.

  1. Posted by Mae on November 25, 2011 at 7:38 pm

    I’m a nurse at a methadone clinic, and we very much advocate for dose increases based on subjective and objective symptoms. We have an induction protocol, and well educated nurses that work to get patients at a comfortable dose within the first 30 days, safely! We don’t have a cap on patient doses, but we do monitor them closely. Patients on doses over 120 get peak and trough done before further increases, and also EKG to monitor for the prolonged QT interval. The nurses provide a lot of education to patients during the first 30 days as well. We are a small, not for profit program and a very nicely run one if I must say so myself.

    PS I really enjoy reading your blog! Thank you for your advocacy on behalf of the patients we serve!! :)

    Reply

    • Thanks for writing! It sounds like you have a well-run clinic. And I agree – nurses are key personnel for education, evaluation…and many other things. Many people don’t get how complex the nurse’s job is & think it’s just about dispensing the dose.

      Reply

  2. I really don’t know how to answer un-objectively as I am one of those patients that has to be on a higher dose. I am at 170 after 2 years of MMT. My clinic does P&T but because I am a hard stick and the nurses gave up several times trying to do a P&T as on one occasion I was stuck 11 times no success and the other time 9 times no success, finally about 9 months after the last try my chart was pulled for a mandatory P&T and I am not sure why the difference but the nurse was able to get both levels/draws with only six sticks, but finally after 18 months I got the P&T. After reading this I am quite upset to read that the doctor and/or nurses could have done things other than the P&T to determine if I needed an increase or nor, but that was never given as any option to me. No P&T no increase. I have still suffered cravings almost daily and I also every evening suffer a routine of what I call withdrawals symptoms. My nose starts to run. I begin to feel flu like symptoms, Goosebumps, hot/cold flushes, leg cramps, sick to my stomach and the worst being not as usual but occasionally I get the stomach cramps, diarrhea where I actually have the hot but yet cold flushing but yet sweating so bad I have to change my clothes that is the worse and thank god that is not a every night occurrence or I would have just given up. I say I experience what I call withdrawal symptoms at night as they play themselves out very methodically at night but off and on throughout the day I experience the same but not head on uninterrupted like I get them at night. Yes I have had staff and nurses look at me like I am wanting more, more, more but actually that’s not fair to jump to that conclusion as I was admitted and in my admission I was told I could increase all the way to 160 and at 160, I would have to see the doctor again and also have a P&T apparently not in that order as I never got approved to see the doctor because I had to have the P&T first and then with my results I would be given an appointment. After their failure of getting my blood of course I requested to see the doctor anyway, but my request were met with rude and accusatory remarks of me being drug seeking etc, suffered retaliations in my objections so I just gave up and at times have sat on my hands etc…as not to get high and give MMT up as not yet were the withdrawals so bad that I was ready to use and suffer the consequences I will face with my family and friends if I start using again. I won’t go into my complaints about the clinic and nursing staff as I have already had a conversation online with you regarding my treatment at that clinic. Those nurses when they had to do the blood draw because my chart was pulled for a mandatory I think they thought I had went over their heads or something (which I did not) began really giving me hell and so even before I got the P&T results back, I left the clinic and went to another clinic, but wrote a grievance also. Anyways I am the perfect one to post on this blog you have written as I am one of those clients that has relevancy to everything you speak of in this blog. As I go even further in my post you will see. I never got the observation choice for increases and had to depend on a P&T and when my results came back I was 881 peak and 226 trough so apparently I am somewhat a fast metabolizer so therefore maybe I was telling the truth and not drug seeking for more methadone which I do not feel high on anyway. But…..I also run qtc’s at 527 was my last one which was done today as on a quick note my grievance was satisfied at the old clinic and the director called me back to talk with me regarding that and we talked about my P&T and what the doctor had ordered before I left and they did indeed have intentions in finally believing my complaints of cravings and withdrawals and the doctor was going to increase me but watch my qtc’s also, but they promised me they would not give up on me just because I am one of those patients that needs higher dose but yet run high qtc’s etc…I do understand you as you have blogged with me concern in dosing me with high qtc’s regarding the fact that it can be fatal but me returning to drugs which I have a 30 year relapse history 11 inpatient treatment and 9 detox visits so I am convinced I will return back to dope is even more dangerous to me as at least this way I do have some quality of life. My addiction to me is like a terminal disease the way I see it as every relapse has been worse than the one before and it cannot get much worse than jail or death and one or the other would be my end I am sure if I return to using. So with all that being said what do you do with a client like me???? Keep me low dose because of my qtc’s and see how long I can deal with the withdrawals and cravings? Put me on suboxone which I have tried three times and I not only cannot afford it without engaging in criminal activity to get the money which leads me into the world where the drugs are there in front of me waiting for me to relapse but I have not had any success with it? Discharge me because I am a liability on Methadone to the practice, but yet a liability to myself if I am discharged (not your problem though)? (OF COURSE I AM NOT SAYING “YOU” MEANING LITERALLY YOU (any MMT doctor with my case in front of them) And..Just for the record upon my readmission yesterday at my old clinic in my medical assessment, the nurse indeed said I displayed quite a few withdrawal symptoms in her COWS (sp???) Assessment. So if they would have not just depended on the P&T maybe they would not have been so quick to judge me. And….one more thing, Early in MMT I do remember at times late evening feeling a little sedated but all I had to do was sit up and/or move around a moment or two and it passed. I have not felt sedated since then. I hope you do not regret asking the following:
    I’d like to hear feedback from patients at opioid treatment centers. What do you think? Are clinic doctors too reluctant to order dose increases? Or too quick to increase doses, without talking to the patient?
    As I am sure my post seems lengthy and maybe even I rambled a bit, but I felt the need to respond to you asking anyone to respond as I am the poster client to all the issues you pointed out in this post/blog you wrote.

    Reply

    • Wow. Yes, your case is a great example of the complexities encountered trying to get to the right dose. Would you mind if I presented your case (anonymously, obviously) to my group of OTP doctors? In my state we have a teleconference once monthly, and I’d like to present your case if there’s time, to see how other doctors would approach this very difficult situation.

      I think some clinics would see you as a liability, and encourage you to transfer. This is sad. And it’s also a reality in our present political environment. There are lawyers who would jump at the chance to get your loved ones to sue the clinic if you died of a prolonged QT interval, even though your options aren’t good.

      Ordinarily, many doctors, faced with your peak and trough results, would consider split dosing. This way, your methadone blood level doesn’t reach such a peak in the mornings, or such a low at nights. In this manner, at times the patient’s dose can be edged back, particularly if the QTc is long, like your. I think I remember you saying you tried this and it didn’t work?

      I’m sad you didn’t get to meet with the clinic doctor when you wanted to do so. I do think if the doctor examined you before dosing, when your blood level is at its lowest, she could have seen withdrawal signs, when they’re severe like you describe.

      Please update us periodically.

      Reply

      • I did meet with the Doctor today? And he did do a few things in examining me. He said my pupils were an 8 (he was telling this to the other staff) and he felt my clammy skin was also a marked withdrawal sign. Before he did the exam he said he would think my peak should have not been in the 800’s as that is a good peak but then he did the exam and he became I think more convinced as he gave me 5 mg a week for four weeks at split dose with a new doctor appointment and maybe redo another P&T and EKG at that time if I still feel bad. But when we first began to talk he took every withdrawal complaint I gave him and he gave me another reason I may feel this complaint like not enough exercise, leg cramps could be deficiency somewhere, flushes could be hormonal, runny nose at night and early morning allergies etc…But I must say after thirty years I have a “real good idea” of what I feel like when I am in withdrawal it happens the same in the order and urgency. And….I must say I also can’t help but throw in the fact that when I dose I feel better. They all go away for awhile. Maybe Methadone would help all those if they are unrelated to withdrawals but I feel that is another factor to take into consideration.

        This morning, I was fearful that maybe the director had made me feel like the doctor would help me if I came back to the clinic but maybe had made promises he was not going to be able to keep. As like I said the doctor at first tried to convince me I was maybe misinterpreting my ailments. He let me know he felt the qtc issue was a very pressing problem but he said we at this clinic do believe in informed consent so he ask me to tell him what I had researched and knew about qtc prolongations so I told him but I also told him that I was more afraid of my history of relapse and how each relapse became worse than the one before so I felt both issues weighed about the same to me but with one option I at least had quality life to look forward to by staying on Methadone.

        In retrospect, those few weeks here back helping my friend with her Father at Hospice let me know I am a few cravings away from a relapse and I had been in a very shaky position romancing the ideas of morphine etc… That scares me. My scales to weigh the pro’s and con’s on I know are different than the doctors and/or clinics, but in all actuality mine count the most in determining the probable outcome as I know what happens if I lose MMT. He in the end admitted this to be a very complex situation, but he did not feel that dope would be a better option in any case so I think he bent some for me and I really appreciate that too. So with that being said, I am going to get more exercise, sign up at the local hospital for the quit smoking support group, pray and think very positive thoughts about this indeed being the chance I have needed to succeed in diminishing my ails and woes.

        As for your request, of course you can use my case in any forum that would educate or help in the study and/or education to benefit MMT. If I can be of any assistance….you can email me and I will give you contact information if you need phone contact with me etc….

  3. I do not mean this in any offensive way at all so please do not think I an putting you or any doctor on the spot, I just really would like to know your opinion on exactly what do you do when you have a client like me with the issues I have and the methadone has worked for somewhat atleast not optimal but I have at least made it so far. So in your opinion (which I respect greatly) what do you do with a client like me???? Keep me low dose because of my qtc’s and see how long I can deal with the withdrawals and cravings in like a compromise in that I can’t take optimal dosing but I have had some quality life at least on dosing sub optimally? Put me on suboxone which I have tried three times but I have not had any success with it in hopes that I can not repeat history? Or, discharge me because I am a liability on Methadone to the practice, but yet a liability to myself if I am discharged?

    Reply

  4. Posted by G Bahm on April 23, 2013 at 10:03 pm

    I’ve been going to a methodone clinic for over 5 years and been on a stable dose for 4.5 years its been doing well for years now I wake up in the middle of the night with slight withdraws my dose is at 120 mlgs a day I think I need to be on a higher dose but the red tape to get over a dose of 120 a day is time consuming and expensive the clinic I go to requries a peak and trough to go higher is that the case at all clinics or is that the law in my state of Louisiana

    Reply

  5. Posted by Ron on June 12, 2013 at 3:17 am

    Thank you for your blog very helpful. I’m a 61 yr old male been an addict alcoholic since the age of nine, was a pro musician for years ruined my career because of shaking so bad could not play anymore and don’t remember over 1/2 of my life, I finaly decided I want to live, I’ve been in treatment since Oct. 23rd. My cravings are finally tolerable at a dose of 175 they have asked me to get a pt, I haven’t drank or used since Oct. 23, and even quit smoking on April 23rd. I’m on a split dose, I am scared to death they will take my split away or lower my dose, I won’t make it if they do and everybody tells me nobody passes a pt. I have all kinds of thoughts going through my head, liability etc. never had a dirty ua. Your thoughts do I need to be scared?

    Reply

  6. im a 34yr old female&ive just read ur blog&iim impressed at ur views of how MMT doctors should treat patients.im prayin u can give me sum advice cause my life is goin n a downward spiral.ive been a MMT patient,in NC for 11yrs&have been very succseful on a dose of 135-140mgs.i have gotten to a level5 take home regimen.(6 bttles a week).i was so proud of myself&was doin great until i seen the Dr. a few weeks ago.he looked over my charts&had an ECG run&said my QT intreavals was to high at 446.(i thought for women it was good at 450&at 500 it should be worried about?)i was lowered 5mgs&was ordered to hve repeat ECGs every 10days.if the QT wasnt better lower 5mgs more!i looked at my take home 2days ago&they had taken me down 5mgs more without tellin me&i come in today&told i had 2 hve ECG&lose 5mgs more if its bad.im n major withdrawl(leg cramps,hot wth cold sweats,etc.)BAD cravings!the dr told me no1 should be ovr 100mgs&i needed 2 get off methadone?!what should i do?it seems his mind was made up b4 i was seen!

    Reply

    • First, your doctor may have a legitamate concern if your QT interval is long. The interval you gave, at 446, would not make me want to bring down the dose of a stable patient, for fear of causing the withdrawal that you described. But then, I don’t know your whole medical history.
      I’d suggest seeing a cardiologist who can give your OTP doctor some guidance about when to be concerned about the QT interval. I’ve sent several patients to cardiologists and they were much less concerned than I was, even with patients with QTs at over 500. Two cardiologists estimated the risk of relapse to opioid addiction to be higher than the risk of a fatal heart arrhythmia caused by methadone.
      But each case is different, and that may not be true for you. So why not see what a specialist says?

      Reply

  7. I had 527 QTC Interval at a clinic in NC….and was told the same thing I take 210 milligrams split dose…When I went to the Doctor outside the clinic…(Cardiologist) he did a EKG and said either the machine was not keyed properly or major operator failure because mine for the last three years in cardiology has been 390 and 409….Maybe we go to same clinic lol and the clinic staff is not setting the little stick on things right…I dont know but I was floored when I found out. Email me at finallyachance@yahoo.com for more info…

    Reply

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