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?



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

52 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!! :)


    • 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.


  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.


    • 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.


      • 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?


  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


  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?


  6. im a 34yr old female&ive just read ur blog&iim impressed at ur views of how MMT doctors should treat 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 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!


    • 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?


  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 for more info…


  8. Posted by Andrea Pate on August 4, 2014 at 12:19 am

    Hi, my name is Andrea, I’m 28, live in West Michigan, and have been going to my methadone clinic for almost 7mo now. I started at 20mg my first day and increased 5mg every other day until I got to 60mg. And then every 5 days after I’ve gone up 3mg. I stopped at 88mg and stayed for 5-6weeks and I just increased to 91mg last week. At my clinic, each patient is given a “cap” by the doctor and can go up or down on their dose as they feel needed. We just tell the dosing nurse at the window that we would like to go up or down. The most you can increase after 60mg is 3mg at a time, every 5 days. I felt like 88mg wasn’t holding me the full 24hrs in between doses as it used to, and was feeling withdrawal symptoms around 3-5am. And had trouble sleeping. I feel much better since going up to 91mg. If you have any questions, feel free to email me. Its Thanks for your article, I really enjoyed the read. -Andrea


  9. Given these variations in absorption rate, what is your opinion on patients experiencing problems of withdrawals and dose not holding 24 hrs when being switched between different formulations or brands of methadone? Since ingredients such as sugars, binders and fillers also vary, is it conceivable for a patient to do fine at say, 100mg on one formulation, but physically feel withdrawal symptoms and require more after a brand switch?

    Would love to hear your thoughts,


    • According to the pharmacologists, there’s no difference in blood levels between liquid, pills, or diskettes. Some patients, however, swear that the liquid is stronger while other patients claim the pills are much stronger.


  10. My daughter was dx with ARDS caused by west Nile almost three years ago. She was in the hospital on life support where they didn’t expect her to survive but the fighter she is after three months she was sent to a Rehab Hospital where she had to learn how to walk and all cognitive deficits. She came home a year ago on a lot of narcotic meds. She was still in the wheelchair but could walk a little ways with canes/walker. She continued out-patient physical therapy and started walking without aides in March. Her cognitive abilities are back 100%. She came home on many narcotic meds as well as Neurontin, Cymbalta, Xanax and many vitamins. Also Synthroid. She decided she was ready to get off the meds as pain is better although will probably never go completely away. She sees a Pain physiologist and chiropractor to help. The doctor set her up with Pain Management. Her said after being on suc high doses for three years Methodone was only option so started her on 5mg every 8 hrs and cut her dose of Dilaudid from 8mg every 4 hrs to 2 mg every 4 hrs. He cut the Oxycodone from 5 mg every 4 hr to 0. She is off it now. He increased the Methodone after the 2nd week to 10 mg every 8 hrs the first two doses and 5mg the 3rd. The 4th week he increased it to 10mg every 8 hrs which is what she is on now. He cut the Dilaudid to 2mg qid. Her withdrawl symptoms have been terrible. It’s horrible to watch her suffer like this after watching her fight so hard to live and then walk and read and learn to do so many things. She has no life at all now. It’s like she is being punished for being on meds she had no control over. I thought Methodone was to help with withdrawl symptoms? We wish now we never would have started this. She suffers some PTSD from all she went through and being in withdrawals for over two months is just about doing her in. My husband and I are going with her to the doctor on Monday. Is there something about Methadone I’m not understanding? If she was to stop this program now she would have withdrawals from it too right? What a mess for our poor daughter!


    • Yes, if she stopped methadone suddenly she would have physical withdrawal, but 30mg per day isn’t a really large dose. I don’t know for sure what your daughter’s doctor is doing. If you are concerned, ask your daughter to allow you to sit in on her doctor’s visits. If shw won’t agree, you can voice your concerns to the doctor, though without her permission he can’t release any information about how she is doing.


  11. Posted by Bridgett Owens on October 17, 2014 at 3:15 am

    I’m fairly new to the Methadone Clinic in Louisiana, started two months ago and had a horrible start in which I was prescribed 35mg dose that made me very sick after 5days all I could do wad sleep which scared my husband. When I was well and able to return to the clinic they started me on 12mg and I’m now on 25mg and withdrawals begin about 4pm everyday even with my prescription of 1 mg Klonipin. I feel as if I need my dose increased but worried my husband will get angry with me and just think I’m doing it for negative reasons. Any suggestions? And also why was I getting so sick at first and now it’s fine except withdrawals? Did my body get used to it? Should I increase to 30mg ?because I also want to be free of the benzodiazepines. Any answers will be greatly appreciated!


    • First, I can’t give medical advice, except to say you need to see your clinic’s doctor. I suspect the clonazepam potentiated the methadone on your first day. If you want to be free of benzos, maybe ask your doctor to instruct you on how to taper it.


  12. Posted by Amy on October 29, 2014 at 4:35 pm

    My husband has been on methadone for around 3 yrs now for opiate dependancy…he is taking 100 mgs liquid daily…still hurting in his legs and back constantly, but I believe the dose is too high because he just falls asleep. No sign of being sleepy..he just goes to sleep. This scares me as he can be wide awake and driving, then just nods off. He was mopping the floor the other night because he couldnt sleep for the pain…and he just fell asleep and fell on the floor. He says he has asked to be lowered and the clinic wont lower his dose. I feel he is at a clinic that is only worried about the money, they wont accept any insurance…its all cash based…


    • Have you asked your husband to allow you to talk to his counselor? If he will agree you may find there’s more information than he’s been giving you. Methadone, at the proper dose, shouldn’t make him fall asleep while mopping, unless he’s on way too high of a dose, or mixing another sedative with it.
      Even if he won’t agree to sign a release, you can call his program and give them information about what you are seeing at home.
      For the record, if a patient tells staff he’s sleepy and needs his dose lowered, I don’t know of one program that would refuse to lower his dose, for safety reasons.


      • Posted by Amy on November 4, 2014 at 10:49 pm

        He signed giving me access the day he started. They say hes not too high because of him still having so much pain on the dose hes on now. But they say hes not ready to be lowered. We r having testing done to make sure he isnt having medical problems to make him fall asleep. Within the last few months there has been almost a completely new staff come in to the clinic

      • Posted by Nicole on May 3, 2015 at 3:49 pm

        My husband is doing the same thing. He started methadone treatment about 2 months ago. It was an amazing thing for him. Within a few days of starting, he says he finally felt normal again after we as a family suffered many miserable months of yo yo withdrawal symptoms, severe depression and thousands of dollars being wasted monthly on getting him just enough opiate to make it through his work day. He started at 30mg was doing much better. By 40mg was he was feeling sooo tired at the end of the day. He is now up to 50 & no joke will fall asleep standing up, mid conversation and we’re back to not having a life because he has no energy. He also is now having numbness and tingling in his arms and legs on and off all day. He twitches and has muscle spasms in his sleep. Last night his pulse was pounding through his neck, as I watched him sleep. His pulse was 125 while sleeping! He was working really hard to breathe. I was very scared I was going to wake up to a dead husband. My husband has a history of high blood pressure and acute kidney failure that was never followed up on. They have never checked his kidney function since starting and after years of narcotic abuse it concerns me hes not excreting this medication right. He didnt like it and asked this morning if he could go back down to 145mg, he explained his symptoms and tild them he felt much better at 45mg. The medical assistant told him NO! She toldhim he was in withdrawal cuz his pupils were dialated. My husband has gone through awful withdrawals and ive watched as he rolled on the floor in pain, sweating, puking, diarrhea, so depressed he was suicidal, he told her I dont feel any withdrawal, I feel perfectly fine…she again told him NO! So apparently he is required to keep increasing with no regard for his health at all. NUMBNESS AND TINGLING? EXTREME FATIGUE? Irregular heart rate?
        Hes requesting less and your refusing? I dont understand! How do we know if theze things are symptoms of withdrawal or overdose? Hes scared and of course so am I. We thought this stuff was safe. Clearly the company has no consideration for his safety or well being. Only his money! I dont know what were going to do. He cant just stop going, he has a full time job, he cant function through withdrawls. Im afraid im going to lose my husband.

      • He needs to talk to his physician, not a medical assistant. Or at least talk to physicians assistant or nurse practitioner. Or program manager. Or complain to your state’s opioid treatment authority.

  13. Posted by joy b. white on November 1, 2014 at 3:39 pm

    well I don’t know where to begin…..I have been in treatment for nearly eight yrs and on a dose of 100mg the past three my clinic got bought out by a large for profit org and we got a new dr this man has troughed everyone on more than 80mgs and if their level is 400+ we r told that we are TOXIC and lowered I have been brought down 15mgs in about a month because my level came back 600 after taking 10mgs he ordered another trough it came back 500 and he lowered me 5 more in a few days I am to be lowered another 5mgs which will total 20mg I have been detoxed …..treatment had worked for me up until this point and I don’t know what to do this dr is telling patients and staff alike that no one should b on anymore than 75 mgs 80 tops help me help us point me in the right direction what can I do to stop this????


    • Aaargh!
      Doctors like this give me a headache.
      Can you go to this website: and type in “TIP 43” into the search box. Then order this doctor a copy. It’s free. While you’re at it, order yourself one too.
      this contains the best practices for methadone prescribing. Put a bookmark in page 70, where it is describes how most people require 80-120mg per day, and that you can’t determine tolerance by trough doses. Maybe highlight with a yellow marker, then give it to this doc and ask him for God’s sake to do some reading to educate himself.
      in fact, maybe you should order TIP 43 for all the staff at your OTP. sounds like they need it!!


      • Posted by Joy beth White on December 5, 2014 at 6:31 am

        well I have ordered the book , waiting it to arrive …. im now at 70mg and there still taking me down my trough came back 560 on 80 mg …I am a good patient I have went up only a total of 20 mg in EIGHT YRS and I asked for that only because I was pregnant and had to which that’s been three yrs ago I pay my bill on time in full and have only had very few relapses in this time three to b exact …I am in terrible withdraw but the staff says I am lying and its impossible w a trough that high I live in southeastern ky the four clinics in the region this doc is over I am considering looking for a place to take me in a close neighboring state if I can transfer and keep my carries I am desperate here I am fearful of whats going to happen with my life all together I don’t want to go back to living the addicts life but I know its going to happen….do u know of any places within a hr or two of me …or of any clinics where I could get carries if I transfere…I feel hopeless now that treatment isn’t even helping

      • This is a bad situation. As I said before, there’s no reason to check blood levels on patients who are feeling well and doing well.
        go to this website: and put in your zip code to find other clinics closest to you.
        please let me know what happens when you show your doctor the evidence-based information that he should already know from TIP 43…

  14. Posted by Matt Edmoand on December 9, 2014 at 3:33 am

    hello , I’ve read your statements above and agree … I’ve been a methadone patient for about 3-4 years now and only positive screened for methadone for the past 3 years straight ..I’ve reached 120mgs for the majority if these three past years and want an increase due to sweating a lot later in the evening … Insomnia n then withdrawl symptoms in the am did my dose time but still no increase ..some days the methadone metsbolizes slower but usually I know it goes fast… I feel far from sedated and for over a year have grown fed up with trying to raise my dose and am considering another clinic.. Here’s the bug issues ..I am on a dose if 3mgs of clonazepam daily … And still almost never any sedation (which is good) and I even go to work on my dose which I often feel requires a slightly higher dose after work ..maybe 5 Mgs would help …one whole daily dose doesn’t work well for me and if I wasn’t in pain I would be try buprenorphine again… (Suboxone) does nothing for my pain.. I go to APT foundation in CT … I’ve gotten bottles for over a year now …and have not had one questionable urine in 3yrs… I talk to my counselor and she wants me to stay on this dose no going up , no going down …im close to leaving but fear withdrawl and relapse… So I believe in higher doses so long as they are monitored … Thank you ..I pray this issue is resolved before I decide to bail on this program all together…half the ppl there abuse everything and many have doses well over 120 but I believe the average dose is 90mgs I hear that most often ..thanks


    • If you’ve read much of my blog you know how concerned I am about benzos with methadone. All I can say is that I too wouldn’t want to increase your dose, for fear it would harm you.


  15. Posted by Emily Robbins on January 6, 2015 at 2:58 pm

    Please help me. I was on 55mg of methadone I have been not able to stay awake 4 to 6 hours after I take the methadone and withdrawing at night. After THREE MONTHS of telling them this, they finally did a peak and trough. Then I went up 5 before they got the results. My couserlour keeps telling me “well maybe you should increase”. So I got the results back And the peak is 549 and the trough 376. Which doesn’t put me above a 2. So they won’t split dose me. So I made them up me 10 today. And my counselor is like why don’t you just do 5. But I made her do 10 cause she’s the one who keeps telling me to go up. I need to know if there are other factors… Like being in love changes chemicals in your brain, I feel less withdraw symptoms when I’m with my boyfriend. I was with him the day the test was done. Can that affect it? I also have rhuematoid arthritis which doesn’t really bother me in the summer but it’s horrible in the winter. I was on depo provera, but stopped getting it. I was due to get one like a month ago but I didn’t cause I thought that was maybe affecting it. The doctor only comes to our clinic like once a week and it’s normally after they close. What do I do? I am so tired of withdrawing. I have relapsed because of it. I can’t have a job if I can’t stay awake during the day.

    I have been on methadone since Oct 2011 i am 24f. Since I’ve been on methadone I’ve had gradual weight change. The highest dose I was at was 90 but I continued to do heroin. But I was stable at 60/65ish for a long time.

    I am so fed up. I’ve called the federal and state methadone authorities and carf. No one can help me. I don’t know what to do.


  16. Posted by Rebecca Ewell on January 20, 2015 at 7:03 pm

    I had been a heroin addict for 23 years and 3 years ago I was finally able to stop for good. The difference was I went to a nonprofit methadone clinic. Or maybe they care more because they have all the state contracts and get a lot of business from them, whatever the reason, they do a great job. My point though is that I had went to one of the for-profit clinics before and you are right, they just gave me more and more and didn’t care if I was testing dirty, they didn’t even watch us do our drops. Very little counseling and no education. The place I’m at now give us classes that teach what is going on in our brains to make us act the way we do, regular doctor visit, ekg after a certain level, p & t’s, regular dr visits, psych appts, the whole nine yards. I am on 140 and I’ve been clean for 3 years now with no relapses. The only side effect is that I have gained more weight than I ever had on me in my entire life but I would rather be too big than dead!
    I wish more people would read articles like this, but unfortunately they just go by the things that they hear from other people and give us all a hard time about being on the clinic.


  17. Posted by tina on February 15, 2015 at 7:30 pm

    I am on 76mg of methadone, and it seems that my clinic is very quick to increase your dose without talking to the patients much, but not very quick to decrease it. They will increase you for any old reason as quick as they can.


  18. Posted by tina on February 15, 2015 at 7:43 pm

    Also the nurses are very rude there and treat the patients like they are “junkies” its horrible.


  19. Posted by Daraunda Bass on February 17, 2015 at 4:26 am

    What do u do if you know a director of a mmtp is treating clients wrong especially ones that suffer with mental illness she dropped a person that was clean 11yrs from 50mil to 5 in 9 days a 50 is a low dose but the build up after 11 years im confused about the whole combat stomp out heroin when u have people that are obviously not there to help I’ve met some wonderful doctors nurses directors over the years a bully has no place in a treatment center dealing with people who have already been through alot and are now trying to better themselves


    • If you are treated unfairly, you can write a grievance describing what happened and submit it to the program manager. All of those are supposed to be reviewed by people in administration further up the line.
      But if it’s hearsay, there’s not much you can do. Then too, sometimes there’s more to the story than you know.
      Still, a bully has no place in medicine anywhere, let alone addiction medicine.


  20. Posted by Mike on February 26, 2015 at 5:59 pm

    Hi, I am a 40m methadone patient in California. I had a very bad car wreck about 6 years ago. After 3 years on massive amounts of pain killers I tried to stop and ended up on methadone. After about 3 months on the clinic my dose was at 90mg. I have had some positive UA’s. In my car wreck I broke my back in 6 places and crushed my pelvis, had to have my arm rebuilt, and many other injuries. Sometimes, especially like now in the colder winter months, the pain is close to excruciating. So, when the pain is so severe I cant take it, I have taken morphine. I know that the 90mg dose is good. I don’t experience cravings ever, and there is no sleeping problems nor any withdrawal symptoms. When I wake in the morning I feel fine.

    I had some positive UA’s and they started raising my dose. When it hit 110mg’s, I could barely stay awake during the day. Now, they have it up to 140, and I have literally become a zombie. I drink cup after cup of coffee or energy drinks to stay awake and that does not even work a lot of the time. I have told my counselor, the doctor, and the director, and they all say, “well, its not the methadone.” I had a trough a while back when I was at 90mg”s. I saw the doctor at the clinic one morning and asked if the results came back. He said they had, and I said, “the levels were ok, right? He said they came back fine.

    The director, my counselor, and the doctor summoned me for a team meeting. The director said that my levels are very low at 250 and that I need to go up. I said I feel fine and don’t want to go up. She then said that I might need to go elsewhere if I didn’t want to go up in not so many words. So, what choice did I have? There are not any other clinics that close. I asked the doctor why he told me the trough came back ok, and he didn’t really have an answer.

    When they raised it up to 110mg’s I started complaining non stop. I am scared to get behind the wheel a lot of the time. I don’t want to fall asleep and injure or kill someone because of my dose being too high. When ever I had counseling, I would tell her over and over my dose is too high. I would schedule more meetings with the director, doctor, and my counselor. They grew sick of the meetings and would tell me I was at the dose I needed to be at.

    SO, after about 6 months of complaining that my dose was too high, my counselor said the director told her there were now reports I was dealing drugs at the clinic!! Of course when I heard this I was both very worried and very angry. I would never sell drugs. I could not believe my ears. So, I immediately scheduled a meeting to get to the bottom of this. I was freaking out until I realized that there were cameras everywhere. Outside, inside, the garage, everywhere, you can not be at the clinic without being on camera 100% of the time. I was relieved when I thought of the cameras. So, I had my meeting, and the first thing I asked was, “did you check the cameras?” She said no!!! I asked why. She would not give me an answer!! She said consider this your first and only warning.

    The clinic here opens at 7. She knows I arrive a few minutes before 7 so I can be out the door at 7:02 and beat the traffic on the way home, otherwise I will be stuck in traffic for 45 minutes to an hour. It is normally a 10 minute drive. She , the director, told me to come in at 7:30. I asked why? She did not say why, so I said, “I didn’t do anything wrong, and the cameras can prove it, why should I have to come at 7:30.” The doctor miraculously agreed with me. So, I was still allowed to come at 7.

    About 2 weeks later, I arrived at the clinic, and there was a letter left for me that said I had to sign it. The letter said I had to come in at 7:30 due to complaints about me. I scheduled a meeting to get to the bottom of it.

    When I arrive early at the clinic, I either bring a book with me, or read the news on my phone. I don’t talk or associate with anyone there. I see people dealing, trading pills, buying and selling urine, etc. I want nothing to do with any of these people.

    I had my meeting with the director, doctor, and my counselor. This time the director said there was noise complaints about me!!! I know this is impossible as I don’t even speak to people there, I stand off to the side, about 20 feet away from the nearest person. I told her this, and once again, I said, “all you have to do is check the cameras.” She said she does not need to check them??? I was left totally confused and angry. It had become obvious to me that for what ever reason she had taken a disliking to me.

    So, now a few more months has gone by, my 140 mg’s is way too high and I asked for another meeting trying to get it lowered. They have raised my dose without even telling me. I found out accidentally by the dosing nurse. She said the dose, and I said, “what is the dose?” She tried to recover and say she was talking about someone else’s dose. I eventually got my counselor to tell me what my dose was at.

    I had counseling yesterday, and she told me the director has called for a new meeting because I have missed days at the clinic. At the clinic I go to, missing days is one of the worst things a patient can do. I told my counselor I have never missed a day, and she checked the computer and said, “you are right, you have never missed a day.”

    So once again, I am freaking out worried that they will kick me out for something I did not do. And yet again, the cameras can prove that I was there every day and never missed a day/dose.

    I don’t have the slightest clue as to why the director has taken such a disliking towards me. My last two counselors have both agreed and said what she is doing is both mean and wrong. She arrived at the clinic about a year and a half ago. Before her, everyone was very kind, and at least gave off the appearance that they really cared for the clients.

    I have asked for exception doses to go see my brother in China twice, my counselor told me she threw both away without even looking at them. I am still in physical therapy from my car wreck. I thought that due to the free time I have, I would like to go back to school and get my masters for when I eventually return to work. Even when trying to get exception doses for reasons of education she would not work with me. It seems like she wants me to fail, or that she is doing everything she can to get me to quit the clinic out of anger and frustration. My dose is 140mg. That is a very high dose, and way too high for me and my system. I am constantly in fear that she will create another issue/problem and kick me out. The problems that she said occurred could have been solved by watching the video there, but she would not check the cameras. What am I supposed to think?

    I would have liked to file a complaint, but she is the person that receives and solves the complaints. It would anger her more if I filed a complaint about her and gave it to her, it would be pointless. Before she arrived at the clinic, the doctor never suggested my dose be raised. Since she arrived,, the large majority of the time he just does what she says. This is more like a retirement job for the doctor. He is around 75 or 80 years old and usually just sits around reading the paper. I am at wits end and don’t know what to do. I have never been treated like this in my entire life. I have never experienced anything as frustrating as being accused of something I didn’t do. It is very frustrating.

    If I have to drive somewhere that is more than a 20 minute drive after noon or 1pm, I always try to get someone to come with me to keep me awake and alert. I have told them this, and they say it is not the methadone. When I tell them that and they say that it drives me crazy. The amount of caffeine I take in cant be healthy. But I don’t have any other choice.

    There is a major meth epidemic at the clinic, people dealing, begging, trading, smuggling in urine, and they have targeted me. When I have used I have always told them. I never tried to hide my use, even if I didn’t have a UA, and I was in counseling, and there was no way I could be caught or found out, I was still honest and told them I had used.

    I have never been anything but honest with them. What do you do in a situation like this? I am sorry to have written so much, but I did not know what else to do. I thought maybe you could steer me in the direction of some sort of resolution.

    Thanks for a cool and informative blog.


    • I’m sorry you’ve had this negative experience. I still think talking frankly to your doctor is your best course of action. She/he needs to know that you are getting drowsy from your dose. You could also discuss the other issues you present. For example, you should always know what your dose is.


      • Posted by Mike on March 6, 2015 at 3:11 am

        So, I met with the doctor and director and told them again about the drowsiness. They told me that no matter how high your dose is raised, that your body adjusts to it after 5 to 7 days. They said you might feel a little tired for a week. But after that week is up, it just becomes your normal dose, that it is impossible to feel tired or drowsy from the dose after the 5 day adjustment time. Once again the doctor and director told me that if I am drowsy it must be from something else. I know it is the methadone. That is the only thing that has changed in my life, the dose is 50 mg’s higher than the 90 mg’s I felt good at. When I was at 90 mg’s, I felt no cravings, and had zero withdrawal symptoms. I don’t know what to do. I do know that even though it has been a while since I have been at 140 mg’s, that once noon or 1 o’ clock rolls around, I start falling asleep. I hate it. I have always been the person that gets six hours of sleep and has boundless energy all day. Not feeling like that is a bummer. I wake after sleeping 8 hours at night and I am so tired and groggy. Well, thanks for responding, that was very nice of you.

  21. Posted by bill on May 13, 2015 at 8:57 pm

    Can a methadone clinic in my discharge a pregnant woman ? If so what’s the laws/rules???


    • Generally speaking, it is not recommended, but it is up to the physician. sometimes if the pregnant patient isn’t doing well in treatment on methadone, her physician may recommend referral to a higher level of care, meaning an inpatient program.


  22. Posted by joanna on June 7, 2015 at 5:13 pm

    I hate the clinic I am at! I have had trouble going up on my dose since I started this clinic! I had a peak and trough done at 100 mg and because it says I am theraputic they will not increase my dose, even though I still di not feel good. I had a COWS done and because I am not in severe withdrawl they wont take my dose up. I threw a fit because I felt like she rushed threw my COWS so the doctor let me do anothwr COWS but then be came back in the room after hearing the results and told me those results were higher but that one was “not real”. I heard the DR in the other room telling the nurse I am intelligent so i geuss he was saying i faked it. Even though i have been begging to go up for 2 weeks now. I was in tears and the dr said its emotional, even though i have delt with not being listened to for weeks so of course i am emitional. I dont know what to do, stay on methodone and be sick or get off of it since i am all ready feeling bad. Nobody will listen to me


  23. Posted by Cathy shaner on August 28, 2015 at 2:23 pm

    Been in treatment Alabama clinic for 9 yrs lost my job they wouldn’t dose me with no money haven’t in 4 days


    • OTPs should provide a taper for their patients who encounter economic difficulties – some places do a 4-day taper, others a 10-day and 21-d at others. Granted, those tapers aren’t going to help much in the long run, but may be of some assistance.
      I hate that we don’t have nationalized healthcare. It’s still a privilege in the country, not a right. If you feel all people should be covered for healthcare, vote!
      Addiction medicine treatment providers are no more obligated to provide free care than any other medical practice. People without insurance have a very hard time, and even if you do have insurance, if you go to the pharmacy without the co-pay, they will not give you the meds.


  24. Posted by Jillian on September 4, 2015 at 12:16 pm

    Wow. Reading the other comments makes me very thankful for the clinic I go to. (Aldie Counseling Center in Doylestown, PA) They offer more than just methadone and Suboxone. They help people get into rehab, detox, halfway houses, etc. They even have a van to drive you.
    The staff is amazing and the nurses truly care about you and your recovery. The staff are non judgmental and are very understanding.
    They accept state insurance. And if you do not have it, they have county funding which goes by your income. (when I lost my insurance for 6 months I was on county funding. I did not work so I only had to pay $10/week)
    The doctor is this sweet old man who tells every patient, don’t be afraid to complain about withdrawal. And if you feel you are ready to detox, we will do it as fast or slow as you want.
    There is no dose capping.
    The counselors are awesome also.

    The only complaint I really have is sometimes the director seems to be on a power trip. For the most part though she’s nice and works with you.

    I feel so sorry for those who have problems at their clinics. It’s so sad that they can actually treat people the way they do.


  25. Dear Dr.: I have been in treatment for one year now. My present dose is at: 150m/d. I am taking my P/T this week. I must submit the P/T on Friday. Could you explain this process in layman’s terms? Is there anything I would do normally that could influence the results?

    Thank you so very much. I’m looking forward to hearing back from you.

    Best Regards



    • Hi Marc, yest I can explain – please check out April 10th’s blog entry from this year – I go into detail about what peak and trough levels mean. You can’t do anything to influence results – just take your usual dose at your usual time to get best results.
      hope that helps.


  26. My husband has been blind dosing/tapering and said he was down to one drip from the dispenser… assuming about 1mg because Im at 3mg and I get about 3 drips and I have more in my bottles than him. Today he went in and they gave him a lot more. When he objected to the dose they told him that hes supposed to be at that much. Which he said was about 6 drips from the dispenser. He was nodding out today from it and we called our clinic and they pretty much told him he was ouuta luck. Can a clinic legally raise ur dose when ur tapering? He doesnt want to be at such a high dose when hes worked so hard to come down.


    • I don’t think a clinic would raise the dose without telling him – odd…He needs to make sure they reduce his dose tomorrow if he was drowsy today. I would surely want information about how much they dosed him at if I were him.


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