Methadone Dosing: Use the Evidence

methadone

methadone

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. (In Tennessee, there are still dose caps. In that state, doctors have to get approval from a non-physician at the state’s Department of Mental Health to take a patient’s dose above 120mg.)

Patients vary widely the way they 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 may be partly true. It may not be harder to come off of, but it 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.

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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17 responses to this post.

  1. Posted by Travis on July 7, 2013 at 8:49 am

    First of all i would like to say that patients should have access to enough methadone whatever that dose may be. But recently i have noticed that some OTP’s are allowing their patients to be on to high of a dose of methadone. Its easy to identify these people because they are heavily sedated. This practice is not only detrimental to the patients health and recovery but it damages the integrtity of the program as well. No one wants to see somone who looks like a zombie. These OTP’s need to do a better job with their follow up exams to ensure the addicts are not sedated. Otp’s and methadone already experience more than enough bad publicity. the program certainly dosent need any more because of this. I completely support Dr Burson when she say’s that a patient’s dose should be high enough to do the job. Im not disagreeing with her at all. I just felt that this problem should be addressed.

    Reply

    • I believe the standard of SAMHSA is that a patient is supposed to have a dose increase as long as the patient continues to relapse. Those standards, the research and best practice were published in the “State Methadone Treatment Guidelines” by SAMHSA no longer in publication, but still in the internet someone made a copy of it. It has been up dated with TIPs 42

      http://www.ctcertboard.org/files/TIP1.pdf

      I do not remember all of the standards and procedures. For what I understand the average dose right now is from 75 to 125 milligrams. There is a few taking 300mgs. And much less people take upwards of 500. I wouldn’t want to be at those high dose, but if the patient needs it and they have discussed it with their doctors they should know. I just hate to run out of methadone or being jailed at those high doses. I am guessing that they have some sort of strategy they have develop if those conditions occur.

      I can only guess that some long survival patients who have cancer are also in super high dose of opiates for pain.

      Reply

  2. Posted by Joy Auren on July 7, 2013 at 2:34 pm

    Yhank God for Doc’s like you!!! We’d be in the dark ages if not!! Glad to know your mending well! 🙂

    Reply

  3. Posted by kevin on July 7, 2013 at 6:17 pm

    I am a patient at one of those east tennesse facilities and I drive 140 miles round trip. Pay 196 every 2 weeks. Plus 20 in gas to get there. Im on 140 right now and then need an increase. My peak and trough along with cows score backs me up. My problem is losing 5 carry outs before the blood test to get another peak and trough for each increase thats another 100 in gas there for 5 days for travel to clinic 36 to send it to state then if the non doctor decides I can have an increase then they make me daily dose a week which is another 140 in gas. It ends up costing me 472 dollars for 2 weeks in gas blood work and fees for my weekly costs. So I have to decide which is worth more. I hurt so much with the withdrawl and lack of sleep but I dont even make that in 2 weeks either. Where do I turn. The clinic may care but the state of TN and people that make these crazy laws dont care

    Reply

  4. Posted by wayovermyhead on July 7, 2013 at 8:41 pm

    Even if someone is on a higher dose than they need, the person soon will develop a tolerance and not be sedated and drooling in the lobby So, @travis the persons to whom you must be speaking of are on more than just methadone….No harm meant in the above I think people tend to know that even if someone begs more and gets it they are only going to feel the high off it a few days no matter how much more they get….and just because staff and people tend to believe there are “lots and lots” of those “bad guys” that take “too much” States are getting involved in regulating what they are and are not allowed to take….Clinics are even falling victim to denying increases so no one gets anything over on them but in turn the ones that do need it lose out more than the ones that don’t need it and get denied. Truth is….people tend to be more under-dosed more often than overly dosed….Personally I feel it would be more fair that there were less people being punished because of the idea that people are taking too much….It is not their fault there are these patients that want to take more than they should but there is less harm in people taking more than they need as they always develop a tolerance and the “high” goes away than those who are being denied much needed increases and their cravings and withdrawals never go away…that is where the real harm and injustice exist….

    Reply

  5. Posted by wayovermyhead on July 7, 2013 at 8:45 pm

    oh and btw Thanks so much for making it “truth be known” that Tennessee is doing things bass ackwards (lol) leaving dose increases to professionals that do not see or even know the patients….

    Reply

  6. Posted by wayovermyhead on July 7, 2013 at 8:46 pm

    Even Ms. Burson says it herself in bottom paragraph….

    “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.”

    Reply

    • As always @wayovermyhead, your comments and posts are a plethora of information and I have truly learned so MUCH from you and all that you do as well as from Dr. Burson. thank you for being such an amazing and informational Advocate for all of us MMT Patients! i only hope that one day I can have the knowledge base that you do! If I keep following your posts, I think that I will! 🙂 XoXo ~ Abby

      Reply

      • Posted by wayovermyhead on July 14, 2013 at 10:24 am

        Thanks Abby and ditto about complimenting me as an advocate….I so appreciate all you have and do offer the MMT/MAT community…Thank You.

  7. Here is an area that has improved by clinical work. Back in the seventies and 80s most methadone maintains treatment facilities were ignoring the substantial amount of research that had been available for the last 37 years (at the time). Most of them paid by the federal government Substance Abuse Mental Health Service Administration and Center Substance Abuse Treatment. Not until around 2000 when SAMHSA took over the monitoring of methadone from the Food and Drug Administration who was making lots of clinical mistakes because what they knew was about the drug itself which was shown to be extremely effective. So whatever clinical mistakes were being made by staff member were not too noticeable because methadone was so damn effective. Since 1972 the chief (can’t remember his name, but I know that his statement was published in The Monitor (the American Psychological Association) monthly magazine

    Except for clinics like Miami Dade Office of Rehabilitation Services, whose clinicians probably became functionally illiterate after they got their jobs and probably have not read a Scientific Journals since they left college, patient failure were their goal. This clinic that no longer exist, thanks the Gods. Where actually contributing to patient’s death by overdose (there were not a lot, but one was too many and by the third time they should have gotten some kind of message). This son of (someone’s mothers) were keeping patients at less than 50 milligrams per day and were ignoring every guideline written by the Feds under the believe than “Oh, they are only guidelines” <that was the Unit’s Supervisor (whose name I will not state in order to protect the guilty) after I brought them "The State Methadone Treatment Guidelines" which actually confused me given that I assumed that he knew how to read.

    What this clinicians would do, was than when patient relapse at such low dose because it would not maintain them for long (if one was doing 5 to 10 bags per day). This bright basters would demand a "Behavioral Contract" <which was not a contract, and they ignored every step and standard that were developed by Pennypaker (University of Florida) and NOVA Southeastern University based on research and best practice.

    These quacks <I could think of a better word to describe them, but I do not think would be appropriate to publish) actually thought that it was bright and good behavioral treatment strategy to threaten the patient's status in the clinic by making the patient sign a contract that if they came back with a dirty urine the contract would call for LOWERING their dose by 5 milligrams. They reasoning were that they were using good negative reinforcement strategy. I do not where they learn such strategy, but I think it most have been in The Inquiry Magazine. Talk about making a contract to make sure that the patient will fail. Of about 5 or so patient that were contract none of them made them and they were discharged. I know of two patients who over dose short of a week later.

    Reply

  8. @ The other Travis 🙂 Yeah, I’ve also gotta say that there’s typically another issue when seeing patients ‘overmedicated’ or sedated. It’s likely not methadone alone unless patients have within the last few days increased their dose; chances are it’s going to be concurrent use of benzodiazepines, soma, alcohol and/or other CNS depressant.

    Reply

  9. I truly believe methadone has such a horrible “name” because of low dosing clinics and I always will.

    As a patient on >250mg per day and a patient advocate- I have attended the American Association of the Treatment of Opioid Dependence (AATOD) and sat through countless state meetings as well. These meetings always have a considerable number of folks who run “low dose”clinics BRAGGING about how low they keep their doses in one breath and in the next breath blaming the “un-motivated” patients for their high relaspse and drop out rates! These people don’t even realize how backwards their thinking is!

    All I can say is that I have been tempted MORE than a few times to stand up and shout to these people “I took more than 250mg about 4hours ago and have managed to listen to you all drone on for two hours without falling asleep! So please PLEASE tell me again why everyone on a methadone dose over 80mg is just a walking zombie! And PLEASE PLEASE” I want to yell “tell me how horrible my clinic is for allowing my dose to happen while I explain to you all the positive things that have happened in my life because I don’t even THINK or remotely CRAVE opiates anymore.”

    I have managed to hold down a professional job in a hospital for the entire time I have been on methadone-I raised a child, have only ten years left on my mortgage, have a college degree and professional license in my state. I have never once believed that my dose of methadone held me back! I am extremely grateful everyday of my life that my clinic had the courage to treat me like a person with a disease, instead of a person who was just looking for a fix.

    Can you imagine how bad a name schizophrenia or OCD or even epilepsy drugs would have if we forced every patient to take the exact same dose with the exact same regimen?While we are at it why don’t we also tell them if they don’t stop being delusional, obsessive or having seizures by the third year on their medications that THEY AREN”T TRYING HARD ENOUGH and take them off the meds! Then blame them when they fail all over again because the craving (that a proper dose of methadone would null) became too much to bare? Never in a million years would be question how long someone takes ANY OTHER medication-or how much they might need. And never has their been a drug that we have tried harder to make the patient fit the treatment instead of the treatment fitting the patient! Unfortunately, this is so very true of any form of addiction treatment.

    Reply

  10. How do you get off methadone?In a safe way,that i won’t be sick?I really want off it after 8 years.i`ve been decreasing 4 yrs.140mg down to 58.It takes awhile to do it right.I just feel like i’ll never get there.

    Reply

    • Posted by Chris G. on January 17, 2015 at 11:42 am

      My brother was on 120mg and tapered down the same way and I saw with my own eyes (after countless people said it wasn’t possible) him get down to 1mg and the. Done! I watched as he had about 2 uncomfortable nights and the. It was FINALLY OVER! Now he has no cravings. As for temptations… I don’t believe methadone will ever remedy these completely as for the mental aspect of them. However that’s why good counseling can make all the difference. Stick with going down and you’ll get there! 😉

      Reply

  11. Posted by LoveOverDrugs on August 16, 2015 at 3:23 am

    I have been on methadone since March and on May 7 at a dose of 60mg a day I was told I was on my stable dose. At that time I was feeling good and was providing clean tests. Then in June I had moved on my own, and since been dealing with stress. Im to afraid to provide a dirty drug screen as I am trying to get my child back, but every night after supper im achy all over, my minds racy, I barely sleep and when I do I can barely move in the morning. When I fall asleep im the hardest person to get up I can sleep for days, when I get up though I have to go get my methadone. My doctor told me to wait and I did but every time I tell him I need an increase he blows me off, now I am to ashamed to ask because maybe I am just looking for a high. But I thought that getting on methadone was suppose to help rebuild your life, mine is exactly the same ? I wake up when I know I can get my methadone in 10-15 mins, get it, feel good for a bit then my body aches and I go to bed waiting to get up and do it all over again… I dont know what to do at all…

    Reply

    • You need to talk to your doctor again. Sixty milligrams is not a very high dose, so I’d want to know your doctor’s objections to increasing it. For example, are you using benzodiazepines, and your doc is afraid of an overdose? Are you missing days of dosing? Is he worried about how you sleep for days, maybe thinking you’re on too high of a dose and it’s making you drowsy?

      Reply

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