Split Dosing

Medication blood level with once-daily dosing compared to split dosing

Medication blood level with once-daily dosing compared to split dosing

Split dosing, when used in reference to the medication-assisted treatment of opioid addiction, means instead of once daily dosing, the total medication dose is divided, or split, into two doses.

Methadone and buprenorphine (Suboxone, Zubsolv, etc.) are long-acting opioids. This property makes them ideal for use in opioid addiction. At the proper dose, both medications relieve physical withdrawal symptoms and cravings in opioid addicts without causing a euphoria or impairment.

When we use these medications for opioid addiction, we prefer to dose once per day. This way, the recovering opioid addict only has to think about taking medication once, rather than using opioids numerous times throughout the day. In active addiction, addicts become accustomed to thinking about opioids frequently; in fact, their whole day narrows into finding opioids, using opioids, and getting ever more opioids. We want to help them break this cycle, and these two long-acting opioids can do this.

However, not all patients will feel normal with once daily dosing of methadone. Patients metabolize methadone at very different rates. Some medical literature says there’s a one-hundred fold difference in metabolic rates of methadone between patients. With methadone, a small percentage of the population metabolizes very quickly, and another small percentage metabolizes very slowly.

This is why methadone induction is dangerous in brand-new patients. Slow metabolizers can accumulate a fatal amount of methadone if such patients are started on too high a dose or increased too quickly.

The activity level of the enzyme that metabolize methadone, the cytochrome P450 3A4, varies a great deal between patients. The activity of the enzyme is thought to be determines by the genetics of each patient. Some patients may metabolize very quickly, with an elimination half-life as short as 8 hours. (Elimination half-life refers to the length of time that it takes for the concentration of a drug to drop to half of its original value in the body). Other patients may have an elimination half- life of up to 130 hours. Most patients average around 36 hours.

Buprenorphine has a consistently long duration of action, of 24-60 hours, with less variability between patients than with methadone. Buprenorphine doesn’t need to be given in split doses when treating opioid addiction, though in some special situations, split dosing may help patients.

Patients who need split dosing are given part of their dose in the morning and part of their dose to take later, as close to 12 hours later as they can manage. Since many opioid treatment programs (OTPs) are set up to dose once per day, in the morning hours, patients who split dose are given half to two thirds of their total dose at their OTP. The other half to one third is given to the patient as a take- out dose for later that day.

We decide which patients need split dosing by listening to their symptoms. During induction, we know the patient’s dose isn’t high enough to last the whole day, so the need for split dosing can’t be determined until later in treatment. Patients who are fast metabolizers often get to 120mg or more, yet feel opioid withdrawal late in the day. Or they may feel drowsy after dosing but feel withdrawal later in the day. These patients may be fast metabolizers.

Before I can order split dosing, I need to get permission from the state and federal authorities, just like I would for extra take homes doses for patient emergencies. In my state, methadone peak and trough levels are usually requested before they grant permission for split dosing. We draw the patient’s blood three hours after their dose, which is the peak. That’s the highest blood level the patient will have on that dose. On the next day, right before they take the next day’s dose, we draw another methadone blood level, called the trough, which is the lowest level the patient ever has on that dose.

Then we compare the peak to the trough. If the peak is more than twice the trough level, the patient is probably a fast metabolizer who will feel better taking part of their dose in the morning and part in the evening.

Pregnant women, particularly in the last trimester of pregnancy, may do better with split dosing. It’s common for methadone metabolism to increase during pregnancy. Blood levels also drop during pregnancy due to plasma volume expansion and other factors, so that a given dose gives progressively lower blood levels as the pregnancy proceeds. Also, studies have shown the fetus is less affected by methadone when the total is divided into two doses.

However, the woman’s home environment and other factors must be considered before ordering split dosing. For example, if the pregnant patient is living with a partner in active addiction, that partner may bully the woman into giving him her second dose. If the pregnant patient is struggling with other drug use, splitting the dose may be too risky.

Some medications induce the metabolism of methadone, meaning the metabolism speeds up. The total dose can be increased to compensate for this, but sometimes the effect is so pronounced that the patient needs to change to split dosing to feel normal.

Every time I order split dosing, the nurses become wary. That’s because the proper way to start split dosing is to give the patient’s usual entire amount first thing in the morning on day one. Then, a take home for half the dose is given to the patient to take home for later use that first day. The nurses worry I’m going to overdose the patient. Starting with day two, the patient gets a half dose in the morning and a half dose in the evening.

If you don’t start the day with a full dose, but rather start on day one with half in the morning and half in the evening, the patient will start off in withdrawal, and can de-stabilize for the first four or five days.

Instead of giving half the dose in the morning and half twelve hours later, I sometimes give two thirds in the morning and one third at night.

Dosing of both methadone and buprenorphine can be split for better control of pain. Even though opioid treatment programs’ primary purpose isn’t to treat pain, many patients have both opioid addiction and chronic pain.

The analgesic, or anti-pain, effect of a dose of methadone or buprenorphine lasts for about six to eight hours. That’s why I warn opioid addicted patients with chronic pain that dosing daily may help with pain in the morning hours, but not in the evening or nighttime. I don’t want to mislead them in their expectations for treatment.

If a patient is doing very well in treatment, has no illicit drug use, is making good progress in their recovery, but still has disabling chronic pain, I’ve asked the state and federal authorities for permission to split dose the patient for better pain control. Sometimes it works great, and sometimes it doesn’t help at all.

Before considering split dosing, I have to look at the patient’s overall situation. A patient being considered for split dosing is at an opioid treatment program for a reason: she has lost control over her use of opioids. It may not be realistic for me to expect this patient to be able to appropriately manage a take home dose until/unless this patient has had time to make progress in her recovery. I do want to get the patient on a dosing schedule that helps her feel normal, but I also want her to be safe.

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31 responses to this post.

  1. Posted by Rpick55@aol.com on July 6, 2014 at 5:05 pm

    ok this is bunch of bull. split dosing is advisable. R

    Reply

  2. Posted by nspunx4 on July 6, 2014 at 6:09 pm

    I have a close friend with a spinal cord injury and extremely severe neuropathy. Due to his opioid addiction and the complicated nature of his injury no one wanted to touch him.

    We tried to advocate for him to get split dosing and or appropriate treatment for his pain. The old doctor at my clinic would not even discuss the idea of split dosing.

    Fortunately he retired and Dr. G started at our clinic. She has been extremely great both with his case and my fiances complicated case (qtc prolongation caused by seroquel, lithium, hypokalemia, and methadone once the psych meds were stopped and a beta blocker started she has titrated to 200mg with no symptoms and very slight qtc prolongation) we also found a great internal medicine doctor with Buprenorphine clinic experience and a good understanding of methadone.

    Between these two seperate practitioners who made a great effort to contact and develop a plan together my friend finally is on split dosing with a moderate increase and his quality of life has drastically improved.

    The right doctor at a clinic can make such a difference to the patients success. Before my fiancé had to jump through hoops to get a 5 mg increase (she was on 220mg and due to the above issue had to start over starting at 20mg/day) it would have taken 20 years for her to get back to an adequate (for her) dose. Dr G was willing to work with her cardiologist and use his advice (he understands the risk of both relapse and arythmia) and the good EKG results to order increases of 5mg every 5 days with an akg every 20mg’s until she got to 200. She has had good EKGs and finally feels comfortable on her dose. Dr G has made a huge positive difference in 2 cases others didn’t want to deal with. Instead of hiding behind blanket policy and protocol she takes an individualized approach and puts the patients needs first.

    A good doctor who wants to help patients and isn’t afraid to tackle complicated situations can improve patient outcomes and quality of life drastically. I am sure there are patients who would benefit from split dosing who can’t get it and that is a shame.

    Reply

    • Thank you!!! I am 1 of those people who was on split dosing in California for 5 years, but when I moved to San Antonio, Tx. and was told at the methadone clinics there, “We don’t do that in Texas”. And why not? It’s ordered by a Doctor for me in Ca.for the last 5 years!! TEXAS, get up to speed w/ the rest of America!!! Unbelievable. S. Viramontes..C.for H.C.S.

      Reply

      • As long as there are records to support the reason for split dosing, I would continue to do so in a patient transferring from another state. That makes it sound like a state law…I will look into this…

  3. I’ve been on suboxone for 6 months now. I commenced it as a substitute for the dependence I had on medications codeine (main stayer), tramadol, soma which I was only ever taking to treat pain I was experiencing when sleeping (yes most people have difficulty comprehending this as they think pain should not occur whilst in a sleep/relaxed state). Even some dumb arse orthopods surgeons don’t believe pain to be possible whilst sleeping, I digress). So i only ever took codeine, and tram with paracetamol at night because i knew it would get me through the night. I wouldn’t pop pills during the day because I knew that by freely moving about during the course of a day it would iron out the pain. Makes sense doesn’t it, a bit like a sufferer of arthritist who may also get pain relief by moving about as nature intended for our bodies. My special little friend (pain) resulted possibly from a spondilolisthesis condition (only mild) and I took a hard fall onto my coccyx/lower back region over 20 years ago.

    Anyhow, my point is not to highlight my pain as we all suffer one way or another. But in relation to this blog from the Dr, before commencing suboxone I was on long acting tramadol. I always liked how I felt on tram (for the most part) because it turns on the serotonin tap so you feel good. However, a potentially dangerous pill IMO. But I used to find that after about 6 to 8 hours I would be craving more of the tram becoming emotionally upset and anxious and generally depressed. One day the tramadol stopped working altogether, that was after about 4 months of continued use. That was scary not for the pain relief no longer there at sleep time, but it also stopped helping my psychological symptoms of helping to keep me happy etc.

    So I went and saw an addiction Dr who thought suboxone would be a good idea. It was a good idea, no more pain and I weaned off not just codeine and tramadol a but all the other junk like iboprufen and paracetamol, so I think I did my liver a favour as well. The first time I took 4mg (I’m a big muscular 186cm 42 years old) I thought… This is a nice feeling, I’m no longer upset, anxious and easier going. I soon discovered that my pain friend had taken a permanent vacation! To sleep right through the night was so fabulous, I had not slept like that since I was a young boy at school. So suboxone is awesome for the type of chronic pain I get. Also, to this point after 6 months I have not ‘pooped’ out on it. I take about 12 mg per day and I find less can be more, unlike conventional opiates. That is the true wonder of suboxone ie. You don’t need much and less can be more. BUT I’m one of the ones who craves it more frequently, as Dr Janaburson explains for some people. After about 6-8 hours just like when I was on tram I start to crave it again. So these medications that are marketed as having longer half lives do not go the distance for me. I think the pain relief is fine for once per day dosing, but I know that physical symptoms like tremors and cold sweats can occur. Thanks for reading.

    Reply

  4. Posted by RobH on July 7, 2014 at 1:30 am

    I am in an outpatient OTP with chronic pain issues. I split dose (2mg suboxone am, 2 mg pm). It greatly helps pain coverage…but I have to supplement with 3 times daily ibuprofen. It isn’t perfect but it beats the hell out of MScontin and God knows how much vicodin for “breakthrough” (as well as all the worrying about how many pills I have left).
    Thanks again for a good article. I knew split dosing worked better for me. Now I know why.

    Reply

  5. I have to do split dosing on subutex but it really wasn’t by my choice. I was started on split dosing in 07.

    this year, The dr did genetic testing on me which proved I metabolized it super fast, and therefore, it justified split dosing.

    The genetics test also explained that drugs such as antidepressants would not work on me bc my body wouldn’t metabolize them.

    Interesting test – and I was glad that it proved to me I wasn’t crazy when I would say the medicine wasn’t lasting as long as it should.

    So everyone is different I reckon and as you have said many times, there is no one treatment that fits all 🙂

    Reply

  6. Oh I guessing should have added that I have endometriosis and even tho subutex is not for pain, it does help treat it. I take 4 subutex per day and I only take one at a time. This may be like a huge no no, but I have never relapsed and I have never had any problems so I am just sharing my experience. But I much rather just take one dose in morning and be done with it for rest of the day. So much easier..

    Reply

  7. Posted by Benjamin Keith Phelps on July 18, 2014 at 8:48 am

    Why do so few docs & nurses – even in clinics – seem to understand that the methadone blockade WORKS ON ITSELF, as well? Methadone blocks the euphoric effects of heroin, yes. But it also blocks the euphoric/sedative properties OF ITSELF at blocking doses. Hence, giving a split dose in the way you describe is the PROPER way to do so. Otherwise, withdrawal is eminent. If you start the patient at half his usual dose that morning when he’s already in withdrawal to begin with, that leaves him in withdrawal. You have to fully dose him, & then add half a dose that evening, as it sounds like you understand, Dr Burson. After 5 clinics, I have yet to be at a clinic that even ALLOWS split dosing at all that I know of! I just arrived in DC & now I’m fighting the good fight for an alternative to a 2-minute time limit for those of us with paruresis – they offer oral swabs, but only if I pay to go get a doc’s diagnosis for having paruresis (first of all, I’m on a voucher program b/c I have no insurance, no medicaid yet, & no job yet – so how exactly can I go to an outside doc? But secondly, how can I prove to a doc at all that I can’t go to the restroom with someone staring at my crotch & saying “Here, pee in this cup on the count of three – 1, 2, 3, go!” That’s nothing more than a hassle designed to treat people poorly. And the clinic I was put in here by the Department of Health is SUPPOSED to be one of the better ones. They took away some of my takehomes when I walked in the door for no reason other than b/c I transferred. As thought watching me swallow a dose for 10 seconds 1 or 2 extra mornings weekly is helping them “get to know me”. What it DOES do is cost me extra money to get across town that I don’t have right now. I waited in NC an extra month & some change to get to my next level for that reason. I guess that was for nothing. Anyway, I started typing to say that methadone blockade ALSO WORKS ON METHADONE. Once you reach blockade levels, taking an extra half dose isn’t going to overdose a patient who isn’t abusing street drugs as well. Not even CLOSE.He isn’t even going to feel it. Anybody fresh in treatment has tried that already before getting out of his addiction & into recovery. That’s how we discover MMT works – by attempting to use & it failing. It sucks to say, but it’s addiction for you. We try to get high on opioids & it fails. Methadone raised up to the nth degree also fails to make us high, so we give up on trying to increase until we “feel it” & learn that we’re better off at a dose where we’re not nauseous & feeling like crap all the time. Often times, a fairly new patient will go back down once they reach over-medication b/c of that. I know I did. I learned where my stable dose was & what was more than I wanted or needed to feel normal. These days, I’m at even less than that b/c I no longer need it after 6 years (155mg). Now I sit at 140mg, & it’s just right for me & has done me well for quite some time now. I had to sit at 120 for 3 years (’10-13) b/c 2 clinics ago, Southlight in Raleigh made going above 120 take an act of congress & God to make happen. I didn’t relapse, but I thought about taking my next dose all the time after a certain time in the evening – “Is it time to dose yet?” “When can I take my next dose?” “Would they do a bottle check if I took it now?” & I got SICK of that. I don’t WANT to think about my next dose. I want to live a normal life w/o thinking about medicine all the time. That’s what MAT/MMT is all about!!! So people who need split dosing to feel normal like that – I UNDERSTAND! And I support them in their effort to have some normalcy in their lives.

    Reply

  8. Posted by John Mark Blowen APRN on July 23, 2014 at 3:15 pm

    This is eye-opening ! Makes a lot of sense to initiate the way you do, Dr Burson. How did you arrive at this method?
    I’m wondering if there could be a ’round table’ discussion, eliciting information from other practices on how splitting is done…The only other info I have about this in pregnant women is Dr John McCarthy’s “Does anybody Have a Clue” article also on the atforum website a yr or two ago – which does not go into specifics at all.
    Thanks

    Reply

  9. Posted by Emily on December 5, 2014 at 7:49 am

    Please help me. My methadone clinic WILL NOT split dose me. They say they cannot do because im not eligble for 30 takehomes a month. Which 1. Doesnt even apply to this situation. And 2. I’ve been in treatment since October 2011. So that’s 3 years. So I am eligble. The guidelines I’ve found say 8 uas a year, my clinic does 12 but definitely 8 of those are clean. Its 130 in the morning. I am withdrawaling. 12 hours earlier I was nodding off. I’m a herion addict – I know what being fucked up feels like. My counserlor keeps tryimg to tell me that I’m sleeping during the day because I’m depressed and that I I obviously cant sleep at night if I sleep all day. But she’s got it wrong. They will not even do the peak and trough test. They wont do it. And I don’t know what I’m supposed to do. I’m at 55mg. I’ve been up to 90mg but I was also doing herion and I think it was making my tolerence stay high. I haven’t changed doses in over 4 months. This crap has been happening for the last 2 months. Nothing has happened to fo anything to my , etabolism. What do I do? Go have someone else do the test? I hate my clinic. There’s only 2 different ones where I live and the other one is worse and further away. They had me fill out paper work loggimg when I was sick and when I felt overmedicated and then just said no we’re not going to even test you. I have rheumatoid arthritis I could go to a pain management doctor. It feels like itd just be easier to do heroin at this point. How do I force them to give me a split dose. I don’t want to go up on my dose. I’m in Texas. Are there laws or somrthing that I could just overload them with information and rules and regulations to make them do it?

    I can’t have a job if I can’t stay awake during the day and withdraw at night.

    Reply

    • Here’s a few thoughts: you don’t get to count the best drugs screens out of the twelve that you’ve had. If you have had recent illicit drug use, your clinic is right to be concerned about the dangers of split dosing, particularly if you’re using drugs that could kill you with methadone like benzos or alcohol.
      But you don’t have to be eligible for 30 take homes per month in order to do split dosing, either…unless things are different in Texas due to their state’s laws.
      First of all, try to stay on a regular sleep/wake cycle if you can. Go to bed at the same time, get up at the same time, and don’t nap during the day. Notice your symptoms and any patterns of sedation/withdrawal. Then ask to talk to the doctor prescribing your methadone, and talk with her/him about your symptoms. If the doctor won’t check peak and trough levels, ask her why she’s made that decision. Really listen to her answer and address that. Try to stay calm and respectful, and if her objection is because she thinks you may be depressed, go for an evaluation for that problem. Then if depression is ruled out by another source, go back and talk to your doctor again.
      Maybe calm and persistent communication will help.

      Reply

  10. I would think drug screens that show illicit substance use (drug screens are inanimate and therefore cannot be positive or negative) may be an indicator that split dosing is warranted if the pt cannot increase alone due to intoxication but the dose does not provide symptom relief/narcotic blockade effect for 24-36 hours.

    If a clinic chooses not to be open evening hours (mine isn’t either) that is their problem not the pt’s the pt should get the most effective treatment available not suffer with subpar treatment because of clinic operating hours policy. In other words if a clinic does not want to offer eve hours for pts who need split dosing then they shouldn’t use take home guidelines as an excuse for providing poor treatment. I believe denying a or who could benefit from it split dosing is poor treatment.

    Reply

  11. Can I get some of the references or studies’ information from you on the subject of split dosing? I am working with a new-to-the-company PA-C that does not “believe in split dosing or peak and troughs” because there are “no studies to prove it” and he feels this way even for the pregnant patients. I am concerned for my clients and would like to show him some proof.

    Reply

  12. Posted by Angel on October 1, 2015 at 5:07 pm

    Split dosing while pregnant is the most safest way to be taken. I’ve been through one pregnancy already with split dosing and had a stable experience. I am currently 19 weeks pregnant and not on a split dose, yet. I feel very up and down and my dose wears off in the late evening time and by morning I am experiencing several withdrawal symptoms. I feel like my dose needs to be increased but I do not want to go up any more. With my other pregnancy I did not need to increase my dose and I maintained very steadily with a split dose. The methadone clinic I am at now does not do split dosing for pregnant clients. I am currently trying to get split dosed I was informed that it’s very rare and their was only a few client’s under special circumstances that has been allowed to split dose. Split dosing is very important and beneficial while pregnant it helps you maintain a stable dose without needing to keep increasing your milligram.

    Reply

  13. Posted by James on April 18, 2016 at 8:02 pm

    I go to a clinic in Tacoma, Wa. I am at 148 mgs and am still not stable. I have been dealing with trying to get my dose stable since I got back on MMT in august 2016. Well my trough levels are as low as 0.035 and they will do an increase of 10 mgs and then make me wait a week and do another blood draw. the trough results take TEN DAYS and thats when they decide. Well they are taking me to staffing meeting AGAIN because my trough was even lower this time for some reason. They only do split dosing for pregnant patients and thats under special circumstances. Well I am a special circumstance. I’m epileptic and have been in the ICU so many times in the past few years from having massive seizures for days to a week at time and every time I go into withdrawal I either have a seizure or I will start feeling like I’m going to have one. I’ve been clean from heroin for 4 and a half years and was on suboxone but I didn’t react well to suboxone and methadone works much better for me. None of my seizure medications interact with it NOTHING I take does and I dont drink or anything and never have any dirty drug tests. EVER,I am printing this out to give to my counselor to take to the “staffing meeting” this is making life really hard for me because I wake up so damn sick every morning and I am on the brink of withdrawal or already setting it in before I go to bed and I dose EVERY DAY between 7-715 ON THE DOT. They have made sure to let me dose before I do my drug tests if I cant pee because they trust me and because of my severe medical problems with the uncontrolled epilepsy, My neurologist told me to get on this because it is what would help me the most because the suboxone isnt working when I was trying to taper I was going into severe withdrawals. My seizures went away so much more when I switched to methadone almost 9 months ago I didnt have one for four months. I am just having too hard of a time going 24 full hours without a split dose. I would prefer a full dose in the morning and maybe 20 mgs at night because that would hold me over until the morning. I know from experience.

    Does ANYONE have any suggestions? Please help. Thank you.

    Reply

    • In general, trough levels aren’t all that helpful. I’m surprised your doctor hasn’t already done both a peak level and a trough level. If the peak is more than twice the trough, you would do better with split dosing.
      Are you sure your seizure meds don’t interact with methadone? Many of them induce metabolism of methadone, causing the patient to have a lower blood level at a given dose than if the patient were not on seizure meds. Of course, you can’t stop your seizure meds – but again, a peak level to trough level ratio would help sort this out.
      Please talk to your doctor and ask about these issues.

      Reply

  14. Posted by Elizabeth on May 27, 2016 at 7:31 pm

    Help! Trying to spilt dose… I am usually model patient, but got thrown in penalty box for missing recall. I should have just called out of work. Here is the issue, when I first started at clinic 8 year ago (had week or 2 of take homes forever and never failed a ut) I took a PT to see if I should spilt dose be I felt horrid after 8 hrs. Test came back and doc said instead of spilt dose, give her a weeks take home early so she can spilt dose on 6 out of 7 days. Dosing onc a day is killing me! After pestering my clinic I saw doc, he agreed, the clinic director agreed I should spilt dose, but they said it had to go to state for approval bc I am on probation for missing take home. It would take about 24 hrs, so I was told Monday afternoon and it is Friday and nothing. I does it really take five days to hear from state (Ga)? I am about to make bad choices bc I cannot continue to feel like crap evert damn day! And I am in disc which they wet so I cannot spilt dose on Sunday’s either. I am a mom to a special needs child and this dosing situation is starting to make me a shadow of the woman I was. Please, any advice would be great.

    Reply

  15. Posted by Ally on May 31, 2016 at 7:28 pm

    I am in Denver colorado and my awesome counselor is jumping through the hoops to try and get me split dosing. I feel terrible and every month or so I increase. Once I increase, I feel drowsy during the day and then at night I start feeling wds. The nurse stated they only split doses for pregnant pt bit my counselor said he is going to try and get split dosing. I’m just crossing my fingers that they approve it.
    The main reason I want to do the split does is how I feel and then secondly would be because it feels hopeless when I keep going up and don’t feel stable. How will I ever taper off if I dont feel stable when I keep going up?

    Reply

  16. Posted by KNick on June 8, 2016 at 11:54 pm

    Jana, this is from 2 years ago, hope you still have perspective? I had transferred from an MMT to a pain clinic where I received 110MGs daily(or 330x10MG tabs). 4 in AM, 4 in afternoon, and 3 in PM. Worked perfectly for my pain issues. For reasons mostly my fault, but separate from the pain clinic(small town), when I showed up they were bringing me down starting w/90MGs a day. 20MGs less everyday. I thought I would have trouble so I dismissed myself and enrolled in local MMT. I was using the 4-4-3 pattern for pain for over 5 years. They are telling me at the clinic they don’t do SD’s. But as you replied to a someone who had moved from CA to TX & could not SD, you said that doesn’t seem right.
    Any methadone(most)users know that the pain duration is 4-8 hours, while the WD length is 7x that(48 to 56,give or take). I am basically opioid tolerant from 35 years of pain & overuse. A single does helps my early day & then stops. My CYP450 does not metabolize it at a fast rate, yet I am on quite a low dose compared to how one MMT tried dealing with my pain; just upping me 20MGs a day until I was at 360 & scarred to death every day and scared to go to sleep at night. Do you have any thoughts, suggestions, or words of wisdom I can learn from?
    My body became physically adjusted to that dosing. Once a day is almost like a tease.
    Sincerely,
    KNick

    Reply

    • I approve split dosing for fast metabolizers ( serum peak more than twice the trough) and pregnant ladies during last three months.
      The problem is that opioid treatment programs are set up to treat opioid addiction and not pain. As you say, once- daily dosing with methadone doesn’t cover pain late in the day.
      It’s a serious problem for many OTP patients who have both addiction and chronic pain.
      Usually I ask the patient to talk with their doctors about finding a non-opioid treatment for the chronic pain. Sometimes this works, and sometimes people come to find out that long-term opioids have made them even more sensitive to pain, a phenomenon known as hyperalgesia.
      These are some ideas you can use when you talk to your OTP doctor, who is the key person to decide what will help you the most.

      Reply

      • Posted by KNick on June 11, 2016 at 5:03 pm

        I am not a fast metabolizer. My first MMT is where I was tested for peak & trough. I did not qualify.
        If I were to guess, I definitely believe I have become hyperalgesic over the years. Growing up & playing sports 24/7 of 365, I can think of 2 occasions where my mother called my HS and had me released for an eye appointment that kept getting moved around, and they(my optometrist) called this morning and needed to get the appointment in. 1)My left wrist which I had been complaining about for 2 months but refused to see my family doctor. My mom takes me, x-rays, diagnosis: broken bone in between hand & arm & thumb needed to be cast immediately & remain on for 2 1/2 months. If it were to heal on it’s own, a high probability of over 50-60% reduction in it’s mobility. 2) Injury occurred on a Friday night. Used crutches all weekend to get around because the lower portion of my left leg was uncontrollable. It kind of flopped around similar to what you might see when a race horse breaks a leg. Still, refused to see doctor. And it was quite painful. It took doctor #3 to convince me I needed surgery, & NOW! MCL, ACL, nerve damage & some other medical terminology that meant(in 1985 at least) no more football, skiing, etc. Cast from foot to groin area for over 2 months; an introduction to meperidine and quick knowledge that I was either allergic or highly sensitive to Phenergan. Was in so much pain they switched to a fent.
        Hyperalgesia must have some relation or connection to being psychosomatic, even if it is very far away?.?.?.?
        Adding hyperalgesia with psychosomatic, & to make it more complicated(what’s the use, FUN, or having no excuse to do more research in hopes of figuring out/thinking your way to a cure for addiction=because gosh darn it, I know it’s out there!), throwing in opioid/opiate tolerance; so really I should be taking Abstral or Fentora! I am kidding and am serious about my disease, this time.
        Had a meeting with my counselor Friday AM, June 10, 2016. Each Friday when dosing is finished, 11:00AM. There is a 1:00PM meeting for all counselors, Administrator in charge of clinic, & I am not sure if the dosing nurses & doctor attend this meeting, although considering certain topics that are discussed I would think their input & knowledge could only benefit the group and decisions that are made. He, Greg my counselor, said they would be discussing my issues with pain, my proposal of positives & negatives for split dosing, or maybe take homes? e.g. I had written that if I were allowed some type of plan, I would still show-up at the clinic every day unless I were fortunate enough to gain employment.
        Everything becomes a moot point within 8 or 9 days if I am unable to secure some form of income. I have stretched my wife’s patience, kindness, & benevolence further than I ever thought I was capable of. The sneaky self-centeredness’, always taking & never giving, plus abilities in deception, dishonesty, & stealing that you either never knew you had, or have promised yourself and others 100 X’s over you will never do again, until the situation presents itself and you realize the decision to act in favor of your disease was actually made months earlier when you promised John Doe never to do it again; If you allow yourself to think close to the level of meditation, you start to realize you’re evaluating a relationship and your disease has convinced you that burning the bridge between you & John Doe is worth the sacrifice if the end result leaves you with drugs, or whatever addiction brought you to this page.
        I don’t want to say “normal”? A sensible person, free from psychological & physical controls, never battles with this type of situation. There is no better choice. There is only the friend, John Doe.
        If I am able to keep that type of thinking, which has never been the case in my past, hence the reasoning by many alcoholics that continue going to meetings. We need to be reminded or old habits will sneak up on us!!
        Thank you greatly for your advice Jana!! And the blog as well! So many topics from other readers or something you address. All are important, or relative, and I can usually find a way to get positive meaning for my life from anything I read!
        Thank-You,
        Sincerely,
        KNick

  17. Posted by Tanya on July 16, 2016 at 10:54 am

    I’ve been on methadone for about 10 months now. I started on 20mg and found myself stable at 33mg until a couple months later when I started gaining weight back so then had to increase up to 55mg. I then discovered I was pregnant. I am now 32 weeks pregnant and during the course of my pregnancy have increased up to 105. I was experiencing withdrawal yesterday and so was increased to 110 and advised to start splitting my dose on my own at home since I have take homes. However nothing was ever mentioned about me taking my full dose and then half that later that day and I was not given an extra half dose to do this. I’m supposed to start splitting my dose today. I’ve been taking my medication of 105 mg every morning and now this morning I’m going to take half that as directed by Dr and then the other half 12 hours later. Does this mean my baby is going to be in withdrawal? I’m scared now to split dose because I don’t want my baby to be in withdrawal cuz they say the baby feels it first. Help!

    Reply

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