Confusion over Methadone Peak and Trough Levels

aaaasplit dose

Recently I’ve had patients write to my blog describing how their opioid treatment program doctors are using methadone blood levels to determine the correct dose. What they described to me was worrisome; patients’ doses rarely need to be checked with methadone peak or trough blood levels. Due to tolerance, a methadone blood level may be adequate for one patient, but far too low for other patients.

A patient’s dose of methadone needs to be determined on clinical grounds. This can include the patient’s description of withdrawal symptoms and their timing related to dosing, physical exam just before the patient is due for a dose, and evaluation of the patient three to four hours after dosing. It may also include an evaluation of ongoing illicit opioid use, other medical issues, and other medication or illicit drug use.

Opioid treatment program physicians rarely need to check methadone blood levels. I usually check peak and trough blood levels when I suspect a patient may be a fast metabolizer who may do better with split dosing. In such a case, the patient describes feeling fine for the first part of the day but in awful withdrawal by night time, despite taking a relatively higher dose. Then if the patient’s peak (highest level) is twice the trough (lowest level) I know they may feel better with twice a day dosing. Certain medications can induce the metabolism of methadone, making the patient metabolize methadone more quickly and drop the blood level. Often in this situation, split dosing helps.

I cringe when patients say things like, “my doctor checks a methadone blood level on everyone when they get to 80mg to see if they need to increase the dose or not.” For the vast majority of patients, getting this blood level won’t be helpful. If it’s used to determine the patient’s dose, it could be harmful. Many patients will still feel withdrawal while dosing at 80mg, even though they may have what would be considered a moderate blood level.

Our patients are tolerant to opioids. For this reason, methadone patients who are doing well, feel fine and have normal lives can have so-called “toxic” blood levels of methadone. A level that would kill someone unaccustomed to methadone may be just what my patient needs.

Some doctors think all opioid addicts want to go higher on their methadone dose than they need, and that these addicts would want limitless dose escalations unless the doctor stops this. In some patients, addiction may drive the addict to ask for dose increases even when not needed. Addiction often tells the patient “more is better.”

I’ve seen this problem too, but not as often as one might expect. More often, I’m the one advocating for a higher methadone dose. Don’t get me wrong, I do want to use the lowest effective dose. Some patients, due to fear of methadone and the stigma against it, are afraid to increase their dose. I point out that studies show patients do the best in methadone treatment if they are on a high enough dose to block the withdrawal symptoms and block the euphoria from other opioids. Particularly if the patient is still using illicit opioids, I recommend a dose increase.

Lab tests aren’t an adequate substitute for talking to the patient and examine the patient. As we used to say when I was in medical school, about a billion years ago, “Treat the patient, not the lab result.”


120 responses to this post.

  1. Posted by Boston NAMA on April 19, 2015 at 2:39 pm

    This is Methadone 101 but apparently too many Doctors have not even been trained in basic Methadone except for what they learn from nursing staff or who knows. As a methadone advocate I cant tell you how many doctors are not educated in these basic skills. Example even pregnant women who come to dose sick every morning are never even aware they can get a split dose. With each year we are seeing more and more giant clinic operators and let’s hope the offer trainings programs to their new and old doctors.


    • Posted by Beth on July 7, 2017 at 4:17 pm

      It sure is. I cannot believe that in 2017 I am having to have a peak and trough done to go above 120 when I was on 195 in another state for 10 years! The numbers don’t mean anything. Some doctors still think that patients are trying to go up to get high. IMO, I don’t like the feeling of being on too high of a dose, it makes me too tired and if I don’t nap I get miserable. It’s just more ignorance on the part of clinics and they are hurting patients. In my state, CT we have had many, many, heroin overdoses yet these clinics are still practicing this antiquated way of prescribing methadone.


  2. Awesome post Doc. Even though we disagree sometimes it is an awesome service to the community that you do this blog. Thank you!


  3. Thank you! This is excellent, and this piece will be a great resource to have and share when this issue surfaces with patients!

    Zac Talbott
    NAMA Recovery of Tennessee
    National Alliance for Medication Assisted (NAMA) Recovery


    • Posted by brent on November 17, 2015 at 11:17 am

      that was a great postby that doctor. i liked your reply as well. the owners of the clinic i go to, BHG, also have clinics in Tennessee
      …actually bhg has treatments centers all around the country


      • Posted by Rhonda on August 26, 2016 at 12:23 am

        I am also an advocate and I go to BHG Methadone Treatment Center in Colorado. I do much better with splitting my dose. I am fine at 130 mg now, if I feel that uncomfort we all know too well they will do their Peak and Trough and up it a few mg. The more I keep increasing, the more tolerant I become to it, the more painful to get away from it if I were to ever think of being insane. My problem is that I have other medical issues, Heart Disease, Pace Maker, Severe Sleep apnea that is central and apparently Opiates are a major culprit in this. These are the Doctors who need educated on Methadone. My dentist was floored by my being on 130 mg a day for a small woman. “Cut down on Methadone” was on a sheet of helpful things I need to do to get my sleep apnea in better control. Like I can just do that! Anyway, where does it end? We build tolerance but if we don’t increase the Methadone, we will even it out. because for those of you who have not withdrawn from Methadone, you don’t want to be suddenly cut off at a high daily dose for several days. I went six days cold from 125 mg a day and it was worse than any hell from any other opiate I have ever used. 25 years of daily opiate use has taken it’s toll but I think we have come a long way in making help available.

  4. Posted by kevin on April 20, 2015 at 5:22 am

    Amen dr burson. Somebody needs to call Tennessee and force them to understand this. They have halted me at 150mg and will not even allow me to ask for an increase even knowing I was on 200.


  5. Posted by Carlos on April 20, 2015 at 11:22 am

    I don’t recall where I read it, but I understand that Dr. Vincent and Dr Marie Nyswande when they initially started their research they compared heroin with methadone treatment and found that patients on Methadone reached a level of dose and stop requesting increases while patients on heroin continue to request increases. This characteristic of methadone convince them that methadone had a medical use. Given that the patients stop requesting increases at their own levels.

    At one time if a patient wanted doses over, I believe it was one hundred milligrams, the clinic had to contact the FDA requesting approval. I believe that this may be one of the reasons why in the law of 2000, the monitoring changed from the FDA to SAMHSA.


  6. Posted by Jennifer W on April 21, 2015 at 11:15 am

    A wonderful commentary on the pitfalls of “treating the lab result, not the patient”. In the world of OTPs, we unfortunately see this regularly, the propensity to allow one test to dictate a patient’s treatment, or potential future in treatment, without regard to the entire clinical picture. It is deeply saddening, but so common. Arbitrary policies that focus on fear of liability and stigma toward addiction rather than the individual patient’s best interest are also common in the OTP setting. This is valuable information for providers and patients.


  7. Posted by Kristin Moore on April 21, 2015 at 2:20 pm

    I have more of a concern…. I’ve been on 100 mg of methadone over the last 3 years. Over the last two months I’ve started a slow taper because I was told by the doctor at the clinic I go to that I shouldn’t have any withdrawal symptoms. In the last two month’s I’ve already dropped down to 80 mgs. I cry everyday and feel like I’m going CRAZY!!!!! Just wanted some thoughts… you think I’m tapering to quick???? I’m also not sleeping well at night but feel like I’m gonna pass out all day, I’ve lost 7 pounds over the last 2 weeks , and my psych doctor put me on clonazepam for anxiety which doesn’t seem to help….WHAT SHOULD I DO????!!!!! Any comments would help.


    • Something is going on – you need to talk to your doctor at your clinic and describe all of this. It could be withdrawal, or could be another issue. And get your psych doctor to talk with your OTP doctor!


    • Posted by Tiffany on June 18, 2015 at 10:21 pm

      I’ve never been on this site before but I read your post and had to comment. I can completely relate to you. This Dr. I only saw once told me that you should taper by 3% of your dose for about 6-8 weeks and then stay at the same dose for about 2-3 weeks and repeat. I was at 130 and I started going down 5 every week, like you I assume and after a month I started to feel like crap so I slowed it to 3mg per week and it made a huge difference. I know it will take longer to get off the methadone but you will have your sanity. And keep the kpins around cuz tapering does suck and you might need them. I just wouldn’t take them every day. Even if you’re not addicted to those when you stop taking them after being on them with ‘done it’s like your wd’ing from those on top of the ‘done. I don’t know why. I hope that helps.

      I found this page looking up peak/ trough levels. Personally I have been on methadone for 13 months, it got me clean. But when I started, it was like I wanted to see how high up in mgs I could get & the drs don’t care where I go, so I got to 175mg and got completely depressed like Kristin was describing. I went down to 80, back up to 140, then 130, stayed there for 4 months, now to 108. I need a split dose. I know my body. I used to take methadone all the time and never took more than 25mg at time. I would take like 20 in the am, 20 in the afternoon and 20 around dinner. Sometimes less. I took a peak and trough a while back, probably around 150mg and it was 30/60. I’m taking another one on Tuesday. I’m so frustrated. I’ve gained 60 lbs in the first 4 months, I’m so depressed, tired constantly except like 2 hrs out of the day. I feel awful every morning and barely want to dose. All I want is to try a split dose. I think your peak needs to be more than 2x your trough.


      • Posted by melanie stearne on April 27, 2016 at 1:27 am

        i just had a peak and traugh done they told me my levels were toxic yet ive been fine other than tired a lot they are dropping me immediately down to 80 mg from 120 im scared to death obout how im going to feel how could they drop someone so much so quickly what should i do ………..?????????

    • Posted by Leslie on August 17, 2015 at 10:24 am

      First off you are not supposed to take clonazepam at all with methadone. It can be a deadly combination. I’m a certified pharmacy technician and also take methadone and had to completely stop taking my clonazepam in order to take methadone. So somebody didn’t do their research before prescribing you both together.


      • Posted by Kristin Moore on August 25, 2015 at 4:55 pm

        I am aware of the risks of mixing benzodiazepines and methadone, and I’m pretty sure the psychiatrist that prescribed them to me knows the risks because we discussed them . I also had to get them approved, which they were approved through the federally funded clinic that I attend. No offense or anything, but they’re are plenty of people that are on methadone and anti-anxiety meds. I’m held accountable for my meds to an extreme which is a good thing, but they get counted every time I’m there, which is weekly right now. Thank you for your concern, but they’re is normally a 60 mg limit of methadone if you’re going to be on benzos, it just depends on the clinic and the doctors, as far as research goes. I’ve also heard of clinic’s that have a NO BENZODIAZEPINES rule no matter the circumstance, I’m guessing that’s the kind of clinic you attend, but for the record I am aware.

      • My reason for opposing benzos is due to the risk of overdose.
        but there are other very compelling reasons to use anti-anxiety medications other than benzos. We have studies that show benzodiazepine use is associated with dementia, and with premature death (read my blog post from September of 2014.)

      • Posted by Kristin Moore on August 27, 2015 at 4:06 pm

        I thought I was replying to a comment that a girl named Leslie had posted, I didn’t mean forthat comment to go to you. I have the up most respect for you and your knowledge and opinions on most everything to do with this entire blog so I’m so sorry if that came off rude at all to you, that wasn’t my intent at all.

    • Posted by mark on January 6, 2016 at 5:26 pm

      I thought that we can’t take clonazapam while taking methadone. I just don’t understand this, I hear this from some doctors and other drs have never heard this. My mother was prescribed both Ativan and methadone from the same dr. Someone else I know was prescribed Valium and methadone same dr. But when you go to a OTP they say it’s deadly. Do some Dr’s just miss this class in school or is this really something just hyped up


      • Not made up. This nation had a peak of methadone overdose deaths around 2007. When analysis was done, most of those patients were being prescribed methadone from pain clinics, not OTPs. Many also were found to have benzos in their systems, and we know combining opioids and benzos increases risk of death.
        Some doctors are not familiar with this data, or may think they don’t treat people with addiction(or don’t know that they do), and assume all patients take their medication exactly as prescribed.
        Some opioid treatment programs still allow benzodiazepine prescriptions under some circumstances, but those patients are watched very closely, and the benefit must outweigh the risk.
        Doctors in general should be less likely to prescribed benzos for more than three months since long-term prescriptions are associated with dementia.

      • Posted by mark on January 7, 2016 at 2:23 am

        So would it be possible for a person that is doing the right thing take benzo’s as prescribed, the normal say 5 or 10 mg valium and be ok with a high dose of methadone in there system. I know that during the first 4 or 6 hrs of dosing that could be fatal but what about the rest of the day? Is it safe

      • Plenty of patients take benzodiazepines and Tametha down and have no problems. Is this the best idea probably not but it can be done safely .

    • Posted by Marlon Gidluck on April 15, 2018 at 2:19 pm

      Any thing more than 2 mg every 10-14 days is way too fast!
      And onc your down to 70 mg then 1mg per 10-14 day period!
      It’s percentages


  8. Posted by Terri on April 24, 2015 at 12:10 pm

    I am currently on 76mg of methadone and just went up 2 weeks ago from 73mgs. It seems to me that every 3 to 4 months towards bedtime I start withdrawaling and have to go up a few mgs. I feel that I should not suffer that I should be comfortable. Can someone give me feedback. I know every person is different but go by the majority, does your body finally become comfortable/stable when they get to a certain dose or am I just gonna keep going through this process of going up a little every now and then? I am tired of feeling uncomfortable after so long on this. I am just confused at this part of my treatment. Thank you for your time!!


    • Usually, tolerance does not develop to the withdrawal-blocking effect of a dose of methadone. But other things can happen to influence your dosing needs. I will say that going up by 3mg is not much of an increase at all.


    • Posted by Kristin Moore on April 25, 2015 at 12:43 pm

      Yes,you will eventually level out on something you’re comfortable with,it just takes time. I don’t know how long you’ve been on methadone or how long you’re planning to stay on it but I would suggest not going up to much more on your dose if you plan on getting off of it. While you’re going up I’m tapering down after being on methadone for 3 years , I was at 100 mgs and in the last two months I’ve come down to 80mgs. It normally takes a few weeks to a month before I start feeling balanced out. Good luck with your recovery.


  9. Posted by T. VerMeulen on April 25, 2015 at 2:34 pm

    Wow! This post comes at such a great point & time in my MMT as I am struggling with yes or no on having a peak and trough done, due to my being on klonopines. Well the Dr increased me 3 mgs & I still feel like I am withdrawing. What should I do?


  10. Posted by Dr. Di on April 28, 2015 at 1:21 pm

    I agree with about 99% of what you’re saying. The big however is what do you do when a patient is a) continuing to increase his dose and not feel better or b) you see an institution locally that ahem, routinely has patients on 200-300+mg a day. Seeing a patient with a trough of 800-1000+ pupils pinned and sweating to me looks toxic, not in withdrawal. A 10-20mg taper done over 1-2 months often relieves these “withdrawal” symptoms of sweating etc.


    • Oh no, I agree with you. You see clinical signs suggesting adequate opioid receptor blockade during the trough, which certainly would give me pause in considering an increase.
      I agree about OTPs where many patients are on 200+mg. That worries me too. Statistically about 1-2% will be very fast metabolizers (I’m not sure about that figure) needing the higher doses. In a clinic where 50% are on more than 200mg…I worry the patients are not being adequately evaluated. If such a patient transfers, I’ve requested to see the physician notes explaining their decision-making process and usually I don’t find them. Maybe they didn’t get sent… or maybe there’s not much evaluation being done…
      a big part of the decision is often asking what the patient expects. some patients are expecting to feel super good all day long (unrealistic), while my goal is to keep them out of withdrawal, functioning well without the use of illicit opioids, and able to concentrate on making life changes.


    • Posted by Tiffany on June 18, 2015 at 10:29 pm

      I just had to say thank you for saying this. I wish the doctors at my clinic had this knowledge. They are just money hungry. It’s so obvious it’s hurtful. 3 minute counsellor sessions. 3 minute dr appointments that ask “are you having any withdrawal symptoms?” them answering for us and saying that we should keep increasing our dose. Us being addicts don’t want to fight that in the beginning. Then down the road we are in “withdrawal” like you described. It’s horrible!


    • Posted by kevin on January 6, 2016 at 5:37 pm

      What do you mean by “withdrawl symptoms of sweating”?


  11. Posted by Benjamin K Phelps on May 4, 2015 at 1:49 pm

    Good article!


  12. Posted by Khris Banks on June 4, 2015 at 5:20 pm

    Hey guys, I am stuck in a huge rut when it comes to my MMT. This is going to be somewhat long but I really need help, I got so much hope when I found this article about what I thought was a lost cause..…OK: I am 23 years old and I have 7 narrowed and/or bulging discs in my neck and spine and also fibromyalgia, I have every possible type of scan showing such and so after going through probably about 50 doctors (including pain specialists and such) and after 3+ years of dealing with unbearable pain and trying every single non narcotic painkiller and/or treatment available; I finally found a family doctor who wrote me a scrip for morphine (I started taking opiates from the street because I couldn’t deal with it so I already had somewhat of a tolerance and I was also taking Benzo’s for aMSContinnd sleep, so the doctor started me at 100 mg of morphine x 2/daily). Which actually did good, def not even close to being pain free but it did help, I later was increased to 290 mg/daily. Then my doctor skipped town and I was left to not only find some other way of controlling my chronic pain but also not even getting ANY kind of taper at all. So I started using opiates for pain (no abuse, although I do/did feel way less depressed and fatigued than without narcotics). So after my doctor left I tried to find a new one but was unsuccesful, so in order to keep myself from committing suicide I obtained opiates off the streets…as time went on and tolerance developed;afterr about 4 – 5 years I was taking a MIfreeM. of 20, 200 MG Extended Release Morphine Tablets (generic MSContin and no that wfr not a typo: TWENTY TWO-HUNDRED MILLIGRAM TABLETS, PLUS A BUNCH OF 10 MG INSTANT RELEASE TABLETS for breakthrough so to simplify: 4000 MG’s daily at ABSOLUTE MINIMUM (which were from the street and were given to me for free). Eventually my access to that person who helped me done and I was put into withdrawal with no taper. So I opted to go on MMT, I was started at 30 mg and due to my massive tolerance I quickly got up to the clinics maximum dose of 160 mg. I was always at the clinic right at 9 when it opened cause I needed to dose first thing in the morning unless I wanted to have absolutely no drive/will to live and from that 160 mg dose taken at 9 am I was lucky to get 6 – 8 hours of relief before withdrawal/cravings set in. As I still didn’t get the proper duration of action on 160 mg I consulted another clinic which told me in person that “yes, we can give you more than that”. I have always had a natural high tolerance to any medication and when I took my Methadone in the morning: I would feel it kick in after only 15 minutes and for that next 6 – 8 hours I felt 100% (no euphoria). After I switched clinics, I accidentally missed 3 doses in a row and my dose was cut in half (standard procedure) anda peak and trough test was ordered and i remained at 70 mg till the results came back (in severe withdrawal and unbelievable cravings). Trough was 200 – 215 and peak came in at either 494 or 637 (I can’t remember exactly). I was told that the results were toxic and my dose would NOT be going back to what I had come to the clinic at and would not be brought back to my regular dose for a proper taper. I was extremely pissed off and frustrated as I was already needing (not wanting) a dosage increase as it was not providing the proper 24 hourish duration of action and was now going to be forced to feel even shittier (when I started methadone, it was not effective enough and was also not providing the proper “blocking” efect. I was still using other narcotics until I hit about 120 mg and from that point on every urine test I provided was 100% clean, than my dose was cut to 70 and I promptly started using narcotics again. The new clinic brought me up to 95 mg and told me they would not increase it any further. There reasons for doing so were: blood work (although I had been requesting an increase since day one and also brought up split dosing but was denied), when I first came to the new clinic, after the decrease and on top of street opiate use, I was also taking massive amounts of benzos (like usually a minimum of 5 – 10 mg of Xanax, 20 – 40 mg of Valium and on some days 60 – 120 mg of Temazepam) as I could rarely get more than 4 hours of sleep a night and for anxiety and the clinic knew that I was doing so as I told them. As a result of the benzo abuse I appeared intoxicated and of course the clinic right away told me that was one of the reasons they cut my dose (even after I tried to tell them that what they were seeing was 100% benzo induced as that amount of them would lead anybody to extreme euphoria and not Methadone but they would not listen and just stayed with the thought it was methadone and I was just asking for unnecessary dosage increases. To this day I am still on 95 mg and have long stopped my benzo abuse (I do not take any for over a year and I even got off ALL my other medications (an SSRI antidepressant & Omeprazole) in order to really show my doctor that I am willing to work with them and they weren’t worried about me being on several sedating medications and hoping that would allow them to help me a bit at least). I know that it was not the Methadone causing that euphoria as my dad is a law enforcement officer and he can tell when I’m buzzing on anything right away, when I just took my regular 160 mgs of Methadone he would not say anything bad and would even say he was happy that I wasn’t high, but when I took my dose and Benzo’s he knew right away). I am still fighting with my clinic for an increase and this article has given me new hope, I am going to print it off and bring it with me to my appointment next week (which is actually with a new doctor as the other one just retired, along with my journal of how I feel and yea). Every urine screen I have done in the past 8 – 10 months has come back 100% clean (despite the intense cravings and general dysphoria after the 4 – 6 hourish that my dose seems to wear off). At that time I get nauseas, having absolutely no energy, no drive to do anything and really no care in the world (I want to work and live a normal life but this fucking clinic is playing me like a puppeteer, no matter what I tell them, this clinics proceedure is to not give a shit about what the patient says, they are right and I am wrong. There exact words have been “well according to your tests you should never be in any withdrawal, the results even came back still higher than we like”. I am so frustrated I don’t know what to do but if this new doctor will not help me I will again be switching clinics…another way this clinic has fucked me is upon receiving my ” toxic” peak and trough test results, they personally called my former clinic to notify them that they had me on a “apparent toxic” level of Methadone and completely burnt my bridge to be able to ever go back there. SOMEBODY PLEASE HELP!!! Thanks for your time everyone.


    • Wow. Obviously your situation is complicated, and there’s no way I can give advice to you online. However, here are some thoughts I had while reading your post:
      1.patients who buy drugs off the street usually have the disease of addiction, in addition to chronic pain. Addiction is a disease, not a moral failing, and often develops as a complication of severe and prolonged chronic pain.
      2. even if you took very high doses of opioids in the past, you may not need high doses of methadone. OTPs’ aim with their patients is to take the methadone dose up until withdrawal symptoms stop. If you try to take your dose up until you “feel it” you will always be frustrated, because tolerance develops to that effect with methadone. However, tolerance to the anti-withdrawal effects does not seem to develop in most patients.
      3. In patients accustomed to methadone, I don’t know what a “toxic” level would be. That phrase doesn’t make sense to me. A methadone blood level that stabilizes one patient could someone not tolerant to methadone.
      4. The blood levels you describe are on the low side, and if the peak it more than twice the trough, you may do much better with split dosing, as it indicates you are a fast metabolizer of methadone.
      5. Massive use of benzodiazepines is a deal-breaker for me to keep a methadone patient in treatment. Above all else, I don’t want to kill a patient. Benzos with any amount of methadone is often deadly. Maybe your doctors are worried you are an extremely high-risk patient and fear you may relapse back to benzos? If so, you would be wise to acknowledge your past use and describe how you’ve addressed the benzodiazepine addiction. Hopefully you are getting good, evidence-based counseling at your present OTP? If not, demand they provide it for you, because that’s a big part of treatment. but if it’s been 10 months since your last benzo use…I’d say you are doing very well from that point of view.
      6. If your OTP doctor says she can’t increase your dose of methadone based only on a blood level, ask her to get and read TIP 43, published by SAMHSA.
      7. talk to your doctor who is prescribing methadone. Dosing issues really shouldn’t be handled except by medical personnel. Nurses can gather data for the doctors, and even counselors can give some input, but you really need to see your doctor and describe all of this.
      good luck and let us know how it goes with your doc.


      • Posted by Khris Banks on June 15, 2015 at 2:57 pm

        Thank you for trying to help, I appreciate anyone that looks at this. I will try my best to explain better…. 1)I was forced to obtain medication on the street due to every Doctor I saw telling me they “couldn’t” give me narcotics, even with all my scans and proof. So I did what I had to do to keep from blowing my head off, it was not a euphoric, abuse motivated thing. 2)Yes your right, I apologize as I should of explained better: by “feel it” I mean: being out of withdrawal. 6 – 8 hours after dosing I am back to complaining of withdrawal symptoms. Not euphoria, I get nothing like that, even when I was at One Hundred and Sixty, as I was still wanting to go up in dosage because even then I barely got Twelve hours. 3) I agree, I had to argue with my nurse that I am not going to “die” from a higher dose. I should mention that it is my nurse telling me all these results and telling me that I can’t go up and then she tells the doctor that, she seems to think she’s the Doctor and on top of that the clinic won’t let me see “my” Doctor by herself without that nurse. What I struggle with is where the clinic gets their “therapeutic range” numbers from and the fact that “tolerance” (even my massive one, and cross-tolerance) is not taken into consideration. 4)I have done so much research and stuff because of my situation and I am confident in saying I know as much, if not more about Methadone than my “nurse”, I’m also a nursing student myself and I’ve also told them I would do better on split-dosing and they said they ” couldn’t” do that because of my blood work (bullshit, if its the same dose how is it any different?) 5)Correct but I go for weekly drug tests that include testing for any kind of Benzo’s and I’ve been clean for almost a year now (11+ months). 6 & 7)Thank you, I believe that my nurse is part (largely) the reason that I can’t get a dose increase. I believe one of the reasons is due to my past benzo use, which I think with the weekly drug tests is irrelevant, thank you!

    • Posted by Carlos on June 8, 2015 at 1:28 pm

      I still have difficulties with the disease modal of addiction. I don’t have any problems with doctors treating addictions. But I have yet to fine physical, scientific evidence and studies showing the evidence of such disease. What I do see is people repeating to each other and affirming it’s existence as a disease. I know that doctors are quite funded of the word disease, and it seems to be more of a authoritative pronouncement rather than seeing conclusive evidence. I agree with Carl Hart PhD that drug policy and treatment ought to be driven by science and not by wishful thinking. The evidence at best might suggest (not concludes) that it is a disease. But I see the same research, such as, twin studies that were done on homosexuality copied from studies on alcoholism have been politicize claiming that it was a way of life. Well why is homosexuality a way of life while ‘addiction’ isn’t. The is too mush political correctness in addiction studies to see things clearly.

      We cannot claim evidence based when politics is invading and fogging the issues. We can not see clearly when the scientific literature is thousand of journals written in hundredth of languages. Unfortunately clinicians in the fields of mental health, substance use and rehabilitation are the most science illiterates in the field of health. One old survey (1998) done by Butler and graduate studies found that ONLY 28% of clinicians in mental health ever read any science (we of course have no idea how much of that 28% read science ), but if that is true and seems to be so by my observation a whopping 72% of clinicians don’t read science. That to me is alarming, and I do not alarm easily. With 72% science illiteracy no wonder we are so blind and allow clinicians to run ”our lives” with their non-evidence pronouncements and treatment has such pitiful outcomes


      • I suppose it’s all in how you define disease. There are behavioral aspects of addiction – but how is that any different from other chronic diseases?
        What’s your proof that asthma is a disease???

      • Posted by Carlos on June 11, 2015 at 9:31 pm

        You mean to tell me that the bronchios and lungs in an asthmatic person are normal? that there is no physical difference between an asthmatic and those who do not have asthma? Isn’t is also true that there is physical difference in the blood for diabetics and those who are not diabetic.

        You may not be aware that there are a scientific questions regarding of psychiatric diagnosis for being both unreliable and invalid. Not many of the 300 and 96 diagnosis in the DSM 5 have ever been tested scientifically. Although the American Psychiatric Association pay a lot of lip service to science and make thousands of claims for which they have ZERO evidence. Like “We are getting better at standards, decision making and differentially diagnosing patients”, which is actually horse rubbish. No other field of medicine, including Emergency Room , which probably have to see most medical condition and real diseases known. When the emergency has to do with neurology, orthopedic, even psychiatry the doctor calls and specialist “on call”. Any way no other field of medicine have to deal with this outrageous amounts of diagnoses.

        The National Institute of Mental Health who is probably the largest funder of mental health research have decided to start creating their own Diagnostic Manual due to the lack of validity of APA DSM system. NIMH has done everything but through away all the work has done in the last short pf one hundred years

        As I said before clinicians in mental health, but specially substance use problems are the most science illiterate group in the field of health. I personally don’t field I can’t my life at the mercy of the professionals. Am a professional on the field myself. Florida License number MH 00001657. I can not trust members of my profession to make critical rational decisions based on science, most talk about evidence based treatment without having the faintest idea about what it means. No scientific standards. The damage they’ve done as a group to me and other patients is beyond repair. Given that they continuous to practice as if they know what they are doing and ignoring that there is a code of ethics to follow.

        So you tell me, what physical, biological evidence is there for a disease?, because I see not much evidence so far and we talk about it as if there is conclusive evidence when the data barely suggest it and it is doubtful at best. This is I think a case of continuous repetition of a concept based on authoritative pronouncement, not science evidence. What physical subjective test exist?, because I don’t know of any? what test exist to show first it’s existence, degree, intensity, prognosis and direction to take for a treatment plan etc. I Know there is test for asthma and diabetes. Non objective test exist for alcoholism and addictions. Not even an MRI can make a distinction before an alcoholic and non alcoholic or addict without substance in their system. There is no termometer,blood test nor genetic test to show predisposition is all at best hypothetical.

        What I say does not negate that people do not get in trouble with alcohol and substances. In fact lots of people do. And I am not anti treatment, but the treatment based on 12 steps does not deserve the dominance that exist in most residential facilities and out patient program. It was never tested before implementation and its effectiveness is near zero, it does not work for most people and I doubt if it works at all and I suspect that directive and in-directive may even cause relapse.

      • Thanks for writing. I was really hoping you would give me your definition of the word “disease.” I gather you believe it to mean some sort of physical finding. Not all diseases show physical signs…for example, what about a diet controlled diabetic? So long as that patient follows diet/exercise regimens, no physical finding of disease exists. blood sugar will be normal. does that mean it’s not a disease?

        I think many people prefer black & white answers…a blood test that shows presence of disease confidently…medicine is not that simple, in many areas. I wish it were…One great example is pain – we don’t have a way to test for the presence or absence of pain. It’s only experienced by each person. If a patient says they have pain, how can a doctor say that’s not true? We can see the effects of pain, as we can see the effects of addiction.

        but I digress. Here are the things you may find interesting:

        A. Thomas McClellan, David C. Lewis, Charles P. O’Brien, Herbert D. Kleber, “Drug Dependence as a Chronic Illness”, Journal of the American Medical Association 2000; 284: (13) 1689-1695.

        this is an older reference, but Dr. McClellan does a wonderful job of explaining how twin studies support biologic influence of addiction.

        I’m sure you have also seen the PET scans done by Dr. Volkow, comparing addicted brains to normal controls.
        we know that drug use itself changes the brain’s structure and function.

        I’m not sure that you will be convinced by any information I can cite, so I’ll leave it at that.

    • Posted by kevin on June 13, 2015 at 3:45 pm

      No offense, but if you couldn’t make it past 9am for your next dose, how did you accidently miss 3.


      • Posted by Khris Banks on June 15, 2015 at 2:25 pm

        Very good question Kevin, it was a long weekend and the clinic was closed on Sunday and Monday. Saturday they were only open from ten to twelve (2 hours). I arrived at the clinic at 12:O5 and that’s how I missed 3 doses.

  13. Posted by Carlos on June 11, 2015 at 10:33 pm

    The truth is that we do not know what it is! The problem seem to be that we humans like answers and certainty. We seem to cause ourselves a lot of anxiety if we are not sure about having an answer to important question. We most have and be a proponent of one of the answers when at this time the answer is, we are not sure what the answer is. And we shouldn’t be competing about what the answer is until we have more studies and research.


  14. Posted by Jason on July 14, 2015 at 8:18 pm

    What is this peak and trouph? what do they do ? all I know I have been what they consider a stable dose for at least three of my 4 years at the clinic ..I requested to go up a little more because I been on same dose for so long now that it just dont seem to work anymore….I get about 12 hours from the 95mg after that its all downhill from there untill I get to dose again wich just cant come soon enough .I was scared for months and months to even ask to go up anymore was afraid Id lose my take homes so I screwed around and now they want to do the test , I have to pay 50 dollars for them to do it and no saying for sure they will take you up I was told they could even bump you down .Id just die ! I dont know what to expect with this test cant what they do what they looking for I thought at first they just asked you questions about how you feel I dont think so after doing some reading now .


    • Posted by kevin on November 29, 2015 at 7:11 am

      Exactly why I canceled my test. Don’t let that scare you. I go in Tennessee where ppl that are not even doctors prescribe your dose but I had to back off cause I know this doctor is too hard on patients on ppl over 120. I’m not on much more but I can’t even take the chance. But honestly don’t let my situation keep you from trying. I wish that you had to be an accredited doctor to work at a clinic. One like Dr Burson that cares about her patients so much she runs a blog on her own time. I would give 10 yrs of my life to be one of Dr Burson patients. Honestly


  15. Posted by Bobby on December 2, 2015 at 12:51 pm

    Hello my name is Bobby I have this problem at clinic I attend. The Dr only will go by these blood test I have told nurses and I even told them of the article I find on web sometimes I think I know more than this Dr the last Dr retired he would talk to you how you feel ect. This Dr is barely even at clinic when try to see him its easier trying to get in to Pope .He also make own rules for take homes he doesn’t follow anywhere need guidelines any suggestions or help could over on how to handle. Thanks


    • I just found out that opioid treatment programs in Wisconsin are commanded by their state regulatory agency to check methadone blood levels. Do you by any chance go to a Wisconsin clinic? I think you have the right to file a grievance if you are denied in your request to see the doctor. Or even if you do see him, and don’t get satisfactory resolution, you can still file a grievance. These are looked at by the treatment team, and hopefully if your doctor has no good reason for doing what he is doing, that can be addressed.
      Many times, a simple conversation with the doctor can clear up miscommunications that occur when an intermediary is used between the patient and doctor.


      • Posted by Paul on December 3, 2015 at 2:31 am

        Most patients in Massachusetts see their doctors maybe 1 time per year and some clinics have a doctor patient ratio of over 1000 to one, clinics use NPs and PAs. Doctors limited to inductions only. I know a chain of clinics with one doctor and 3000 patients, but every complains about raising the buprenorphine Doctors to over 100. Why are the OTPs so worried that they will lose their patients to Data 3000 waived doctors. Let’s sera blog on this issue.


      • I think one doctor with 3000 patients is overextended, obviously. Physician extenders like nurse practitioners and physician assistants can help with many things in the OTP, but I still think a patient ought to be able to see his/her doctor when requested.
        But this isn’t a problem only in OTPs. In all of medicine, physicians are asked to see ever more patients per time unit, and organizations turn to cheaper physician extenders for help. The problem at OTPs comes to the attention of government officials only because OTPs are inspected by so many governmental organizations, but the problem is pernicious in all of medicine.

  16. Posted by Michelle Riddle on January 3, 2016 at 10:06 am

    My brother had a peek and trough and they said his peek and trough was high instead of helping him they put him on a 10 day detox! He is on the 3rd day of detox now and he is so sick. Please what can we do to help him?He has been on methodone for 10 yrs. and only has failed a drug test 2x in 10 yrs. I’m afraid they will end up killing him.


  17. Posted by tyjana swineford on April 3, 2016 at 1:31 pm

    hi I live in Indianapolis and I’ve been going to a methadone clinic for about 2 years and I’m at 190mg. of methadone… I was at 190 for about 6 months when I asked to increase..I did the peak and trough and the results showed I was too high so I couldn’t increase.. that was about 8 months ago…Im starting another peak and trough tomorrow and I’m worried it will say the same thing…I’ve felt like crap for a while now (withdrawals )…we shall see what happens..


    • I’d be more interested in the ratio of the peak to the trough…please ask to see your doctor and have her explain her reasons for increasing or not increasing.


  18. Posted by Prefer to remain anonymous on May 17, 2016 at 2:06 pm

    I have been on 115mg of methadone for the last two years, and have been on methadone for a total of 4 years. I have been using daily on top of my dose for about 7 months now, after a year & 8 months of clean time – minus my daily dose of methadone of course, rather I was clean from all other substances, most importantly, my weakness – opiates. I was doing well, until my dose quit holding me through the day. I requested an increase & they refused until I had a peak and trough done because I am over 100mg & that is their “rule”. I never got it done because the clinic I was at required I paid for it. That clinic recently made me transfer to the other clinic in our area because of repeated dirty UA’s and they decided there was nothing more they could do to help me. My first day at the other clinic required that I get the peak and trough test done before they would even allow me to dose. So I was forced to miss a day, against my will, and did the peak and trough test the following morning. The clinic got the results back and claim that the methadone levels in my body are toxic. Now I’m being forced to drop my dose drastically. I am so upset. I wanted to increase my dose because it is not keeping me well through the day & causing me to use to keep withdrawal at bay. I do not want to use! I want a sufficient methadone dose. Now they are dropping me from the amount I am on which doesn’t suffice and I am beyond scared of how sick I will be and now having to continue to use. I am so devastated I don’t know what to do. The clinic won’t listen to me and refuse to believe that 115mg does not keep me well. I came to them asking for help because I want to be clean, and now I am going to be even worse off than I am now. Any suggestions or advice anyone may have would greatly be appreciated. Help 😦


    • I’m gonna say what I always say – you need to talk to your doctor. Methadone levels can help doctors decide the patient’s best dose, but should never be the only data considered. Also, other medical problems could be going on that are making you feel bad. Many times patients in recovery assume any bad feeling is withdrawal, and ignore important medical symptoms, focusing only on their medication dose. Do you a primary care doctor to do a general screen for other medical conditions?


  19. Posted by Tammy Sherlock on May 26, 2016 at 5:09 pm

    I want to know if I’m taking methadone daily and I have a peak n trough coming up and I’ve used fair amount of Norco will it affect my peak and trough test?


  20. Posted by Marie on June 1, 2016 at 5:14 pm

    I am trying to go on split dosing in GA, it was approved by doctor, but then the approval was taken away by chairman of clinic until they do a 3 day peak and trough. They told me they will draw my blood 3O minutes after I dose for three days in a row. I. Had a peak trough done when I first started 10 years ago and this was not the manner in which they tested me. Have you heard of a pt being done like this?


  21. Posted by k on June 7, 2016 at 8:51 am

    Dr Burson I am desperate for a little more advice, my low end 2 years ago was 469. I just had my yearly physical and my doctor said that if my number on the lower end up 500 or more he wouldn’t raise me. I’m at 150 now and my dose doesn’t last half the day. If I take my dose by 6 am faithfully I feel sluggish and tired and just want to lay around by 2pm. I have been on this dose for 2 years which may not mean anything. I have the mindset that I don’t want to keep going up but I want to be where I am comfortable or I can at least tolerate the dose I am on. I hate Tennessee so much but ky is not better. Please if you could answer my question cause my “golden doctor” according to the clinic I go to says he doesn’t give increases for a trough over 500.


    • Most doctors would like a trough of around 400; however, several of my colleagues say they prefer a trough of at least 600ng/dl.
      Did you also get a peak methadone level drawn?
      Blood levels can help the physician and patient decide if the dose if correct, but other factors need to be considered. A lab test always must be interpreted in light of clinical information, which includes your symptoms, which is how you feel during the day, your physical signs, which are observable to other people (like wide pupils, sweating, restlessness, running nose, sneezing, and the like). Your health issues and other medications can affect your methadone dose requirement.
      I find it unusual for a doctor to make a decision solely on the basis of a lab test. Can you ask your doctor to check your pupil size, blood pressure, and heart rate right before you dose? If there are observable signs he may change his mind. Also, have you had a full physical exam with labs done recently to screen for other medical problems that can cause sluggishness, like low thyroid, anemia, etc?
      Just some ideas.


  22. Posted by Jwalk on July 4, 2016 at 3:48 pm

    I am at a BHG Clinic in Lexington Ky. I have never even met the Dr. I was at 120 mg at the clinic I went to before and I felt fine. I thought I was going to have to switch to Suboxone so I weaned down to 100 mg. I still felt ok. I found a way top stay on mmt but transferred to a different clinic. When I started there the Dr did a trough and lowered me to 90 mg. Now he did another it was .306. I pray he doesn’t lower me again. He does the trough on everyone. He doesnt want anyone over a 100 mg. He’s over 5 different clinics and is the worst.


  23. […] Posted April 19, 2015 by janaburson in Methadone dosing. Tagged: methadone blood levels, methadone dose, methadone peak and trough. 17 Comments […]


  24. Posted by Rhonda on August 26, 2016 at 12:43 am

    More of a question for someone who knows. So, I would like to try Suboxone after being on Methadone for 4 years at 130 mg. I am very afraid of the taper off to start suboxone. Who has done this, how bad was it, how low did they have to go on Methadone before starting Subs and was it a good swap!! Suboxone for Methadone I mean. Also, I am an addict and when I first started I wanted as much Methadone that I could possibly get!!! If someone had a higher mg than I did,I was jealous!!! i think a lot of people should have a long talk with themselves about why they are soo determined to get on such a high dose. More is better and maybe someday they will give me enough to catch a buzz!!! LOL but seriously


  25. Posted by Stephanie Blonshine on October 23, 2016 at 11:13 am

    I wish you were my doctor!! My husband and I go to a Methadone treatment clinic..and we both been struggling to stay clean…we both are at 120 (your not allowed to go any further than that) but my husband needs to go up every single morning he is going through withdraw not bad but enough to make him somewhat sick. At his last clinic he was at 170 and was fine. our doctor [deleted for privacy] puts everyone in the same category.. But yet he says it’s our plan..and when we see him he always wants us to start detoxing…and there new thing is if you want to go up on a stage with a take outs you MUST sign a piece of paper stating your willing to go down 12 mg a husband is a “lifer” he won’t ever be able to get off of it…he’s been doing so GOOD But yet they want to reward him by taking something away..I just don’t understand it. My dose was holding me for about a year but now it seems like I need to go up but I can’t because I have to get a peak and trough..and I don’t want to just for the simple fact when a friend of mine got it done he actually took him down instead of helping and giving him a little more…also with the peak in trough(after you have it done) he will only take you up 5 mg once a week up to 20 it would take me or my husband get to 140 in a month or more..we both find it ridiculous.. Last time I saw him I told him I was having cravings he looked right at me and said then you shouldn’t have take homes…I don’t think he understand what cravings mean…if I was at MY proper dose I wouldn’t have these cravings…I would like to have more take homes (I go 2xs a wk) but I’m not going to sign anything that reduces my Dose..
    My question to you is do we really need to do peak and trough also if this is “our plan” as every doctor puts it ..then why can’t we get another doctor? No one (who gose there) likes him he puts us as one..we should all be the same amount and he makes his own rules..I could understand if I was dirty but my husband and I have been clean for MANY Years..(ME 3 years my husband a little less) I’ve not had one dirty drop as since I’ve been there( but I struggle to stay clean..) he refuses to let me go up or have more take outs..I just don’t understand and I also don’t understand why we can’t choose our doctor ..when he’s been on vacation we had a part time doctor and she was willing to let us go up but she said I can’t undermined your doc. But if I was there I wouldn’t have a problem with it…[deleted for privacy]…I would just love to know the guildlines..I know I’m a addict but I’m far from stupid..that’s how he treats us..less than.. [deleted for privacy] shouldn’t be a Methadone doctor..please if you could give me some advice I would highly appreciated it..thank you



    • What you describe isn’t state of the art treatment.
      you could try filing a grievance, or talking to your state’s opioid treatment authority (SOTA). Or you could transfer to one of the other two methadone clinics in your town.


  26. Posted by Desiree gallardo on January 18, 2017 at 3:29 pm

    How do you determine a peak and trough level if someone is on a split dose as I am please help me understand that I would really really appreciate it


  27. Posted by Brian Semmons on February 4, 2017 at 3:08 am

    At my clinic in Columbus Ohio they use EKG machine and tell you your tcl. Levels are high and take you down especially if you are over 120 MLG. I refused one day they refuse to dose me said no take homes I work its hard to have time to argue wen you have to be at work one Dr fixed my dose after being sick and the other Dr lowers without even seeing you need help.


    • You must talk to the medical director of your program, and explain what is going on. It obviously isn’t productive to have two doctors doing different things. There should be a medical director who can make sense of it and educate her colleagues.
      Now, if your QT interval is dangerously long on your EKG, your doctor may have a good reason to take your dose down, but that’s something that should be explained to you.


  28. Posted by Laura Loy on March 16, 2017 at 2:53 am

    I have a high metabolism. Would this be good for me. I was on 120 at volunteer in Chattanooga.


  29. Posted by Jessica Kolodziej on April 7, 2017 at 4:57 pm

    Can you forward me any medical journals that support this so I can forward to my doctor? Im being denied a phase due to a trough of 970 and peak of 2375. I have gone to this clinic 5 years never missing a day, weekly counseling, and completed 10 additional informational groups they offer (they only require 8). I have only had 3 dirty uas when I first started and I live 75 miles one way away w my boyfriend who is not a user and my 5 kids. I own a farm and run a rescue and volunteer my time to help endangered heritage breeds. I was on a split dose of 430 until june 2016 when i spilled my dose on me my candy n box. A so called friend told the clinic i was giving my dose away so because of those 2 things happening w in days i lost my split n phase n was brought to 330. I have gone down to 225 on my own then requested a split dose again w new dr and he brought me down to 205 3/4/17 and a week later ordered another trough which was 970. Then I was denied 3/27/17 for medical due to unstable dose and high trough level.


  30. Posted by David wilson on April 22, 2017 at 2:20 am

    I am a patient at the only clinic in baton rouge , i have been on methadone since dose gradually rose to 200 mg . a new doctor decided that my dose was too high and dropped it to 150. Needless to say by 6 oclock i am miserable. This was done with NO peak and trough test! Now they are going to start testing all patients with peak and trough . this doctors background is psychiatry . this clinic is the only choice in this area , i do not really see any option , but being sick every day is getting unbearable. Thankyou for the informative article . lm 49 yrs old ,


    • You need to talk to your doctor. Is it possible he/she thinks peak and trough alone are adequate to determine the patient’s dose? if so, recommend you doctor read TIP 43…or a copy of my blog post…


  31. Posted by Megan on April 24, 2017 at 8:49 pm

    I am in a methadone clinic and I am having some difficulties with my clinic right now. I am on 90mgs and 2-4 hours after I take my dose i get a weird feeling that comes over me that kinda feels like I went n did a little bit of dope. My eyes get really heavy, face gets itchy, get really warm, n just want to basicly nod off or sleep. I have told my doctor n nurses at the clinic this problem also my counselor. Now I have been on the clinic for over a year now and have my take homes n everything and am doing very well staying clean. But the problem is that about 6 months ago I was up to 150mgs and didn’t feel the way I am feeling now. I have decreased down to 90mgs now n feel over sedated. When I was on 150mgs they did a peak n trough level on me and my levels came back a little low that I could go higher on my dose if I wanted to. I chose to decrease cuz I didn’t want to be on the methadone for along time. Now that I am on 90mgs and having theses feelings n symptoms I am having they did another peak and trough level on me and my levels came back high, I don’t know much about the peak and trough levels n what they really mean but my doctor told me they shouldn’t be elevated being on only 90mgs n I shouldn’t be feeling the way I do after I take my dose every day. Now when my peak and trough came back this time they said that my top number and bottom number were both high. So they sent me for blood work to see what’s going on with me. Now I haven’t took anything illegal or anything I am not prescribed at all nor have I done any type of drug. I have stayed clean. I am prescribed effexor, prilosac, and ibuprofen 600 that’s all I take other than my 90mgs of methadone everyday. They don’t understand why this is happening to me at all or why I feel the way I do 2-4 hours after I dose. The nurse keeps hinting to me that the only way my peak and trough could have came up high on the top n bottom number is if I was talking something that I’m not supposed to and I’m not. Can a doctor who has experience with methadone please email me back asap with any information on what or why this is happening to me when I take my dose every day. I’m in desperate need of help with this cuz my clinic isn’t helping at all there just pretty much accusing me of using. Please someone email me with information.


    • To me it sounds like both your symptoms and your methadone levels suggest overmedication. I can’t explain why that would happen all of the sudden, but I agree with decreasing your dose, so that you won’t feel so sleepy just after dosing.
      It also sounds like your doctors are looking for causes – I would want to know the status of your liver function, because methadone is metabolized by the liver. Impaired liver function can result in slower methadone metabolism. Keep talking to your doctors – sounds like they are trying to help.


  32. Posted by Stephanie Wright-Blonshine on May 12, 2017 at 4:45 am

    I went to my clinic today and I had a counseling appointment. Which is never a problem but today I went in and was informed that I needed a peek in trough done. I have my take outs and I’m at 145. I haven’t used ANYTHING in three or more years… NOTHING..But for some reason they said I needed one of these test done. What I’m scared about is if they see my numbers and then tell me oh your levels are too high. When in reality I could probably go up a tad more but for the most part I’m ok with 145. Can the doctor take you down if they think it’s too high even though I think my dose is fine.
    My husband goes to another clinic (I hated there) he’s been on methadone for over 12 years…He’s has heart kidney and liver failure ..Has had 5 strokes and a heart attack..His clinic won’t allow him to have anymore take outs because he refuses to go down on his methadone. The doctor in that clinic is sorry for my language but a jackass. My husband goes 2 times a week he wanted weeklies but they told him he wasn’t allowed because he won’t decrease his medication..They are telling him it’s the new law when I know different….My husband hasn’t used in over 10 years and he had a lot of medical issues ..His personal doctor along with all his specialist told him it would be very dangerous for him to go down on his dose because of his heart but yet the doctor at the clinic is still trying to make him..It’s as if he the doctor is the dope dealer and treating people like addicts..I just wish something could be done about it.
    Lansing, Michigan


    • It’s the doctor’s responsibility to adjust a patient’s dose to what the doctor feels is best. So yes, your doctor can and should take your dose down if he believes it is too high. However, appropriate dosing isn’t determined only by blood levels. It can help in some situations, but it isn’t usually best practice to check a patient’s blood levels if they are doing fine and have no sedation.
      However, in your husband’s case, liver failure can dangerously affect methadone blood levels. If liver function deteriorates, it may not be able to process methadone and the blood levels can increase, so I wonder if that’s what the doctor is worried about.


    • Posted by Melanie Stearne on June 29, 2017 at 8:41 pm

      Hi i had a peak and trough done last year I’ve been clean 4 years and I was just not feeling right well I got a very urgent call to come back down apparently the levels in my blood were toxic and I was on 110 so they dropped me emmediately a to 80 staying that my my heart could have stopped and my level was extremely dangerous and sent me home altho I felt no difference in the bigdrop I am now feeling not right again I don’t think they have enough information on this drug first of all what we get at the clinics is not the same as what t hospitals give us and the effects on us are bad there needs to be some research and investigating done on this medication I truly believe it causes severe medical problems that they don’t let is know about ease keep searching for answers


      • I’m not sure why your program would do peak and trough levels if you weren’t having any problems.
        Methadone patients with opioid use disorder have tolerance, and there’s not one blood level that’s “toxic” due to tolerance.
        I’d recommend you talk to your doctor about what, specifically, your program means when they say a certain level can “stop your heart.”
        Methadone can affect your heart, but that’s detected on an EKG, not on blood levels.

  33. Posted by Jeff Mabry on June 27, 2017 at 10:23 am

    I am terrified that our new doc at the clinic is going to change up my treatment
    Program i have worked hard to get where
    I am peak and trough cant work for everyone because everyone is different.


  34. Posted by Melanie Stearne on June 29, 2017 at 8:59 pm

    The program I’m on does not allow Benson’s to many people are overdosing they will not bring you up if you have that on your system I’m on 90 mgs been clean 4+ years and extremely tired all the time I hate it the won’t split doses at my program but I have all my bottles weekly so I do it myself if I take a full dose in the am I’m tired all day if I split it up through the day imbetter going for peak and trough again last time I had toxic levels and dropped from 110 to 80 in 1 day and felt no different so maybe I need to go down again but not so much so quick


  35. What does it mean if my trough level says (501High) i dont have my peek level back yet.


    • Well, I don’t consider a level of 501 particularly high. Patients usually feel the best when the trough is at least 400-600 range. Really, a single trough isn’t much help, but if your peak is more than twice the trough, it tells your doctor you may feel better with split dosing.


  36. Posted by JD on August 27, 2017 at 4:25 pm

    I am a methadone patient and was sent for this test cuz I am still having issues with withdrawal starting 10-14 hours after I dose. And my results came back as follows through level was .53 and my peak was .65 and I’m now told I’m in the normal range so I’m stuck dealing with being sick the doctor said. What can I do is there anything or anyone I screewed?


  37. Posted by Jarrrd on September 7, 2017 at 9:25 am

    Hi I have been on opioid substitution therapy in New Zealand for 18 years ha e been on a stable dose of 115mg of liquid biodone we recently got a new doctor an when my partner and I went on our annual international holiday the new doctor was not happy to prescribe the liquid so gave us two weeks worth of methetabs 5mg pills after returning from holiday and back too liquid my normal cramping that disappeared on holiday has returned with vengeance I have been waking around 4 am sweating sneezing an genuinely riddled with anxiety up until chemist opens at 8 am I have asked new doctor to prescribe pill form but he argues they exactly same bio availability however my symptoms don’t agree
    He has now proposed a trough test but could not give me a range on where a therapeutic trough is I asked if he could also check my peak but he was resistant in doing this
    What is the average acceptable trough level keeping in mind nz has what they call a 120 mg cap although some centres have patients in the 300-520meg a day


  38. Posted by Stormie on October 11, 2017 at 2:02 pm

    I’m on a dose of 130 and I’m Still sick feeling so I need to go up but had speak and trough done ans it came back toxic can my hep c cause that because it’s definitely no to much of a dose I’ve taken 150 mgs before????? Please help because I got dropped ten mgs and I’m sick


  39. Posted by steven townsend on December 28, 2017 at 11:16 pm

    I go to a methadone clinic in W.V. the Dr. there made me take a peak and trough at 75mg’s. it has taken me 6-7 mo. to get to 100mg. now I’m being told I will have to have another peak and trough done to go any higher . the last one was peak 463 trough 297 I think. I know these numbers are very close. What do I do I shake can’t sleep and my dose wears off in about 8-9 hours.


    • I have no idea. I don’t know why your doctor got a peak and trough at 75mg, or why he wants to get another. Levels aren’t routinely obtained, so there must be other concerns??


  40. Posted by Kim on January 6, 2018 at 2:41 pm

    Thank you for such a refreshing and hopeful point of view. Unfortunately, most treatment facilities adopt peaks and troughs testing as, “law”. As far as going into an ER, the medical staff assume that you are drug seeking and will NOT treat!! Unfortunately, people need to disclose to medical facilities that they are on methadone treatment. We need help in society to make all aware that methadone treatment is not just used for drug addiction. It is also a common opiate prescribed for severe pain, as was the case in WWII because of the morphine shortage. Please, I ask you to supply your “adequate” findings and expertise to every methadone treatment facility and hospital in Tucson, Az. We desperately need your assistance. Thank you for all that you do in the field of addiction medicine. Another “human being” on methadone and an ER RN.


    • Well thank you.
      I don’t know why so many physicians are now using methadone levels in ways not supported by science. It’s vexing. I think doctors like having levels and labs to tell them what to do, but it’s way more complicated than that.
      If a person is not treated appropriately by a provider only because that person is on methadone, that’s malpractice. As much as I hate to support trial lawyers, sometimes a malpractice case is the only way to make changes.
      I’ve had a few patients lately who have good cases, should they decide to pursue them.


  41. Posted by Aleesha on January 11, 2018 at 6:56 pm

    Thank you for your post. I do have o e question if you don’t mind. I am currently on Methadone and some days I feel fine, but others i wake up not feeling well. Watery eyes, creepy crawly skin, excessive yawning etc… I had a P/T done and my peak was 960 and my trough was 500. I’m currently at 165mg and only got to that dose due to a previous low P/T. The clinic still have not let me know wht they think, but I’m curious if you think I would do better on split dose or are my levels Ok? Thank you for your time.


    • Typically we think patients with peak more than twice the trough can benefit from split dosing. Your levels are not quite there…but still talk to your physician.


  42. I’m in this same exact predicament I. Lakeworth Florida. I have been on 160mg for almost 2 years. One day I had to see my cousler to schedule my 3rd take home. My current living situation was extremely stressfull and she advocated maybe a increase might be good. So now I filled out paper work for a increase and 3rd take home. That weekend I received only 2 take homes and was not phased for whatever reason I had no idea. Come to find out the following week I’m told I cannot get the increase nor any more take homes until I get the peek and trough done because the dr thinks I’m on a toxic dose. Really after 2 years of me being on this amount and doing extremely well. To make a long story short my director and counselor are pinning all the desicion are being made by the dr and not them. The dr is dropping me 10mg a week for 4 weeks and then I have to go get another peek and trough. Also he stated if I feel any withdrawals it’s all mental and that I must see a psyciatrist and if I don’t go see a psyciatrist that I will be discharged!!! Central Florida treatment center is the most corrupt clinic I’ve ever been to in my life…it really is. Anyways I now have to meet with the dr (which they told me at first no patient is allowed to speak to dr) Thursday because I am extremely worried and concerned about my decrease . This dr needs to loose his job I just don’t know who to call or reach out to get this looked at by someone who oversees the dr desicion a. If someone could please email me at with some info I would greatly appreciate it. Thank u all and have a good day.


    • I’m not sure what’s up with this recent obsession with methadone blood levels. It sounds like your doctor believes that a blood level will tell him what your dose should be. But it’s good that you are going to see the doctor, and hopefully you can get more information.
      You could ask him if he’s read TIP 43, published by SAMHSA, about guidelines for patients treatment with methadone. In particular, ask if he could read pages 72-77 where determination of dose is discussed.
      You can download this document for free at:


      • Posted by Kyle on February 6, 2018 at 4:17 pm

        Thanks u for u reply I am great full to have someone like u who is so kind and willing to share ur expertise knowledge and wisdom on pointing me in the right direction. I say in the clinic for almost 30 mins after I dose due to being told I had to “wait” until the dr was completely done with his other patients and he would see me last…get this….the director comes out and gets me, pulls me in the room with my counselor (2nd time now) and proceeds to tell me the dr is not gonna see me because everything the director is telling me is exactly what he is telling me. This dr out right is refusing to talk to me and I met the guy one time on my intake visit!!!!! Now I’m ticked !!! I had to get up immediatley and not respond because was ready to go back to 18. Year old Kyle and just snap yell and prob beak something which I ultimately know makes me lose all the leverage I got going for myself. Sorry to be blabbering but I just really wanna set the scenario with what type of place this is and how careless they are of patients. Anyhow make a long story short regional director told me he understood my concerns and would make the call for me to see the dr if I wanted. he also reminded me he cannot change a dr desicion. So at this point I just gave up I let central Florida treatment win. I let them decrease me from 160 I’m now 130…and will be 120 next week and have to get another peek and trough. I’m ready to just find another clinic I just don’t know what else to do. This clinic does the bare minimum of what they are required to do legally. I wish someone could go in there everyday for a month and just whatch….place was under investigation before and it needs to happen again I just don’t know who to inform janaburson. Sorry I type so damn much wish I could just talk lol. Thank u for ur time of reading my post and response

  43. Posted by Dale Moore on March 31, 2018 at 10:11 am

    I have recently had 2 peak and troffs done and in both results my troff was high than my peak which i dont understand at all.
    Could you please tell me why this is happening?


  44. Posted by Charlie on August 21, 2018 at 3:52 am

    I have been on 290 mg for 5 yes, I was on a low split dose for yes only to take more off the street to feel ok.. I finnally met a Dr who ununderstands and didn’t want a peak and though so he increase me by ,10 -20 every other day til I was stable.. Thanks to the Dr IAM normal feel nothing and have been normal for 5 yes now..Thank u


  45. Posted by hustlababy09 on August 29, 2018 at 4:28 am

    This is a great article. It was a very good read and I agree 100% with everything you said. I wish more doctors were like you. Your patients are truly blessed to have a doctor that not only looks out for their best interest but is also very educated in MMT and correct dosing. So many doctors now are not educated on this at all and it causes so many problems for the patients. I also think that you’re truly amazing for sharing your knowledge on your blog during your downtime, and I hope that other physicians learn from you. They really could learn a lot from you. Thank you so much for sharing!



    • Thank you for your kind words!


      • hello, i recently did a peak and trough wanted to know a little more about my methadone levels. I am currently on a split dose of 100 mg in the morning and 100 mg in afernoon usually i take first dose at about 7 am and 2nd dose at 1 or 2pm.. i was not fasting during my recent test although the test results say i was? i took my first test which the results of the trough was 600nl/dl and just about 2 hours later the peak was 740nl/dl So my questions, 1. should i have been fasting if yes how long? 2. is it more ideal for me to wait 2 hours or 4 hours between peak and trough draws? and 3. is 140 difference in 2 hours a good rate of metabolisim or am i metab to fast? thank you. p.s. you can email me the answer as well as answer it here.

        p.s.s. Also as i said above i normally take my doses at 7am and 1 pm. on my test date i took my trough test at about 1;53 p.m. then i dosed imeadiatly, then they drew the peak at 3:54 p.m. as the lab closed at 4pm. would the change in time significantly effect my results. should i test at 7 am take my dose then take my peak dose between 9am and 11 am?

      • Oh wait – you are already split dosing. I don’t know how to interpret methadone blood levels on a person who is already split dosing. At least there’s no indication to split further.

  46. hello, i recently did a peak and trough wanted to know a little more about my methadone levels. I am currently on a split dose of 100 mg in the morning and 100 mg in afernoon usually i take first dose at about 7 am and 2nd dose at 1 or 2pm.. i was not fasting during my recent test although the test results say i was? i took my first test which the results of the trough was 600mg/dl and just about 2 hours later the peak was 740mg/ So my questions, 1. should i have been fasting if yes how long? 2. is it more ideal for me to wait 2 hours or 4 hours between peak and trough draws? and 3. is 140 difference in 2 hours a good rate of metabolisim or am i metab to fast? thank you. p.s. you can email me the answer as well as answer it here.


    • Fasting doesn’t affect methadone blood levels. And when the peak to trough ratio is less than 2, as your is, it’s I usually wait until 3 hours, but 2 is a reasonable time


  47. Posted by NO NAME on January 8, 2019 at 8:10 pm



  48. Posted by LAURA ALBRECHT on March 22, 2019 at 8:46 am

    I wish I could have you as my doctor. I’ve been at my clinic over 2 years. It’s almost 2 00 am and I can’t sleep because of how uncomfortable I am. My body ache, my feet are crawling, I’m having chills, my nose is running. It’s always so hard to sleep. I had a peek and trough done about 16 months ago and I haven’t been allowed to increase since. I’ve just given up hope.


  49. Posted by Andrea on January 29, 2020 at 10:29 pm

    I have a question I’ve been over 160mgs a day for 9 years and all the sudden they say I’m overmedicated. But my ppek was 437 and my trouph was 1080…isnt that completely backwards! I have been clean 9 years and now I’m being rapidly dropped to 120mgs then doing another test.


    • Your peak can’t be higher than the trough, first of all.
      I’m not sure why you are being told you are overmedicated – that’s a clinical determination – or should be. Numbers don’t tell us whether the dose is adequate, too low or too high all by themselves. The clinical picture is of the upmost importance.
      If the peak is more than twice the trough – as yours seems to be – split dosing often gives better outcomes.
      All I can say is you need to see the medical director at your facility and ask her your questions.


  50. Posted by Aimie levine on September 19, 2020 at 12:14 pm

    My question is : is it possible to do a blanket peak and trouph methadone test on every patient in a maintenance clinic using only one set of data? Meaning I always was taught that to perform this test you needed to take an am sample to get a baseline number to see how much methadone was still in the patient after their dose the prior day then dose the patient ask them their symptom related questions and have them return in three to four hours for the pm peak test for comparison. I’ve recently learned of a clinic testing their entire population by only doseing in the am and asking no symptom related questions while aquiring no am sample. Then asking the clients to return for their pm peak test in three hours again asking no questions in regards to withdrawal or stabilization. But what I don’t understand is how they can due a peak trophy test using only one pm sample of data there’s no am sample to compare the pm sample to in order to tell if the patient is to low or to high. Can you explain if their is a new blood peak and trouph methadone test that uses only pm data or if this test was just performed in the wrong manner?


    • No, you are right. It appears from your description that the clinic you speak of is doing only peak methadone levels. And without asking patients about symptoms I don’t know how much information that really gives.


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