II. Indication: Methadone Management for Opioid Addiction
-
Methadone is considered a second line agent (compared with Buprenorphine)
- Consider Methadone in failed Buprenorphine or in which dispensing at clinic is required
- Minimum age 18 years
- Physiologic Criteria for Opioid Dependence for >1 year
III. Precautions: Overdose
- Day 5 is highest risk time period in Methadone initiation
- Lethal Overdose risks
- Children with Accidental Ingestion
- Concurrent use of Alcohol or Benzodiazepines
-
Urine Drug Screen may not demonstrate all interacting substances
- Methadone may not appear on drug screen (depending on assay)
- Buprenophine (partial opioid Agonist)
- Used by Drug Abusers as a substitute for Methadone
- Overdosage involving Methadone should be observed closely
- References
- Weinstock et al in Majoewsky (2012) EM:RAP 12(6): 1
IV. Advantages: Methadone Therapy for Opioid Addiction
- Cost effective intervention ($4500 per year)
- Decreases risk of acquiring infection
- HIV Infection
- Hepatitis B Infection
- Hepatitis C Infection
- More effective than short-term interventions
V. Management: Methadone Dosing for Opioid Addiction
- See Methadone in Chronic Pain
- Initial Dose: 20 to 30 mg per day
- Reassess dose after 4 to 10 days
- Ideal maintenance dose criteria
- No overmedication
- Euphoria
- Sedation
- Satisfactory dose
- Withdrawal symptoms alleviated
- Opioid craving diminished
- No overmedication
VI. Management: Acute Pain while on Methadone
- Tenets
-
Acute Pain Management
- Continue Methadone at maintenance dose
- Avoid increasing Methadone dose (lasts 6 hours only)
- First line: Non-Narcotic Analgesics
- Second-line: Short-acting Narcotic Analgesics
- Larger and more frequent doses needed
- Avoid mixed opioid Agonist-Antagonists
- Avoid pentazocine (Talwin)
- Avoid butorphanol (Stadol)
- Avoid nalbuphine (Nubain)
- Avoid Buprenorphine
- Surgical procedure
-
Chronic Pain Management
- Chronic Pain Clinic referral
VII. Management: Discontinuing Methadone
- Duration of Detoxification Protocol
- Short: 30 days
- Long: 31 to 180 days
- Taper to low dose Methadone (10 mg per day) first
- Start Clonidine 0.3 to 0.5 mg qd
- Treat adverse effects
- Analgesia with non-Narcotics
- Diarrhea with Loperamide (Imodium)
- Insomnia
- Acute Withdrawal in Emergency Department
- Methadone 10 mg IM or 20 mg orally