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Methadone for Opioid Dependence
Aka: Methadone for Opioid Dependence
- See Also
- Opioid Dependency
- Methadone in Chronic Pain
- Indication: Methadone Management
- 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
- Precautions: Overdose
- Day 5 is highest risk time period in Methadone initiation
- Day 3: Methadone fat stores are saturated
- Day 5: Methadone blood levels increase
- 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
- Methadone is a long acting agent and likely will persist longer than Naloxone (Narcan)
- Other undetected substances may have been taken concurrently in Overdose
- References
- Weinstock et al in Majoewsky (2012) EM:RAP 12(6): 1
- Advantages: Methadone Therapy
- 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
- Management: Methadone Dosing
- 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
- Management: Acute pain while on Methadone
- Tenets
- Methadone patients are tolerant to maintenance dose
- Patients receive no analgesia from Methadone
- Acute Pain Management
- Continue Methadone at maintenance dose
- Avoid increasing Methadone dose (lasts 6 hours only)
- First line: Non-Narcotic Analgesics
- Acetaminophen
- NSAIDs
- 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
- Administer half Methadone dose IM before procedure
- Administer half Methadone dose IM after procedure
- Chronic Pain Management
- Chronic Pain Clinic referral
- 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
-
Drug Interactions (may require higher Methadone dose)
- Rifampin
- Phenytoin (Dilantin)
- Carbamazepine (Tegretol)
- Resources
- American Methadone Treatment Association
- http://www.americanmethadone.org
- National Alliance of Methadone Advocates (NAMA)
- http://www.methadone.org
- References
- Barnett (1999) Addiction 94(4):479-88 [PubMed]
- Demaria (1995) Postgrad Med 97(3):83-92 [PubMed]
- Krambeer (2001) Am Fam Physician 63(12):2404-10 [PubMed]
- Martin (1991) J Psychoactive Drugs 23(2):165-76 [PubMed]