Part D: Critical Questions and Links to Information Regarding Clinical and Regulatory Requirements for Implementing Methadone Maintenance Programs: Examples of Approaches

Question 3: What are the guidelines for initial dosing?

Answer:

Australia
Determining the initial dosing of methadone is guided by a number of factors that include the severity of the patient’s opioid dependence, drug use history, and the results of the medical examination and urine test. Prescribing the first dose of methadone requires consideration of whether the patient is using other central nervous system depressants and their hepatic functioning. Practitioners are directed not to exceed 40 mg for an initial dose, lowering the limit to 30 mg for patients at risk for overdose (http://opiateaddictionrx.info/pdfs/methadone_clinicalpractice_guidelines.pdf).

Canada
Patients are given a specific first dose of methadone, based on assessment outcomes, and observed for a period of time to determine reaction and toxicity. Guidelines require initial low doses (10-30 mg for first 3 days) for those at normal risk, and lower doses (10-20 mg) for those who have a higher risk for methadone toxicity, including those who use depressants, are alcohol dependent, are 60 years or older, or have respiratory problems (www.cpso.on.ca/publications/MethadoneGuideNov05.pdf).

United Kingdom
Concern for risk of overdose requires practitioners to start initial dosing between 10 and 30 mg daily. Patients using sedatives, including alcohol, are limited to 20 mg a day. The initial stabilization period lasts for 2 weeks, at which time the dose is increased by 5-10 mg (http://opiateaddictionrx.info/pdfs/RCGP_UseOfMethadone.pdf).

United States
The acceptable initial dose for methadone treatment is 30 mg daily, unless a reason for a higher dose can be evidenced, which could increase the initial dose to no more than 40 mg a day. Based on the judgment of the program physician and careful observation of the patient, dosing can go up to 60 mg a day prior to stabilization (http://dpt.samhsa.gov/pdf/draft_accred_guidelines.pdf).