Background
- Full opioid agonist
- Serum levels peak 2 to 3 hours for methadone
Dosing
Initiation
- From 1
- May be considered in patients who are not high risk for adverse events (acute respiratory illness, sedating medications, liver or renal failure, or uncertain opioid tolerance)
- In these patients, start at 10 to 20 mg and titrate 10 mg every 3 to 5 days
- Start at 30 mg
- Increase dose by 10 to 15 mg every 3 to 5 days up to 75 to 80 mg
- Faster for people who are at lower risk for adverse events
- thereafter increase by 10 mg every 5 to 7 days
- May use SROM as adjunct with daily observed dispensing
- For missed doses:
- After 4 missed doses, reduce dose by 50% or to 30 mg (whichever is higher)
- After 5 or more missed doses, restart at 30 mg
St. Paul's Protocol
| Day |
Dose
|
| Protocol 1
|
| 1 |
20 mg TID or 15 mg QID + 3h post-dose assessment
|
| 2
|
| 3
|
| 4 |
70 mg daily + 10 mg q3h prn x2 doses
|
| 5 |
Day 4 dose, titrated every 3-4 days
|
| Protocol 2
|
| 1 |
30 mg TID + 10 mg q3h prn x3 doses + 3h post-dose assessment
|
| 2
|
| 3
|
| 4 |
70 mg daily + 10 mg q3h prn x2 doses
|
| 5 |
Day 4 dose, titrated every 3-4 days
|
St. Michael's Protocol
- Start methadone 40 mg and titrate up by 10 mg daily until 70 mg, then hold for 3 days
| Day |
Methadone |
Morphine
|
| 1 |
40 mg |
30-50 mg po q2h while awake + 30-50 mg po q3h prn for mild withdrawal + 20 mg IM for severe withdrawal
|
| 2 |
50 mg at 10:00 |
As above + 50% of total Day 1 requirements as Kadian at 16:00
|
| 3 |
60 mg at 10:00 |
Kadian Day 2 dose at 10:00; switch standing morphine to prn
|
| 4 |
70 mg at 10:00 |
Kadian Day 2 dose + 50% of additional morphine Day 3 dose; continue prn
|
| 5 |
70 mg at 10:00 |
Kadian Day 4 dose
|
| 6 |
70 mg at 10:00 |
Kadian Day 5 dose + 50% of additional morphine Day 5 dose
|
| 7 |
85 mg at 10:00 |
Kadian Day 6 dose
|
CPSO Guidelines
- Patients who miss 3 or more doses must be assessed in person before getting a new prescription
- Patients who miss a dose must remain on that dose for another 3 days before considering titration
- No dose increases without assessing patient
- Patients on benzodiazepines must start at lower doses and should generally not receive carries
- Patients should not receive additional opioids except for acute pain management
- Obtain an ECG before increasing the dose above 120 mg
References
- ^ Lisa Bromley, Meldon Kahan, Leonora Regenstreif, Anita Srivastava, Jennifer Wyman. Methadone treatment for people who use fentanyl: Recommendations. META:PHI; 2021.
