Methadone

Background

• Full opioid agonist
• Serum levels peak 2 to 3 hours for methadone

Dosing

Initiation

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