Methadone: Difference between revisions

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βˆ’
== Dosing ==
 +
== Background ==
  +
⚫
=== Initiation ===
  
  +
* Full opioid agonist
⚫
==== St. Paul's Protocol ====
  
  +
* Serum levels peak 2 to 3 hours for methadone
  +
  +
==Dosing==
  ⚫
===Initiation===
  +
  +
==== META-PHI Protocol for Fentanyl ====
  +
  +
* From <ref>Bromley L, Kahan M, Regenstreif L, Srivastava A, Wyman J. Methadone treatment for people who use
  +
  +
fentanyl: Recommendations. Toronto, ON: META:PHI; 2021. www.metaphi.ca</ref>
  +
* 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====
 
{| class="wikitable"
  
{| class="wikitable"
βˆ’
! Day !! Dose
 +
!Day!!Dose
 
|-
  
|-
βˆ’
! colspan=2 | Protocol 1
 +
! colspan="2" |Protocol 1
 
|-
  
|-
βˆ’
| 1 || rowspan=3 | 20 mg TID or 15 mg QID + 3h post-dose assessment
 +
|1|| rowspan="3" |20 mg TID or 15 mg QID + 3h post-dose assessment
 
|-
  
|-
βˆ’
| 2
+
|2
 
|-
  
|-
βˆ’
| 3
 +
|3
 
|-
  
|-
βˆ’
| 4 || 70 mg daily + 10 mg q3h prn x2 doses
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|4||70 mg daily + 10 mg q3h prn x2 doses
 
|-
  
|-
βˆ’
| 5 || Day 4 dose, titrated every 3-4 days
 +
|5||Day 4 dose, titrated every 3-4 days
 
|-
  
|-
βˆ’
! colspan=2 | Protocol 2
 +
! colspan="2" |Protocol 2
 
|-
  
|-
βˆ’
| 1 || rowspan=3 | 30 mg TID + 10 mg q3h prn x3 doses + 3h post-dose assessment
 +
|1|| rowspan="3" |30 mg TID + 10 mg q3h prn x3 doses + 3h post-dose assessment
 
|-
  
|-
βˆ’
| 2
+
|2
 
|-
  
|-
βˆ’
| 3
 +
|3
 
|-
  
|-
βˆ’
| 4 || 70 mg daily + 10 mg q3h prn x2 doses
 +
|4||70 mg daily + 10 mg q3h prn x2 doses
 
|-
  
|-
βˆ’
| 5 || Day 4 dose, titrated every 3-4 days
 +
|5||Day 4 dose, titrated every 3-4 days
 
|}
  
|}
   
βˆ’
==== St. Michael's Protocol ====
 +
====St. Michael's Protocol====
  +
βˆ’
* Start methadone 40 mg and titrate up by 10 mg daily until 70 mg, then hold for 3 days
 +
*Start methadone 40 mg and titrate up by 10 mg daily until 70 mg, then hold for 3 days
   
 
{| class="wikitable"
  
{| class="wikitable"
βˆ’
! Day !! Methadone !! Morphine
 +
!Day!!Methadone!!Morphine
 
|-
  
|-
βˆ’
| 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
 +
|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
 
|-
  
|-
βˆ’
| 2 || 50 mg at 10:00 || As above + 50% of total Day 1 requirements as Kadian at 16:00
 +
|2||50 mg at 10:00||As above + 50% of total Day 1 requirements as Kadian at 16:00
 
|-
  
|-
βˆ’
| 3 || 60 mg at 10:00 || Kadian Day 2 dose at 10:00; switch standing morphine to prn
 +
|3||60 mg at 10:00||Kadian Day 2 dose at 10:00; switch standing morphine to prn
 
|-
  
|-
βˆ’
| 4 || 70 mg at 10:00 || Kadian Day 2 dose + 50% of additional morphine Day 3 dose; continue prn
 +
|4||70 mg at 10:00||Kadian Day 2 dose + 50% of additional morphine Day 3 dose; continue prn
 
|-
  
|-
βˆ’
| 5 || 70 mg at 10:00 || Kadian Day 4 dose
 +
|5||70 mg at 10:00||Kadian Day 4 dose
 
|-
  
|-
βˆ’
| 6 || 70 mg at 10:00 || Kadian Day 5 dose + 50% of additional morphine Day 5 dose
 +
|6||70 mg at 10:00||Kadian Day 5 dose + 50% of additional morphine Day 5 dose
 
|-
  
|-
βˆ’
| 7 || 85 mg at 10:00 || Kadian Day 6 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
   
 
[[Category:Opioid substitution therapy]]
  
[[Category:Opioid substitution therapy]]

Latest revision as of 21:20, 26 July 2022

Background

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

Dosing

Initiation

META-PHI Protocol for Fentanyl

  • 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
  1. ↑ Bromley L, Kahan M, Regenstreif L, Srivastava A, Wyman J. Methadone treatment for people who use fentanyl: Recommendations. Toronto, ON: META:PHI; 2021. www.metaphi.ca
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