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Establishing Optimal Methadone Dose 

From: Chapter 8: Phases of Treatment: Stabilization, in Methadone Maintenance: A Counsellor's Guide to Treatment (© 2003).

Achieving a stable dose of methadone for the client is one of the most important objectives of the Stabilization Phase.

Although setting and changing doses is the responsibility of the prescribing physician, MMT counsellors should have a thorough understanding of dose issues for the following reasons:

  • Arriving at an optimal dose of methadone is fundamental to MMT. It is unrealistic to be part of the MMT treatment team and not understand methadone dose issues.
  • Clients will invariably raise issues related to their methadone dose in counselling sessions.
  • Counsellors have an important psychoeducational role in assisting clients to understand the dose-stabilization process.
  • Counsellors typically spend more time with the client than any other team member and are in a good position to monitor the client’s response to the methadone dose.
  • Changes to a methadone dose are often made in consultation with the treatment team, with the counsellor providing valuable input about the client’s progress to assist the physician in arriving at an optimal dose.

Dose Stabilization

The initial dose is set consistent with the client’s history, signs and symptoms, but usually it does not exceed 15 to 30 mg per day (Kahan et al., 2000). The initial dose is deliberately set low to minimize the risk of overmedication. Lack of tolerance to the effects of higher doses can result in fatal methadone overdose.

Achieving an Optimal Maintenance Dose

Normally, the physician will try to achieve an optimal maintenance dose as quickly as possible. But there are important safety considerations. It takes five to 10 days to achieve a steady state level after the dose is changed. However, in the first week of treatment the dose may be increased every three to four days with careful monitoring.

Each dose increase will usually be in the 5 to 15 mg range to avoid overmedication. Once a daily dose of 60 mg is achieved, the rate and amount of dose adjustment will usually be no more than 5 to 10 mg every seven to 14 days.

For most clients, the optimal maintenance dose will be between 50 and 120 mg per day. There are, of course, exceptions. Some clients may respond well to a lower dose and others will require more. Individual differences in clients, related to their level of dependence and the way they metabolize methadone or other drugs and/or medications they may be taking, can result in wide variations in optimal dose.

Counsellors should avoid the common, but mistaken belief that keeping the methadone dose as low as possible is a primary objective of MMT. As Vincent Dole (1988) has argued, “There is no compelling reason for prescribing doses that are only marginally adequate.” 

     

Phases of Treatment: Stabilization

Other online chapters from Methadone Maintenance: A Counsellor's Guide to Treatment:

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