Methadone Dosing

I am not a doctor. I do not treat patients with methadone. I do not prescribe methadone. But in the methadone death cases I have seen and in my discussions with physicians, pharmacologists and toxicologists, the issue of safe dosing has been front and center. The problem with dosing methadone, is that one size does not fit all. Some people can tolerate higher initial doses than others. While a low dose of methadone (2.5 mg three times of day) is thought to be well-tolerated even in opiate naive individuals, a person beginning even this protocol of methadone therapy should be carefully monitored for side effects that could indicate respiratory depression. One pain doctor I know starts patients at 2.5 mg, 3-4 times a day, unless he has solid confirmation from previous pharmacy and medical records that a person has been continuously using opiates at a determined level. This same physician increases the dose only every 7 days, and only by 2.5 mg. Sure, other pain doctors may criticize him for a dosing schedule that may not provide complete analgesia to pain patients during the initial phase of methadone treatment, but this pain doctor would rather endure that criticism than lose a patient to overdose. For more information about safe dosing of methadone in pain settings, the FDA cites Goodman F., Jones W., Glassman P., Methadone Dosing Recommendations for Treatment of Chronic Pain, Pharmacy Benefits Management Strategic Healthcare Group, United States Department of Veterans Affairs, December 2001.

Methadone clinics are known to start their patients at higher initial doses because of their goal of addressing withdrawal symptoms and the belief that opiate-tolerant patients can safely receive higher doses. But methadone clinics must also use caution in determining the initial starting dose, and must match the dose to the level of withdrawal and the history of opiate use. Good physicians will tell you that a person in mild withdrawal from low level daily opiate use should be started at a lower dose of methadone than a patient in raging withdrawal from high level daily opiate use. SAMHSA has warned that the 40 mg a day federal limit for methadone clinic patients should not be a one-size-fits-all dose. If clinics dose all their patients at this initial dose, patients will die.