Dose levels
Changing dose level
Compliance
Monitoring drug use

Dose levels

Doses should be determined for individual patients but generally a higher dose is required for maintenance than is required for initial stabilisation. Typically effective maintenance doses are greater than 60mg/day.

There is a dose response relationship between maintenance doses of methadone, retention in treatment and continued use of heroin.
  • Methadone doses in excess of 60 mg/day are associated with higher retention rates and less heroin use. This has been demonstrated in both randomised controlled trials and cohort studies.

  • Cross tolerance to heroin increases as a function of increasing methadone dose and results in blockade of the euphoric effect of concurrent heroin use. A daily methadone dose of 60mg or greater should be sufficient to ensure a substantial level of tolerance to effects of heroin in the majority of individuals.
Maintenance doses for effective MMT are typically 60-100mg/day.

Doses in excess of 100mg/day may be necessary to achieve successful maintenance with patients who have a fast methadone metabolism but there is no evidence from treatment outcome studies to suggest that routine dosing at levels in excess of 100mg/day results in any additional benefit for the majority of patients.

Changing dose level

Patient input to treatment decisions, including determination of dosing levels, promotes a good therapeutic relationship by enhancing patient trust and responsibility. When making decisions about changes in dosage the following should be taken into consideration.
  • Concurrent use of illicit opioids and continued injecting use may indicate the need for a higher dose;
  • Individual variation in methadone metabolism.
  • Use of other medications (See Appendix 1).
  • Pregnancy (See Section 4.8).
  • Polydrug use (See Section 4.9).
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Compliance

  • Daily administration of methadone is recommended to ensure that plasma methadone levels are maintained and to avoid withdrawal symptoms.

  • If plasma levels are not maintained, cross tolerance to heroin will be lessened, reducing the capacity of MMT to moderate the euphoric effect of heroin. Reduced compliance is therefore associated with an increased risk of relapse to heroin use.

Monitoring drug use

Reasons

  • Assessment of drug use enables monitoring of progress in treatment and can give useful information for making decisions on clinical management. Monitoring can also be used to support contingency management approaches.

  • Concurrent use of other drugs with methadone by patients may threaten their safety (see also Appendix 1)

  • Monitoring drug use can also provide a basis for program evaluation.

  • There is little evidence to support the use of drug monitoring as a deterrent against unsanctioned drug use.

Options

  • Self report, urine testing and clinical observation are currently available monitoring approaches. Hair analysis, saliva and sweat analysis may be an option in the future.

Self report

  • Self report can be a reliable guide to drug use in settings where no negative consequences result from disclosure. However, in the clinical situation there are always contingencies which patients may perceive as punitive. Consequently, caution should be exercised when making clinical decisions based solely on self-reported drug use. The best information is usually obtained from a combination of self-report and urinalysis.

Urine testing

  • Urinalysis is an objective measure of drug use, however:

    • urinalysis may not be a reliable indication of drug use if collection is not observed. Observed urines are demeaning to both patients and staff. Reliability of unobserved urines may be increased by checking the temperature of the urine sample.

    • Urinalysis will only detect recent drug use. The actual time frame varies depending on the drug being measured and will also depend on the threshold level set by the testing laboratory. Appendix 4 can be used as a guide.

    • False positives and false negatives do occur.

    • Research literature suggests that urine testing does not reliably reduce drug use.

    • Methadone programs should not be punitive. Top of page

  • Urinalysis is most useful in the following circumstances:

    • Patients in the early stages of treatment.

    • Where clarity of drug use is required for diagnostic purposes .

  • Frequency of urinalysis

    • Medicare allows for a maximum of 21 urinalysis tests per patient per year.

    • It is expected that the average number of tests will be significantly lower than this maximum and will decrease the longer a patient has been in treatment.