ADM Methadone Start
This is an Addiction Medicine Consultation. True to the name, as a consultant, I have not put in nor have I changed any orders. The below recommendations are just that, recommendations. Please discuss recommendations with the entire primary team and follow as desired.
Patient meets criteria for severe opiate use disorder by DSM 5 criteria. Risks/benefits/alternatives were discussed in detail and patient has made an informed decision to begin methadone.
- obtain ECG prior for QTC. If QTC>500, do not give methadone
- Check HIV/HCV/HBV/Utox/LFTs/Preg test if not done
- If pregnant, obtain FHTs or NST as indicated
- ADTS consult. Educated on harm reduction.
- When ready (cravings, withdrawal, and awake/alert – consider COWS), start methadone 20mg daily. 1 hour later check RAMSAY score for sedation. If over-sedated, reduce next day’s dose by 5-10 mg. 4 hours later, if still having cravings or w/d and RAMSAY shows no over-sedation, can give another 5-10 mg. Max dose on day 1 is 40 mg (usually 20-30mg is enough for most people).
- Day 2, give all of day 1 dose at once in the AM. If still having w/d or cravings and RAMSAY shows no over-sedation, can give 5-10mg additional. Max dose on day 2 is 50 mg (usually 20-40 mg is enough for most people).
- Day 3, give all of day 2 dose at once in the AM. If still having w/d or cravings and RAMSAY shows no over-sedation, can give 5-10 mg additional. Max dose on day 3 is 60 mg (usually 20-50 mg is enough for most people)
- Do not increase dose after day 3 for another 5 days given the long half-life. Can increase by 5-10 mg q5 days after that for cravings or w/d symptoms.
- QTC >500
- respiratory depression
- recent use of other sedatives (benzodiazepines, barbiturates, z-drugs, opiates, EtOH)
- if RR <8 or Ramsay >2, do NOT give additional methadone
The following adjunctive medications can be used for symptom control:
- acetaminophen 650mg q6 prn pain (as tolerated by LFTs).
- clonidine 0.1-0.3 mg PO q6-8 hours prn vasomotor symptoms (hold if BP< 100/70 and NTE 1.2 mg/day).
- hydroxyzine 25mg po q6 hours prn anxiety.
- trazadone 50-100mg po qhs prn insomnia.
- loperamide 4mg po initially, then 2 mg PRN each additional loose stool (NTE 16mg/24 hours).
- ondansetron 4mg po/SL/IV q6 hours prn nausea.
- melatonin 3mg po qhs prn insomnia.
- Methadone may NOT be prescribed for OUD. Schedule appointment for next day with a local methadone treatment center.
- Provide discharge rx for nasal naloxone.
- Consider PEP for HIV if indicated.