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.