Dear members

Sometimes restarting methadone is not straightforward, I would like to check your opinion of one case of an adult person who was receiving 80 mls of Methadone, stable on this dose, for some reason he could not get to the pharmacy and the prescription was stopped. At the time of the medical review he was somehow confused and displaying low mood. He had not been at the pharmacy for 12 days. He did not remember the amount of heroin that he was using in the first few days after the prescription was stopped, but stated that his heroin use in the last week prior to the medical review was of £10 bag of heroin (0,2 g of heroin approximately) every other day since then. He is not clear whether if he used heroin IV or smoked (it was not possible to check his groin) the patient was not on withdrawals, no track marks on his arms. He also stated that the last heroin use was the same day of the medical review: 09:00 AM, medical review was at 04:00 PM.
The patient’s information seemed to be not reliable.
The saliva test that day was positive for Methadone, cocaine and opiates. During the medical review he denied consuming illicit methadone.
I think that according to what the patient says a safe restarting dose would be 10 ml of methadone which corresponds to a 0, 2 g of heroin every other day roughly. I am aware that he was receiving 80 mls 12 days ago but he could have lost tolerance dramatically since then according to the reported heroin use. The Saliva test means nothing for me because he could have used a very small amount of methadone before the saliva test.

Any input would be highly appreciated

Thank you very much

Omar

It is safe but may be a little low. If he was on supervised consumption I would want to see him daily, increase by 10ml a time until at 30ml and review his condition. Leaving him on 10ml when he had a recent tolerance to 80ml may just mean he takes more street drugs, more often.

Why would he not tell you the truth? What does he say about the positive methadone?

Dear Jim

I know that it was a little low, but I was not able to supervise him, because he came to the clinic on Friday evening. No chances of supervising him on sat or sun. Do you think I should have started him on 30 ml?
Omar

Hi Dr O,
That's a good old fashionned late Friday evening problem isn't it?

Odd that he appeared confused and vague.Presumably he was not physically unwell? Perhaps he was just affected by the heroin and crack he had taken that day? I would first want to be sure that he not physically unwell.

Difficult at that late hour on a Friday evening to safely prescribe anything for that day, unless his pupils were remarkably large and he could convice me he was alert and very much in opiate withdrawel.

Otherwise I would write the script to start as supervised consumption the next day, (hopefully you have a pharmacy somewhere around which is open saturday and sunday? We have lots of them around Birmingham these days.. poor pharmacists)

As this is a "restart " prescription, rather than a brand new induction into treatment, I would have started him on 30mgs,(or possibly 35 or 40mgs depending a bit on age, size, and his known previous response to methadone) aiming for a therapeutic and a non lethal starting dose for someone with a known recent history of prescribing at a moderate maintenance level.

see Orange book guidelines: Methadone dosing: page 50 "With heavily dependent misusers who are
tolerant, and where the clinician is experienced
or competent, a first dose can be up to 40 mg
but it is unwise to exceed this dose."
http://www.smmgp.org.uk/downlo...inicalguidelines.pdf

I would speak to the pharmacist and enlist their support to supervise him over the weekend, and would aim to see him again on Monday.

I would expect to need to increase his dose by 10mgs after 3-4 days, and again 3-4 days later, aiming to get him back to his 80mgs maintenace dose as quickly as possible, if he is in agreement with that aim.

I have just looked back at your description of his presentation. This is someone who would disturb my sleep over the weekend, because it is not at all clear what has been goiing on. Is he depressed? Is he ill? You say he was not "in withdrawel" . mysterious. Maybe you could explain that you are very worried about his health and wellbeing and frightenned to add methadone back into the mix, and could he continue heroin over the weekend so that you can review him with a bit more leisure amongst the swine flu on monday morning? His response to that suggestion might help you to come to a safe prescribing solution between the two of you.

quote:

Reply

Dear Judith

Thank you very much for your very helpful and comprehensive reply, I was certainly worried to add Methadone to the rest of substances. I would have normally asked him to come back on withdrawals the same day in order to start Methadone safely. The fact that I was not able to check that made me a little more extracareful than usual. The pharmacist was instructed to dispense him next day only if he was displaying withdrawals. The person has been titrated safely now.


Omar

Hi again, Omar,
I am delighted that everyone survived the weekend. I think you were right to be very nervous and cautious in such an unclear situation. Our patients are well experienced at keeping themselves alive with all combinations of variable strength street drugs but as you say, adding the long acting methadone to the mix can be the most dangerous of all. We get used to prescribing high dose maintenance methadone but have to be always wary of the dangers of the induction period.

At the other end of the scale, I have just prescribed my highest ever maintenance dose of methadone, at 350mgs daily. The chap had been on 200mgs daily for some years, and had been telling me he was in the habit of buying up to 200mgs extra most days, for several months.(his swabs were always clear of street drugs) . I had tried to ignore these statements, and move conversation on to non-medication related topics, but a few weeks ago he told me he was running into debt because of this, so I put him back on supervised consumption, and increased his dose every few days, after speaking to the pharmacist who was happy to monitor his state before the dose each day.

Today he came in triumphant, saying he has paid off his debts, and not bought any extra medication for two weeks. Result! And he looks bright as a button, so was clearly being completely honest about his level of tolerance. He tells me he has taken 500mgs in the past, without feeling over sedated, but he says there is no point in taking that much as the extra has no effect!

Now that he has broken his habit of wasting his money buying extra he hopes to be able to slowly reduce again. Time will tell.