COMMUNITY PRESCRIBING FOR OPIATE DEPENDENCY

All clients should have been assessed by the local specialist service prior to commencement of methadone prescribing. This assessment should have established the presence of a physical dependency supported by laboratory urinalysis evidence of at least one opiate positive urine sample.

For the non-tolerant adult a dose of 40mg methadone may be fatal. In most cases the starting dose will be 30mg methadone daily or less. Patients will often complain that this dose is too low to 'hold' them; reassurance should be given that the dose will be reviewed and increased as necessary, but that current guidelines prevent any larger dose being dispensed initially. The prescribing physician should remain aware that whatever the patient's claims, there is no objective evidence available as to the amount or purity of street heroin used by the client.

The immediate aim in the first week of treatment is to control withdrawal symptoms. If time allows, the client may be seen daily for the first several days of treatment, and the daily dose increased in increments of 5 to 10mg. Additional doses in the first several days should be titrated against the severity of withdrawal (see appendix 3, page 117 for opiate withdrawal syndrome). In any event, a total weekly increase should not usually exceed 30mg above the starting day's dose. Steady state plasma levels should be reached five to seven days after the last dose increase. In busier surgeries it will be acceptable to increase in increments of 10mg per week following prescription of the starting day's dose.

Following the first week of treatment, dosage may be increased in increments of up to 10mg per week to reach a final stabilisation dose of between 60 and 120mg, although some users will stabilise on less. (Drug Misuse and Dependence - Guidelines on Clinical Management; DoH 1999). Stabilisation is usually complete by the end of the sixth week of methadone treatment, but this may take longer in some individuals.

PREscriptIONS

For the first months of treatment, all prescriptions for methadone should be dispensed on a 'daily pick-up' basis. The majority of patients should also be placed on a supervised consumption regime in conjunction with a local pharmacy for the first three months of treatment. The formulation should be methadone mixture 1mg/ml. Methadone tablets and injectable formulations should never be prescribed unless directed by specialist advice (tablets may be crushed and injected).

ADVICE

All patients and carers (with consent) should be provided with basic advice on the dangers of overdose with methadone and its recognition. Medication should always be stored out of the reach of children in a locked cupboard.

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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.