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Methadone for Opioid Dependence

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  1. See Also
    1. Opioid Dependency
    2. Methadone in Chronic Pain
  2. Indications for Methadone Management
    1. Minimum age 18 years
    2. Physiologic Criteria for Opioid Dependence for >1 year
  3. Advantages of Methadone Therapy
    1. Cost effective intervention ($4500 per year)
    2. Decreases risk of acquiring infection
      1. HIV Infection
      2. Hepatitis B Infection
      3. Hepatitis C Infection
    3. More effective than short-term interventions
  4. Management: Methadone Dosing
    1. Initial Dose: 20 to 30 mg per day
    2. Reassess dose after 4 to 10 days
    3. Ideal maintenance dose criteria
      1. No overmedication
        1. Euphoria
        2. Sedation
      2. Satisfactory dose
        1. Withdrawal symptoms alleviated
        2. Opioid craving diminished
  5. Management: Acute pain while on Methadone
    1. Tenets
      1. Methadone patients are tolerant to maintenance dose
      2. Patients receive no analgesia from Methadone
    2. Acute pain management
      1. Continue Methadone at maintenance dose
      2. Avoid increasing Methadone dose (lasts 6 hours only)
      3. First line: Non-Narcotic Analgesics
        1. Acetaminophen
        2. NSAIDs
      4. Second-line: Short-acting Narcotic Analgesics
        1. Larger and more frequent doses needed
      5. Avoid mixed Opioid agonist-antagonists
        1. Avoid pentazocine (Talwin)
        2. Avoid butorphanol (Stadol)
        3. Avoid nalbuphine (Nubain)
        4. Avoid Buprenorphine
    3. Surgical procedure
      1. Administer half Methadone dose IM before procedure
      2. Administer half Methadone dose IM after procedure
    4. Chronic Pain Management
      1. Chronic Pain Clinic referral
  6. Management: Discontinuing Methadone
    1. Duration of Detoxification Protocol
      1. Short: 30 days
      2. Long: 31 to 180 days
    2. Taper to low dose Methadone (10 mg per day) first
    3. Start Clonidine 0.3 to 0.5 mg qd
    4. Treat adverse effects
      1. Analgesia with non-Narcotics
      2. Diarrhea with Loperamide (Imodium)
      3. Insomnia
  7. Drug Interactions (may require higher Methadone dose)
    1. Rifampin
    2. Phenytoin (Dilantin)
    3. Carbamazepine (Tegretol)
  8. Resources
    1. American Methadone Treatment Association
      1. http://www.americanmethadone.org
    2. Methadone Information Exchange
      1. http://www.mindspring.com/~methinfex
    3. National Alliance of Methadone Advocates (NAMA)
      1. http://www.methadone.org
  9. References
    1. Barnett (1999) Addiction 94(4):479
    2. Demaria (1995) Postgrad Med 97(3):83
    3. Krambeer (2001) Am Fam Physician 63(12):2404
    4. Martin (1991) J Psychoactive Drugs 23(2):165

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