Opioids Methadone Mega Thread and FAQ

[Tchort]

Those are not WD;s, everybody i know, gets those feelings at some point of the day. I get them like 5-6 hours after taking methadone, for me it helps to take a 30min nap and/or go to shower.

You won't get those feelings away, no matter how much you increase your dose, actually i guess they can start to get worse with higher doses.

For the morning WD dose increase might help for a short period of time, but soon you are again in that same situation, but with higher dose. Its stupid that the clinics don't allow people to take a little booster dose at the evening, i would need much lower overall dosage if i could redose at the evening. I have 65mg/d, i would instantly swap to 50mg morning and 10mg evening if i could, when i started the treatment, i could have managed with 40mg in the morning and 10mg in the evening.

My friends with high dose says that its not smart to go to that route where you increase your dose constantly every time you get some negative feeling(one friend has increased hes dose by 35mg;s and is again at the same situation that he was before dose increases). People need to get some perspective here, and try to remember what those real WD felt before the treatment and then think, is it really that bad.

You are on a low dose; numerous studies conducted in various nations, political climates, and points in time all suggest that higher doses of Methadone are preferable to lower doses (the average dose for most MMT patients is recommended to be in the 80mg-120mg range).

There is a big difference between Methadone side effects (feeling overheated, sweating, etc) and residual withdrawal syndrome i.e. an inadequate dose of Methadone (restlessness, agitation, anxiety, depression, etc).

In certain circumstances a split dose is advisable- although, unfortunately, not many American and European MMT providers allow it.

It is foolish to simply accept sub-par treatment for the sake of being on a lower daily dose of Methadone.

The best thing to do in situations like this is to consult your counselor at the clinic and/or the staff doctor/nurse practitioner.

 

[Pegasus]

You are on a low dose; numerous studies conducted in various nations, political climates, and points in time all suggest that higher doses of Methadone are preferable to lower doses (the average dose for most MMT patients is recommended to be in the 80mg-120mg range).

I would love to read these. Links, please?

I'm curious to in what regard it is "preferable" to be on such a high dose? Certainly not for long term recovery and eventual withdrawal from the drug...

 

[Tchort]

I would love to read these. Links, please?

I'm curious to in what regard it is "preferable" to be on such a high dose? Certainly not for long term recovery and eventual withdrawal from the drug...

Higher doses are preferable for a number of reasons:

1) More likely to lead to better patient compliance (by 'holding' for a full 24 hours)

2) doses above 60mg/day and almost always in the 80mg-120mg/day range provide sufficient cross-tolerance to render all but extremely high doses of opioids unable to produce euphoria

Today, many methadone maintenance treatment (MMT) programs appear to prescribe inadequate daily doses of methadone more for philosophical, moral, or psychological reasons than being guided by sound pharmacologic and medical principles. Many clinicians also assume that lower doses automatically prevent methadone overmedication and eventually lead to opioid abstinence.

Such attitudes and practices are contrary to recent scientific evidence suggesting that even doses in the 80 mg/d to 120 mg/d range once recommended by some guidelines would be inadequate for a great many patients.

When “Enough” Is Not Enough:New Perspectives on Optimal Methadone Maintenance Doses

STEWART B. LEAVITT, PH.D.1, MARC SHINDERMAN, M.D.2,SARZ MAXWELL, M.D.2, CHIN B. EAP, PH.D.3, AND PHILIP PARIS, M.D.4


.Abstract


Some methadone maintenance treatment (MMT) programs prescribe inadequate daily methadone doses. Patients complain of withdrawal symptoms and continue illicit opioid use, yet practitioners are reluctant to increase doses above certain arbitrary thresholds.

Serum methadone levels (SMLs) may guide practitioners’ dosing decisions, especially for those patients who have low SMLs despite higher methadone doses. Such variation is due in part to the complexities of methadone metabolism. The medication itself as a racemic (50:50) mixture of 2 enantiomers: an active “R” form and an essentially inactive “S” form. Methadone is metabolized primarily in the liver, by up to five cytochrome P450 isoforms, and individual differences in enzyme activity help explain wide ranges of active R-enantiomer concentrations in patients given identical doses of racemic methadone.

Most clinical research studies have used methadone doses of less than 100 mg/day [d] and have not reported corresponding SMLs. New research suggests that doses ranging from 120 mg/d to more than 700 mg/d, with correspondingly higher SMLs, may be op-timal for many patients.

Each patient presents a unique clinical challenge, and there is no way of prescribing a single best methadone dose to achieve a specific blood level as a “gold standard” for all patients. Clinical signs and patient-reported symptoms of abstinence syndrome,and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately “enough” methadone in MMT.

http://www.medicalassistedtreatment.org/89311/209234.html

High-Dose Methadone Improves Treatment Outcomes
By Patrick Zickler, NIDA NOTES Staff Writer


--------------------------------------------------------------------------------

Methadone has been used effectively for more than 30 years as a treatment for heroin addiction. The medication blocks heroin's narcotic effects without creating a drug "high," eliminates withdrawal symptoms, and relieves the craving associated with addiction. Methadone is administered orally in licensed clinics and its effects typically last 24 to 36 hours.

Although methadone has been used for decades, no clinical consensus has been reached about the most effective daily dose. Many clinics do not adjust dosages according to the needs of individual patients. Instead, they administer fixed doses. One clinic might use doses of 25 milligrams (mg) per day for all patients; others may administer daily doses of 60 mg. "Federal regulations require that a clinic receive a special exemption in order to provide patients with doses greater than 100 mg per day, but no contemporary studies have examined the effectiveness of daily doses greater than 80 mg," says Dr. Eric Strain, a NIDA-supported researcher at The Johns Hopkins University Medical Center in Baltimore.

Dr. Strain and his colleagues investigated the effectiveness of high-dose -80 to 100 mg per day-methadone treatment and found this dosage to be more effective in reducing heroin use than treatment with a moderate dose of 40 to 50 mg per day. The study involved 192 patients. Sixty-five percent of participants were male; pregnant women were excluded from the study group.

During the first week of treatment all patients received 30-mg daily methadone doses. Daily doses were increased until, by the 8th week, half the patients were receiving a moderate dose of 40 to 50 mg per day and the other half were receiving a high dose of 80-to-100 mg per day. These doses were maintained through the study's 30th week. Dosages were then decreased by 10 percent each week during the final 10 weeks of the program. Patients were encouraged to enroll in long-term community-based treatment programs following completion of the 40-week study.

Dr. Strain and his colleagues evaluated the effectiveness of treatment through analysis of twice-weekly observed urine testing, weekly patient reports of heroin use, and the length of time patients remained in treatment. "The high-dose group used opiates significantly less during treatment than did the moderate-dose group on average," Dr. Strain says. "Patients in the high-dose group reported using opiates no more than once a week. The moderate-dose group reported using drugs two to three times per week on average." Among patients who completed the 30-week active phase, 33 percent of high-dose patients remained in treatment throughout a 10-week methadone phase-out, compared with 20 percent of moderate-dose patients. There were no gender-related differences in outcome for high- or moderate-dose groups, and no difference was reported between the high- and moderate-dose patients for side effects such as grogginess or constipation.


In an earlier study, the researchers found that moderate-dose treatment of 50 mg per day was more effective than low-dose treatment of 20 mg per day. "The current study provides strong evidence that we can achieve much better outcomes at dose rates much higher than 50 mg per day," Dr. Strain says.

Dosages exceeding the currently regulated ceiling of 100 mg per day may provide the best result for some patients, Dr. Strain says, but he notes that clinical trials would be needed to support changing this regulation. "The most important aspect of our research from a therapeutic and public health perspective is that methadone treatment over a broad range of doses results in significant clinical improvement for opioid-addicted patients," he says.

Sources
Strain, E.C.; Bigelow, G.E.; Liebson, I.A.; and Stitzer, M.L. Moderate- vs high-dose methadone in the treatment of opioid dependence: A randomized trial. Journal of the American Medical Association 281(11):1000-1005, 1999.

Strain, E.C.; Stitzer, M.L.; Liebson, I.A.; and Bigelow, G.E. Dose-response effects of methadone in the treatment of opioid dependence. Annals of Internal Medicine 119:23-27, 1993.

http://www.nida.nih.gov/NIDA_Notes/NNVol14N5/HighDose.html

List of more studies:

-Maxwell S, Shinderman MS. Optimizing long-term response to methadone maintenance treatment: a 152-week follow-up using higher dose methadone. J Addict Dis. 2002:21(3):1-12.

-Maxwell S, Shinderman M. Optimizing response to methadone maintenance treatment: higher-dose methadone. J Psychoactive Drugs. 1999;31(2):95-102.

-Payte JT, Khuri ET. Principles of methadone dose determination.
In: Parrino MW, editor. CSAT state methadone treatment
guidelines. Rockville (MD): Center for Substance
Abuse Treatment: Treatment Improvement Protocol (TIP)
Series 1, U.S. Department of Health and Human Services;
1993:47 – 58. USPHS Publication (SMA): 93-1991.

-Eap CB, Finkbeiner T, Gastpar M, et al. High inter-individual
variability of methadone enantiomer blood levels to dose
ratios [letter]. Arch Gen Psychiatry 1988; 55:89 – 90.

-D’Aunno T, Vaughn TE. Variations in methadone treatment
practices. JAMA. 1992; 267(2):253 – 258.

-Strain EC, Stitzer ML, Liebson IA, Bigelow GE. Methadone
dose and treatment outcome. Drug Alcohol Depend 1993;
33:105 – 117.

 

[splenda]

I increased my dose to 160mg and I'm definitely getting more coverage in terms of my dose. I don't feel 'as sick' in the mornings before I dose now, and the aches and pains aren't as pronounced, although still there. I've only been on 160mg for less than a week though, so I might give it another week to stabilize before I decide if I need to increase 10mg more or not to get a full 24hours of coverage.

I'm going to hopefully get my 2nd takehome next week... the clinic has their clinical meeting with the doctor this week and I was supposed to turn in my letter showing that I'm going back to school and have another clean UA before the clinical for the clinic to allow me my 2nd takehome. I've already turned in that letter, and I just took the UA today, so I hope the results come back in time before thursday (or maybe they'll just let it slide since they only have clinical meetings every 2 weeks... if not, and if they have to wait for the UA results which might not come back till next week, I'll have to wait another 2 weeks for my 2nd takehome .)

 

[splenda]

Higher doses are preferable for a number of reasons:

1) More likely to lead to better patient compliance (by 'holding' for a full 24 hours)

2) doses above 60mg/day and almost always in the 80mg-120mg/day range provide sufficient cross-tolerance to render all but extremely high doses of opioids unable to produce euphoria

Today, many methadone maintenance treatment (MMT) programs appear to prescribe inadequate daily doses of methadone more for philosophical, moral, or psychological reasons than being guided by sound pharmacologic and medical principles. Many clinicians also assume that lower doses automatically prevent methadone overmedication and eventually lead to opioid abstinence.

Such attitudes and practices are contrary to recent scientific evidence suggesting that even doses in the 80 mg/d to 120 mg/d range once recommended by some guidelines would be inadequate for a great many patients.



http://www.medicalassistedtreatment.org/89311/209234.html



http://www.nida.nih.gov/NIDA_Notes/NNVol14N5/HighDose.html

List of more studies:

-Maxwell S, Shinderman MS. Optimizing long-term response to methadone maintenance treatment: a 152-week follow-up using higher dose methadone. J Addict Dis. 2002:21(3):1-12.

-Maxwell S, Shinderman M. Optimizing response to methadone maintenance treatment: higher-dose methadone. J Psychoactive Drugs. 1999;31(2):95-102.

-Payte JT, Khuri ET. Principles of methadone dose determination.
In: Parrino MW, editor. CSAT state methadone treatment
guidelines. Rockville (MD): Center for Substance
Abuse Treatment: Treatment Improvement Protocol (TIP)
Series 1, U.S. Department of Health and Human Services;
1993:47 – 58. USPHS Publication (SMA): 93-1991.

-Eap CB, Finkbeiner T, Gastpar M, et al. High inter-individual
variability of methadone enantiomer blood levels to dose
ratios [letter]. Arch Gen Psychiatry 1988; 55:89 – 90.

-D’Aunno T, Vaughn TE. Variations in methadone treatment
practices. JAMA. 1992; 267(2):253 – 258.

-Strain EC, Stitzer ML, Liebson IA, Bigelow GE. Methadone
dose and treatment outcome. Drug Alcohol Depend 1993;
33:105 – 117.

TChort speaks the truth++

Also, I've noticed that people on lower doses tend to crave and use other opioids very often since their dose doesn't completely block other opioids from having an effect. Some people stay on low doses (under 100mg) simply so that they can still use/get high from heroin/morphine/oxycodone/other opioids.

 

[Pegasus]

Higher doses are preferable for a number of reasons:

1) More likely to lead to better patient compliance (by 'holding' for a full 24 hours)

2) doses above 60mg/day and almost always in the 80mg-120mg/day range provide sufficient cross-tolerance to render all but extremely high doses of opioids unable to produce euphoria

.

Yes, this is what I thought. Really though, that being "best interest" is questionable. What if you're planning on using methadone as a quick intermediate between a full agonist and sobriety? There is certainly no need to use that large of a dose of methadone.

As to the reason concerning the blockade of methadone, I do agree with this as being a benefit that only happens at higher doses, but I don't believe this is necessary for everyone. Maintenance programs generally test for the use of other opiates, so I would think this to be sufficient to deter the MMT patients from using other opiates while on lower doses. For a few select people though, I do agree that a large dose that blocks any reasonable dose of other opiates is helpful... I just don't think that this group is the majority by a long shot!

 

[Pegasus]

Another thing to remember here is that high doses of methadone are not going to provide euphoria for eternity! If the patient is seeking this euphoria so intensely, then it's hard to say that the higher doses will really be the answer as they will only satisfy for so long. The lower doses at least can be titrated up as the patient feels necessary. What should the patient taking 120mg+/ day do, when he wants to feel the effects stronger? Go higher?

You have valid points and this is a complex issue, but I think it's best that we don't say that any one way is concretely the best way to approach the subject...

 

[splenda]

Another thing to remember here is that high doses of methadone are not going to provide euphoria for eternity! If the patient is seeking this euphoria so intensely, then it's hard to say that the higher doses will really be the answer as they will only satisfy for so long. The lower doses at least can be titrated up as the patient feels necessary. What should the patient taking 120mg+/ day do, when he wants to feel the effects stronger? Go higher?

You have valid points and this is a complex issue, but I think it's best that we don't say that any one way is concretely the best way to approach the subject...

Most people here prefer to be on lower doses of methadone so that they can use other opioids. They don't care if they piss positive for opioids because they don't care for takehomes and the clinics don't kick you out even if you have a ton of positive UAs.. so, I'd suspect that people on lower doses of methadone are more prone to be looking to get 'high' than those on higher doses.

 

[Pegasus]

^That may be some people, but not all. I was on it for a very brief period, because I have always "flirted" with opiate addiction and once I know I'm addicted, I like to maintain and then taper off very quickly. That's just me though...

Many other people just want to save themselves the eventual hellish withdrawals that high-dose methadone is known to cause. Not only this, but to taper off these high doses requires going at a very slow rate over a lot of methadone, equaling a ton of money being spent before all is said and done.

These are just two reasons why it is logical for people to be on lower doses other than to be able to get high over their dose. This doesn't even mention that 40mg taken daily is enough to cause most people to have the blockade to a significant degree to where they can't just easily dose on 40mg oxycodone or whatever and be high...

I agree and respect with your principle in part, but I believe there are more legitimate logical applications for MMT than are being given credit for here.

 

[splenda]

^That may be some people, but not all. I was on it for a very brief period, because I have always "flirted" with opiate addiction and once I know I'm addicted, I like to maintain and then taper off very quickly. That's just me though...

Many other people just want to save themselves the eventual hellish withdrawals that high-dose methadone is known to cause. Not only this, but to taper off these high doses requires going at a very slow rate over a lot of methadone, equaling a ton of money being spent before all is said and done.

These are just two reasons why it is logical for people to be on lower doses other than to be able to get high over their dose. This doesn't even mention that 40mg taken daily is enough to cause most people to have the blockade to a significant degree to where they can't just easily dose on 40mg oxycodone or whatever and be high...

I agree and respect with your principle in part, but I believe there are more legitimate logical applications for MMT than are being given credit for here.

Withdrawals from methadone aren't 'easier' simply by being on a lower dose. The majority of the problems from 'methadone withdrawals' are idiotic people who go cold-turkey on the program. MMT works for people who put their dedicated effort into it and won't work well for someone who still wants to get high or for someone who plans to get off of methadone one day thinking that they'll be able to fight their addiction off of methadone (which, in 95% of cases addicts who think they'll be able to fight their addiction and get off of methadone relapse.) Addiction is a life long issue and must be treated as such. If you don't want to relapse and if you don't want all the problems related to addiction then stay on the methadone. If you want the problems of addiction and if you want to relapse and live a shitty life of constant withdrawals, scoring, risking arrest, etc. then get off of methadone.

In the end, MMT works for those who put the effort to want to get clean. And, those who want to get clean end up usually raising their dose higher to get more craving reduction and to feel generally more 'opiated' than if they were on a lower dose; because it is this minor 'opiated' feeling that really allows people on methadone to stay off of using other opioids (it's not a 'high' feeling but a feeling of knowing that there's an opioid in your CNS taking its effect.)

 

[Pegasus]

You're entitled to your opinion, but this is just not true:

Withdrawals from methadone aren't 'easier' simply by being on a lower dose.

They absolutely get more difficult the longer you are on methadone and the higher the dose you are at.

I'm trying to acknowledge that for some people the treatment like this is a reasonable idea, but I don't think by any means it should be forced on anyone thinking of using MMT. There are a ton of people with tons of reasons why they want to be on MMT, and to try to put them all into the same category is just not helpful, IMO.

 

[splenda]

You're entitled to your opinion, but this is just not true:



They absolutely get more difficult the longer you are on methadone and the higher the dose you are at.

I'm trying to acknowledge that for some people the treatment like this is a reasonable idea, but I don't think by any means it should be forced on anyone thinking of using MMT. There are a ton of people with tons of reasons why they want to be on MMT, and to try to put them all into the same category is just not helpful, IMO.

What's the goal of MMT, to stay clean by maintaining on another opioid, right?

Or, the other goal would be short-term detox/short-term MMT to get off of opioids, right?

When I talk about the treatment of MMT, I'm talking about the first option and not detox. In fact, for detox, I believe buprenorphine is better. But for maintenance, methadone works much better (just my opinion.)

 

[Tchort]

The protocol for a short maintanence (a few months) or Methadone assisted detox are different from long term MMT. Regardless, the history of MMT is one of forced underdosing and superfluous dose ceilings (generally 100mg).

If complete abstinence is the goal of someone entering MMT, they should work the program the best way possible. Experiencing cravings and physiological discomfort is traditionally a sign of too low a daily dose. It's circular reasoning: I won't raise my Methadone dose because that will make it harder to get off of the Methadone eventually, but I won't get off of the Methadone because I will go back to using drugs.

Older studies from NYC clinics in the '60s that involved chronic underdosing (average 40mg/day per patient) showed terrible results all around: higher incidents of opioid abuse and polydrug use, lower patient retention in the program/higher drop out rates, less stability at home (also lower employment/school figures), etc.

I don't disagree that people should have complete control over their daily dose and proposed maintanence or detox schedule, and shouldn't be forced to use higher doses- I don't believe that this is a problem. It has always been the other way around- most MMT patients are coerced to stay on a lower dose, or are stigmatized for seeking a higher dose, or have unscientific dose-ceiling regulations put upon them by the state authority, etc.

 

[Pegasus]

^Okay, that is fair middle ground. I will say that I believe the 40-60mg doses should hold more people the full day than whatever study is giving credit for, but alas, that's not really too big of a discrepancy to debate.

I just wanted it to be acknowledged that there isn't any set in stone dose that should be applied for MMT, as every individual differs. We agree on this, so hooray!

 

[DOOMpostor]

For People On Methadone Maintence has this ever happened to you..?

ive been on Methadone for 3 years and like 2 months and so many times ive heard "how long you gonna be on it?" ,"being on methadone is just trading one addiction for another" "just seeking a free high arent you?" and i was wondering if others that are in my position hear the same shit and if you do what is your reply? ....DOOM

 

[Captain.Heroin]

People say that about Suboxone too.

They're morons though. Heroin is a different league, much better than methadone or Suboxone. Don't let it get to you.

The next time someone says that to you, flip them off:

hehehehehhe %)

to the methadone mega thread!

 

[splenda]

ive been on Methadone for 3 years and like 2 months and so many times ive heard "how long you gonna be on it?" ,"being on methadone is just trading one addiction for another" "just seeking a free high arent you?" and i was wondering if others that are in my position hear the same shit and if you do what is your reply? ....DOOM

Yea, I get that all the time from idiots who don't want to put the effort to get clean and therefore methadone doesn't work well for them.

My reply to them usually is simple: I state the fact that they most likely don't want to get clean and don't want to treat their addiction and prefer to still use, therefore they aren't going to find success with methadone. What these people need to realize is that addiction is unfortunately a life-long issue and cravings will haunt you till the day you die. It sucks, but it's the truth. Methadone is one way to treat the addiction and to turn around the low-quality of life that addiction creates. If you're happy with your MMT and are successful on MMT at controlling your addiction than you shouldn't have anything to 'prove' to anyone; if anything, those people who say bad things about MMT are usually jealous at your success with methadone.

 

[thelung]

There are plenty of old timers at my clinic. Being on methadone for life is not uncommon.

 

[debaser]

Just a quick question, which surely has already been mentioned in this thread, but I can't read all the megathread today (sorry):

When I'm down to 1mg a day, will it be bearable to stop without meds? Or will I need at least some basic drugs such as clonidine and/or loperamide and/or a little bit of a benzo? Thanks for any answer.

 

[stuckinaloop]

Anyone with input please reply:

I got on the clinic about a month ago. Was using 2-3 bundles east coast powder a day sniffed.

They got me up to 80mg, I feel fine after dosing (not high one bit). I dose like 7 or 8am, work 9-5pm. By the time it's like 7, my pupils are huge, I just don;t feel sociable, and I am tired as fuck like falling asleep with my light on. My counsler said I need to raise my dose but then im thinkin I gotto come back down to get off so whats teh point.

Methadone has been good for me, becuas on suboxone I had really bad cravings I was always jumping back and forth, on methadone I have basically ceased all use of opiates besides meth. Now with that said, I dont wanna be on it for ever.

One part of me wants to go back to Suboxone. cause atleast I could be stable 24 hours a day on suboxone. I dunno, I mean I wanna try and come off everything..

QUESTION

i've only been on the clinic a month. do you think I could jump off at 80mg and switch to subutex? I have 23 pills I was thinking to make the switch and just try to taper to nothing and attempt sobriety drug free.

Anyone have experience switching to suboxone and not lowering down to 30mg on your methadone?