Methadone Maintenance Guidelines
Downloadble Version: Methadone Maintenance Guidelines
(82 pages)
Published November 2005, Appendix K added November 2007
Introduction and Table of Contents
In 1996, the College of Physicians and Surgeons of Ontario (CPSO; the College) began administering the provincial methadone program on behalf of the Ministry of Health and Long-Term Care. The mandate of the College’s program to improve the quality and accessibility of methadone maintenance treatment in Ontario is achieved in cooperation with the Centre for Addiction and Mental Health (CAMH) and the Ontario College of Pharmacists (OCP). The profile of methadone treatment in Ontario has been enhanced through outreach activities and the recruitment of physicians to prescribe methadone in the treatment of opioid dependence.
The following guidelines are a combination of evidence-based research and clinical consensus for prescribing methadone in the maintenance treatment of opioid dependence. These guidelines are not intended to substitute for sound clinical judgment. In a specific instance where a patient’s individual circumstances provide clinical justification for deviating from the guidelines, a physician may do so. However, it is expected that he or she will document any deviation from the guidelines in the patient’s medical record indicating the clinical reason(s) for doing so.
The College’s guidelines were developed for use by doctors providing methadone maintenance treatment in Ontario. Each province regulates methadone treatment and guidelines may vary between provinces. These guidelines replace the College’s October 2001 and August 1996 Methadone Maintenance Guidelines, and Health Canada’s “The use of opioids in the treatment of opioid dependence,” published in 1992.
Preface
Evidence-based Review
Limitations
Levels of Evidence
Introduction
Effectiveness of Methadone
Conclusion
General Expectations
Criteria for Admission
General Considerations
Assessment
Document the Patient’s History
Focused Physical Examination
Initial Urine and Blood Screening
Explaining Treatment Options
Treatment Agreement (Plan)
Methadone Dosing Issues
Safety of Initial Doses of Methadone
Effectiveness and Safety of Different Methadone Dosing Levels
- I. Opioid Withdrawal, Tolerance and Overdose
- II. Guidelines on Methadone Dosage Adjustment
- The early stabilization phase (0–2 weeks)
- The late stabilization phase (2–6 weeks)
- The maintenance phase (6 weeks +)
Management of Low and High Maintenance Doses
Split Doses
Methadone Tapering
Missed Doses and Loss of Tolerance
Vomited Doses
Urine Drug Screening
Urine Collection
Frequency of Urine Testing
Urine Toxicology
Counselling
Carry Policy
Clinical Stability
Length of Time in Treatment
Safe Storage
Carry Schedule
Reassessment and Reduction of Carry Privileges
Managing Relapse
Exceptions to Carry Schedule
Prescription Issues
Involuntary Dismissal from Care
Methadone and Acute Pain
MMT in a Correctional Facility
Issues Unique to Providing MMT in Correctional Facilities
Treatment Planning for Release
Reporting to CPSO
Observed Administration
Appendix A
Diagnostic Criteria for Substance Dependence
Appendix B
Diagnostic Criteria for Opioid Withdrawal
Appendix C
Suggested Criteria for Methadone Treatment
Appendix D
Opioid Detoxification Protocol
Appendix E
Initial Patient Assesment Form
Appendix F
Sample Methadone Treatment Agreement
Appendix G
Sample Addiction Medicine Clinical Note
Appendix H
A Patient’s Guide—Avoiding Overdose
Appendix I
Sample Letter to Pharmacy
Appendix J
Patient Treatment Form
Appendix K
Managing Potential Methadone Overdose
Patient Information Sheet on Methadone Overdose
Against Medical Advice
Emergency Department Management of Methadone Overdose
Methadone Overdose Protocol for the Ambulatory Patient