Methadone Dose in the Treatment of Opiate Dependence

Susan M. Stine, MD, PhD, Thomas R. Kosten, MD

Disclosures

Medscape Psychiatry & Mental Health eJournal. 1997;2(6) 

In This Article

Dosage Controversy

Finding the optimal maintenance dose in methadone treatment is resisted by some addiction-treatment workers. First, they often have preconceived notions that abstinence is an achievable goal and that methadone maintenance does not "cure" the addict. Second, they prefer lower doses because of fewer adverse effects and easier withdrawal from methadone. Finally, they believe that smaller amounts of methadone would be diverted to the street if doses were lower.

Patients are also resistant to increases in treatment doses of methadone. This is often based on street lore that claims methadone "rots the bones," decreases libido, and is more difficult to "kick" than heroin.[4,5]

Patients on more than 60mg/day of methadone are more successful in maintaining drug-free urines.[6] Additionally, a series of large-scale studies has demonstrated that patients maintained on doses of 60mg/day or higher had better treatment outcomes than those maintained on lower doses.[6,7,8,9,10] These studies have confirmed that doses below 60mg/day appear inadequate for treating most patients. This is especially important at the beginning of treatment, when patients may experiment with heroin to test the effectiveness of the medication.

The effectiveness of methadone is even greater for patients on 70mg/day and is still more pronounced for patients on 80mg/day or more. A study of 6 methadone programs over a period of 3 years in 3 northeastern US cities revealed that opiate use was directly correlated with methadone dose levels.[6] In patients receiving higher than 71mg/day (47 of 407 subjects) no heroin use was detected. However, patients on doses below 46mg/day were over 5 times more likely to use heroin than those receiving higher doses. Caplehorn and colleagues[10] reported that a cohort of 62 Australian patients who received higher doses (80mg vs. 40mg) of methadone were 2.2 times less likely to use heroin. In another study by Capelhorn and Bell,[11] patients (n = 238) on doses greater than 80mg were half as likely to leave treatment as those on doses between 60 and 79mg, and one fourth as likely as those who received less than 60mg.

In a review of 24 methadone treatment programs in the US, the General Accounting Office[12] concluded that the lowest effective dose to stop heroin use is 60mg/day and that low-dose maintenance (20-40mg) is inappropriate. Despite these observations, some clinics have maintenance doses of 30mg/day and policies that prohibit prescribing a higher dosage.

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