College of Physicians and Surgeons of Britsh Columbia Methadone Maintenance Program: Clinical Practce Guideline February 2014 Revised July 2014 | Updated September 2015 Methadone Maintenance Program: Clinical Practice Guideline CONTENTS Preface .................................................................................................... 1 Introduction ............................................................................................ 2 1. The History of Methadone .................................................................................................................. 2 2. Authorization to Prescribe Methadone .............................................................................................. 2 2.1 Full Authorization ...................................................................................................................... 3 2.2 Temporary Authorization .......................................................................................................... 4 2.3 Hospitalist Authorization ........................................................................................................... 4 3. Pharmacology of Methadone ............................................................................................................. 4 3.1 Absorption ................................................................................................................................. 5 3.2 Duration of Action/Metabolism ................................................................................................ 5 3.3 Tolerance ................................................................................................................................... 5 Admission to the Methadone Maintenance Program ............................. 6 1. Criteria for Admission to the Methadone Maintenance Program ...................................................... 6 2. DSM-IV-TR Diagnostic Definition of Opioid Use Disorder ................................................................... 7 3. Treatment Considerations .................................................................................................................. 8 3.1 Detoxification ............................................................................................................................ 8 3.2 Outpatient and Day Treatment Programs ................................................................................. 8 3.3 Residential and Support Recovery Programs ............................................................................ 8 3.4 Alternative Pharmacotherapies ................................................................................................ 8 3.5 Mutual Support Groups ............................................................................................................. 9 3.6 Mental Health Services .............................................................................................................. 9 Assessment for Initiation ...................................................................... 10 1. Assessment Checklist ........................................................................................................................ 10 2. Treatment Goals and Plans ............................................................................................................... 11 3. Problematic Alcohol Use ................................................................................................................... 11 4. Process (Behavioural) Addictions ...................................................................................................... 12 College of Physicians and Surgeons of British Columbia i September 2015 Methadone Maintenance Program: Clinical Practice Guideline Contents Maintenance and Monitoring ............................................................... 14 1. Methadone Dosing ............................................................................................................................ 14 1.1 Initiation (Induction)................................................................................................................ 14 1.2 Titration ................................................................................................................................... 15 1.3 Stabilization ............................................................................................................................. 16 1.4 Split Doses ............................................................................................................................... 16 1.5 Missed Doses ........................................................................................................................... 17 1.6 Dosing Precautions .................................................................................................................. 18 1.6.1 Side Effects of Methadone ......................................................................................... 18 1.6.2 Toxicity ....................................................................................................................... 19 1.6.3 Fatal Overdoses .......................................................................................................... 19 2. Urine Drug Testing (UDT) .................................................................................................................. 20 2.1 When and Why to Order UDT ................................................................................................. 20 2.2 Method of Collection ............................................................................................................... 20 2.3 Urine Toxicology ...................................................................................................................... 20 3. Carry Privileges .................................................................................................................................. 22 3.1 Criteria for Initiating Methadone Carries ................................................................................ 22 3.1.1 Biopsychosocial Stability ............................................................................................ 22 3.1.2 Safe Methadone Storage ............................................................................................ 22 3.2 Carry Schedule ......................................................................................................................... 23 3.3 Exceptions to Carry Guidelines ................................................................................................ 23 3.4 Prescriptions for Carries .......................................................................................................... 23 3.5 Reassessment of Carry Privileges ............................................................................................ 23 4. Counselling ........................................................................................................................................ 24 4.1 The Methadone Prescriber’s Role ........................................................................................... 24 4.2 Brief Interventions ................................................................................................................... 25 4.3 Transtheoretical Model of Change .......................................................................................... 26 4.4 Community Substance Use Services........................................................................................ 26 5. Documentation of Benefits ............................................................................................................... 27 5.1 Categories of Benefits ............................................................................................................. 27 6. Prescriptions for Methadone Maintenance ...................................................................................... 28 College of Physicians and Surgeons of British Columbia ii September 2015 Methadone Maintenance Program: Clinical Practice Guideline Contents Discontinuation of Methadone Maintenance Treatment ..................... 30 1. Discontinuation in Stable Patients: Treatment Goals Achieved ....................................................... 30 2. Discontinuation in Unstable Patients: Treatment Goals Not Achieved ............................................ 31 3. Involuntary Dismissal ........................................................................................................................ 31 4. Transfer of Care ................................................................................................................................. 31 Advice to Physicians Downsizing or Leaving Their Methadone Maintenance Practices .......................................................................... 33 Special Populations ............................................................................... 34 1. Introduction ...................................................................................................................................... 34 2. Adolescent Patients........................................................................................................................... 34 3. Women of Child-Bearing Potential ................................................................................................... 35 4. Pregnant Women .............................................................................................................................