Maximum methadone dose

[youdontknow]

I was just wondering what is the max dose a clinic is allowed to give you?

[moda00]

Interestingly enough, to put a limit on this, known as a "dose cap," is not allowed. In addition to being disallowed outright, to do so in a sneaky way, such as an unspoken/informal policy which has the same effect as an official policy, or even setting arbitrary requirements, such as requiring a patient to pay for additional blood work before going over (x) milligrams, is considered an informal dose cap and has also been challenged. I believe this is due to the accreditation standards- clinics (in the US, this is) are accredited by one of two national organizations, and both have certain rules that must be followed. Dose caps are one of these rules. Since everyone's tolerance and metabolism differs, it is considered extremely irresponsible to arbitrarily restrict dose (and has no medical or recovery benefits or improved outcomes) to do this. If you are interested I can find some more info on this.

[Cruella]

Swim has never known anyone to get over 100mg dose at her clinic on the west coast, but has heard that in New York 300mg is the most there. When swim asked why the difference, she was told that the heroin in the New York area is much more potent and requires a lot more methadone to "treat" the addiction. Swim has only HEARD this and does not know for a fact thouugh. Hope it helps anyway !

[Junkhead23]

In the UK the maximum they will prescribe is 30mls when a person first enters treatment regardless of strength of heroin to avoid overdose so I cant see the giving out 300mls to someone for 1 day that is ridiculous. Any doctor will tell you that even taking 100ls is ridiculous and actually quite dangerous

[teddybearpicnics]

There is definitly a max dosage for your day one intake. But as far as how high you can go...Swim is from the east coast, USA, and has known people on 180mls, and they said they could still go higher. Swim doesn't think there is a ceiling.

.teddy

[moda00]

Originally Posted by teddybearpicnics

There is definitly a max dosage for your day one intake. But as far as how high you can go...Swim is from the east coast, USA, and has known people on 180mls, and they said they could still go higher. Swim doesn't think there is a ceiling.

That is true.. I don't know that it's set on a federal level or anything, but I think it is mandated either by the state authority in the US, or the individual clinics or accreditation bureaus, as far as the limit on the first day's intake and how one can increase when first starting on MMT.

At swim's clinic it is I believe 30 mg max for the first dose, and then 5 mg daily until one is comfortable. I think that is fairly standard, although I have heard some start around 40 mg or have 10 mg increases..

[youdontknow]

Yeah at my clini they usually start people out at 15 or twenty if the person is really bad off (i started at 20). Then 5 mg increases a day until you get to 50 then when you get to 50 you can go up by ten. I know this guy up at mine who is on 210 a day.

That just seems like a ridiculous amount. The only reason i could think of to be on that much is to get high, at which point youve really lost the true purpose of the methadone.

[burned_no_more]

SWIM used to get his suboxones at a clinic everymorning (thank GOD I don't have to do that anymore, so depressing) and he'd have to sit in the dosing booth for a while cause they made him wait to make sure the pills disolved and he would get to hear everyone elses doses. There were some folks in there getting over 200mg's a day. Holy CRAP.

[moda00]

Originally Posted by DeadLegend

Yeah at my clini they usually start people out at 15 or twenty if the person is really bad off (i started at 20). Then 5 mg increases a day until you get to 50 then when you get to 50 you can go up by ten. I know this guy up at mine who is on 210 a day.

That just seems like a ridiculous amount. The only reason i could think of to be on that much is to get high, at which point youve really lost the true purpose of the methadone.

It really is a misconception that "over 100 mg is too high" or "over 200 mg is only a dose for someone who is abusing the system to get high." Just like people who are addicts can have varying tolerances, people who are dependent and in maintenance treatment have these same variations. One regular OC user/addict might do 20mg in a day, say a quarter of an 80.. another maybe does two 80mg pills in an average day, and another perhaps ten or twelve or even twenty 80's..

When swim was injecting heroin, she would occasionally pick up with several other addicts who were in similarly bad shape- daily IV use, withdrawals, etc. and similar using histories, but swim found that there was a big difference in the actual amount of heroin each person would do as a normal dose, despite their similar length of use, drug of choice, and frequency of use. This carries over to any opiate, including methadone. Most patients get onto methadone directly from active addiction, and their tolerance will be at a different point than another person's on methadone just as it was during active addiction. It's very individual and not all that straightforward as one might make it out to be.

Of course when the effect one desires is to get high, on is constantly escalating their usage and doses over time, but with MMT, one has to get to a stable point based on their tolerance at that point in time, and hold it there. An indicator, therefore, of someone abusing MMT to get high has nothing to do with dose itself, and is much more likely indicated by someone who is not willing or able to stabilize on a dose, but is constantly attempting to increase their dose (whatever that dose may be).

I am sure we have all seen that there is a very wide variety of opiate tolerance, as far as how one is using, one's metabolism, etc. We don't even know or understand all the factors that go into it yet, but it's certainly complex. I know certain amounts might sound "high" or "ridiculous," but research and best practice has not backed up that there is any reason to put a dose cap, which is why it is not permitted by the regulations! Trust me, they like to make it as hard as they can- think of all the hoops one has to jump through, with intake paperwork, fees, call-backs, urine drug screens, clinic attendance, phases.. if they could justify a dose cap, they probably would- if there really was evidence that doses beyond a certain number indicate abuse of the system and result in an opiate "high" they would quickly institute policies reflecting this, don' you think? Many clinics do so informally because of these misconceptions- but in reality it makes for less effective and stable treatment and does not serve the best interests of the patients, and those who have researched it have found this to be true.

In addition, realize there is no dose cap for daily or per dose opiate intake for pain management purposes- because tolerance can increase indefinitely, and opiates are not ever "toxic" like other substances become beyond a certain fixed point. That is just not how opiates as a drug work.

I just feel it is really inappropriate to comment on someone's dose in a way which would question their motives or their recovery based on a number- there are tests and measures available- such as abstinence from drug abuse, quantitative measures like peak/trough, ability to function at work/school, physical and mental health and appearance, etc. which give a good clinical picture of how an individual patient is doing- it is quite possible for a patient to be on "too low" of a methadone dose (for THEIR individual body and tolerance) at 250 mg and still be struggling with withdrawals or the dose not "holding," as it is entirely possible for someone to be stabilized at 30 mg and then choose to abuse the system and increase beyond that to the point where they might wind up at "too high" a dose and having opiate side effects (sedation, pinned pupils, euphoria, etc.) at 50 or 60 mg.

Like I said, there is a reason best practice and policy prohibits dose caps- because dose alone is not in any way a reliable indicator of progress or treatment effect, and it is not helpful implement policies which imply otherwise.

At swim's clinic, there are people on less than 20 mg/day, and there is a guy who takes 320 mg. There might be a higher dose, I don't know- but of the people swim has discussed it with in conversation, that's the highest she has heard. This individual is serious about his recovery, and it is clear by looking at his eyes, his gait, his interactions with others, and his daily routine that he is not in the frame of mind of getting high, nor does his body respond in that way. Now, he is a very large guy, over 6 feet tall and probably over 300 pounds, so that may be part of it, but swim thinks it is much more than just simple visible factors like body type or size, or measurable variables such as length of time using opiates. Neither do the individuals swim knows on 15 or 20 mg feel constant withdrawals from their "low" dose- you know? Swim takes 120 mg and would personally be very sick if she took only 15-20 mg, as she would be very high and very nauseous from 320.. but that is her, and her body and tolerance should not and do not impact anyone else's. Swim is glad that her clinic is aware that tolerance varies, and uses a wide variety of self-evaluation and staff evaluation, quantitative and qualitative measures, to evaluate the adequacy of a dose.

Reputation Comments on this post:

good points made

[youdontknow]

ok well ill add that these words came out of the persons mouth too "yeahhh man im on 210, gets me fucked up all day every day"

Despite whatever you say you have to admit that there are people there just to get high.

[moda00]

Originally Posted by DeadLegend

ok well ill add that these words came out of the persons mouth too "yeahhh man im on 210, gets me fucked up all day every day"

Despite whatever you say you have to admit that there are people there just to get high.

Of course, and I believe I did. There is a big difference between saying, the only use for any amount over x milligrams is to get high, versus sharing that a specific individual on that dose claimed his intentions were such. One anecdote does not generalize. I know that people abuse the mmt system as any other system- it happens. But to say that it is related to dose is wrong. Please re-read my post for the specifics as to why that is so. Thanks!

[Dickon]

In a hypothetical dream my cat said....

The most I was ever scripted was 164mg/day. Er?????? Breakdown was 100mg oral per day, and 9 50mg/ml amps a week, which averages out at just over 164mg/day. The least I used in those days was 200mg/day, and the most was 700mg all i.v. However, that's nothing compared to a medical case study that mentioned someone scripted 2000mg a day. I just hope that wasn't 1mg/ml English stuff!!! 2 litres is a bit much of the green mixture we get to drink. Recently on the sugar-free stuff, I was all but retching if I drank 300mls or more. Oddly I was most stable on my first methadone script of 30mg a day. Go figure! [Strange cat]

Dickon

[drug-bot]

swims clinic said that theres federal guidlines that prevents them from giving a patient more than 30mg on the first day of admission (swim lives in the usa). but after that theres no dose limit, though after you reach a certain dose the clinic requires you to either submit to blood work (to see how fast ones body is metabolizing the methadone, and some clinics may try doing split dosing before increasing). at swims clinc when he needed to go up over 85mg to 90mg they reguire the clinic doctor to approve it and any other increases the doctor must approve it, for dose increases up to 90mg one only needs their clinic appointed councellors permission.

theres no legal dose limit but like what swim said some clinic enforce and some even brag and promote they only give low doses, which is very unethical and not based on scientific research, and its possibly illegal (denying appropraiate medical care to a client/patient, which exactly what it amounts to). and higher doses of methadone have been proven time and again to dramatically reduce ones intake of illicit street opiates, heres some proof-

Following a 1-week orientation period, patients receiving high-dose (80-100 mg) methadone treatment had less self-reported heroin use and lower rates of drug-positive urine samples than patients on moderate-dose (40-50 mg) treatment. Urine results are shown as 3-week averages of twice-weekly samples.

http://www.drugabuse.gov/NIDA_Notes/.../HighDose.html

[top]Résumé / 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 is 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 optimal 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://cat.inist.fr/?aModele=afficheN&cpsidt=796295

Reputation Comments on this post:

	good post- concise and gives research
	Useful information, and abstract.

[Gappa]

Hey buddys.. How you been??
I haven't been here lately. SWIM almost died on the 14th from a M done OD. I came in in full resperatory failure and they did the Wiesemann detox. THAT SUCKS BAD I have been in the hospital till even today. It really was an accident and I should have been more careful 170mgs of done with no tolorance should have never happened.

[youdontknow]

yeah no shit that should have never happened, even half of that would have been enough to kill you!

[Aberdonian]

Hi folks, Most iv heard of anyone on in my area of scotland is 150mg more usual dose is 80-90 mgs, last time i was on methadone they started me at 30, then increased 5mls daily till i was at 70 an that held me no probs, i came down 2 to 5mls a week all the way down to 18 and all that time felt good, not high just sorted, cant imagine how someone on 300+ must be able to shit lol, i was bad enough on that dose an i know its off topic but i would never recommend someone do an accelarated detox off methadone, i did it off 18 mg after i started usin brown again at that level and iv never been so ill in my life!

[Dickon]

I'd like to come back on the post drug-but made about higher doses leading to lower illegal drug use. My cat knows from experience of taking moderately large amounts of methadone that once you are taking 150-250mg of methadone a day there is little to no point in taking heroin.

I do not understand this, and was at first reluctant to believe it, except my own experiences bore it out, but the equianalgesic morphine/methadone dose varies from 2-1 to 20-1 (according to one oft-quoted table of conversion: I've linked to a reference below) for low doses of morphine (<30mg) to high doses (>1001mg) of morphine respectively.

This makes sense of the fact that when my cat was taking 200-250 mg methadone a day (although sometimes more) he was able to take 4,500 mg of morphine sulphate in a day (2 doses of 2g and 2.5g each) and not feel a great deal. He also tried a similar experiment with a large quantity of heroin, but got little from it, despite i.v.ing it. The theory and my own experience makes sense of the fact that high dose methadone will reduce the use of illicit opiates. My cat used to buy more methadone, and use benzodiazepines and alcohol to try to get a better buzz. It didn't work, with even a 250mg dose of injectable methadone giving only a slight effect. Cat injected 700mg one day, but I don't remember any particular purring.

There is one counterintuitive piece of information I came across, and again my cat's experiences make me believe this isn't simply a statistical anomaly. If you are on a certain dose of methadone on a fairly regular basis, and increase it by a significant amount this will increase the likelihood of using on top, not decrease it. As far as I remember this does not apply to small dose increments, but I can definitely bear this out. If Growltiger was taking 200mg a day and one morning for a treat took 300mg then he seemed particularly prone to have a little 100mg or 150mg "top up" later in the day. I have no reason to believe that Growltiger is a "quick metaboliser" of methadone, he's simply a greedy kitty when it comes to using drugs.

I know I have a very incomplete understanding of why the above facts are true. Perhaps the most useful to lesson to be learnt is that extrapolating from simplistic mental models will get us into trouble. But here's something that's just occurred to me now that makes an interesting hypothesis. If one is dosed with 50mg methadone, according to the equianalgesia criteria, this is equivalent to 750mg morphine (15-1), after about 24 hours (i.e. one half life; methadone is usually dosed daily) one will have 25mg methadone in one's system which is equivalent to 200mg morphine (it is almost considered equivalent to 100mg - there are obvious problems with the conversion table, but we're dealing with a concept in brush-strokes not particulars), so let's say 187.5 mg to make the numbers easy. This would constitute 2 half-lives of morphine (going from 750mg to 375mg to 187.5mg), whereas 120 mg of methadone would be considered equivalent to 2.4g of morphine, and 60 mg of methadone (half as much again) will equate to 1.2g of morphine.

So if we consider a higher dose of methadone we are thinking of the serum-equivalent-morphine-level as halving over a 24-hour period, but for the lower dose the serum-equivalent-morphine-level will drop by a factor of 4. This might partially explain why a higher dose of methadone may be better for maintenance. This is pure speculation, I hasten to add, and there are a few technicalities that have occurred to me already, but I will not load conjecture upon conjecture here. If anyone has come across this idea explained or refuted scientifically I'd love to know.

Here is one reference (secondary) that contains the equianalgesic conversion used, and sites (3!) primary references: http://www.gotpharm.com/Detail%20Doc...Management.pdf

I'm just glad that Growltiger is off methadone!!

Dickon

[baron samedi]

Hello everyone,
SWIM has been on methadone for a few days now. At present he is on 30mg, which he assumes to be very low. He was started off on 10mg, which didn't even scratch the surface.
It would be dishonest to say that the increase to 30 did not make some difference to the general feeling of sickness he was experiencing but still has it in his mind that he is way too low. TBH, apart from some relief from the physical symptoms it still feels to him as if he has taken nothing sronger than an aspirin.
He is worried that without a dose increase, he is going to start looking for ways to potentiate, whether it is by more opiates, benzos, cannabis, herbals or whatever.
Do you think that the people administering his dose would agree to him being put on a more moderate dosage (say 50-60mg) to help the psychological withdrawls he is suffering from?
He must assure the other SWIMs that it is not his intention to become a long term methadone user, rather he just wants to be on a dose that feels more equivalent to what he's used to, then he can start to think about slowly tapering off the meth, without causing any disruption to his general daily activities.

[Dickon]

I don't know what county you're from baron samedi, France perhaps, judging by your screen name, but in the UK at least there has been a consensus that higher doses (80-120mg and above) lead to better retention in treatment. Methadone is not "designed" to give a high, but to stop the withdrawal symptoms. I trust you are aware of that. Although my cat was stable a long time ago at a 30mg dose, it is nonetheless rather low. I would say that you had a good chance of getting a higher dose if you feel that is what you need. However, it depends where you are, and who is making the decision, so I've no idea if you actually will get what you feel is appropriate.

Bear in mind that if you do want to quit, the higher your dose, the harder that will be. Not many people have the intention of becoming long-term methadone users, but a lot do. It's a hard drug to come off, as I expect you know.

Best wishes

Dickon

[baron samedi]

Cheers SWIDickon, SWIM is actually based in the UK as well. He is somewhat worried however that the practitioners caring for him are going to be very reluctant to move him to a dose which will actually stop him from craving and ultimately relapsing.
Their reasons for doing so are perfectly understandable to SWIM, but it doesn't necessarily change SWIM's opinion that a higher dose might be more beneficial for him.
Obviously, SWIM doesn't want to be dishonest to his drug workers, and in fairness his physical withdrawl symptoms have been eased by this dosage, but how can SWIM convince them that he needs a higher, more normal, dose?
He also agrees with all your advice about the addictive potential of meth, and is approaching all this with a great degree of caution.