Methadone Dosing – Finding the Right Dose for You

Getting the dosage right is extremely important – it makes the difference between success and failure – and there is no good reason to stay on a daily dose that has you living with sickness when an appropriate dose could keep you stable and comfortable.

This isn’t a contest and you don’t win any prizes for staying on a low daily dose – in fact, if your methadone dose isn’t keeping you comfortable, you’re at huge risk of relapse. Some people will do well on small daily doses, such as less than 50 mg per day, others may require 200-300 mg per day to get the same symptoms relief. Most people do best on doses that range from 60 mg per day to 120 mg per day.

• The optimal methadone dose is the dose that eliminates withdrawal symptoms for a full 24 hours but isn’t so high as to over-medicate, sedate or induce unnecessary side effects.¹

Though with most medications, doctors try to keep you on the lowest dose that just gets the job done (as a way to minimize side effects and lasting harms) with methadone, this is contraindicated and likely to lead to relapse and significant harms.²

Read on to learn:

• More about the link between insufficient doses and relapse.
• How everyone needs an individualized daily dose and about the many factors that influence your dosing needs.
• How to deal with artificially imposed dosing caps.

Insufficient Doses Linked to Relapse

Though you might feel that toughing out a low dose saves you from unnecessary side effects or excessive dependency, the only thing this discomfort really gains you is an increased risk of relapse and treatment failure. Consider the following research results which illustrate this point:

• Doses below 60 mg per day are considered insufficient for most people. In one study, people maintained on 40 mg per day were more than twice as likely to also abuse heroin as people maintained on 80 mg per day, and people maintained on less than 60 mg are 4 times more likely to exit treatment early than people maintained on 80mg or more a day.^{3 4}
  
• The Centers for Disease Control (CDC)  recommends doses of 60 mg to 120 mg as appropriate for most people, while acknowledging that some people may need more. There is a dose response effect to treatment. With higher doses you see progressive reduction in opiate abuse. ⁵

Is Your Dose Too High or Too Low?

It can take a little while to dial in an optimal daily dosage, and because of methadone’s long duration of action, dose adjustments are best made very gradually, in fact, it can take between 5 and 10 days after each adjustment to achieve a steady-state level.⁶

As you and your doctors work to find the perfect dose, watch for signs of over and under medication, such as:

1. Under-medication – opiate withdrawal symptoms, especially late into the full day cycle, such as: cravings, anxiety, agitation, aching muscles and joints, nausea, depression and others.⁷
   
2. Over-medication – Sedation, nodding, scratching, itchiness, pinned pupils, euphoria, slow-thinking.

What Factors Influence Your Dosage Requirements?

Why do some people require significantly more methadone than others to get a full 24 hours of withdrawal symptoms relief?

This comes down to individual differences in drug use history and to how quickly you metabolize the drug. For example, some factors that can influence the amount you need include:

• How much heroin or other opiates you were using prior to initiating methadone – the heavier your past habit, the more methadone you’ll need to keep you stable.
• Your unique enzyme profile - Your liver metabolizes methadone with substrates of the cytochrome P450 enzyme, particularly CYP3A4. Greater quantities of active enzymes in the liver result in lower methadone levels in the bloodstream – the faster you can break it down and get it out, the less there is to keep you stabilized. Research shows that some people with very high CYP3A4 levels can have as much as 30 times the liver enzyme activity as others with very low levels. Very quick metabolizers will require a much higher dose for adequate withdrawal symptoms control.⁸
• Other health conditions that can affect metabolism - such as liver or kidney conditions that affect methadone elimination.
• Other medications that you take – Other medications can interact with methadone to increase or decrease its effects. Some medications will reduce the activity of CYP450 enzymes to potentiate methadone and other medications will do the opposite. Sedative medications, such as benzodiazepines, can also add-together with methadone to cause synergistically increased over-sedation.
• Other drugs of abuse that you use – cocaine or crack, for example, will accelerate methadone metabolism to decreases its effects. Acute alcohol use will increase methadone's effects but chronic drinking will increase CYP450 enzymes and decrease methadone’s effects.
• Pregnancy – pregnancy reduces the methadone’s bioavailability.
• Chronic pain – Studies show that people with chronic pain tend to need higher daily doses for stabilization.⁹
• Environmental factors, such as severe acute stress – Acute stress can worsen your perceived withdrawal symptoms.

Won’t a Higher Daily Dose Worsen Your Dependency?

Because one person has a difficult time coming off 60 mg a day doesn’t mean another person, coming off 120 mg a day, would have a more difficult experience.

If you’re a fast metabolize, your daily use of 120 might cause less dependency than the 60 mg given to a slow metabolizer  – comparing with others doesn’t always give you an accurate picture of the situation.

There is plenty of research, however, showing that an insufficient daily dose increases your relapse risk, and that those given an adequate dosage have a better chance of opiate abstinence.¹⁰

Dealing with Low Dose Caps

Federal regulations do not call for dose caps or fixed dosing and clinics that impose low dose maximums or do not allow for individual variations in dosing operate contrary to established best practices.

1. Getting under-medicated increases your relapse risk and your risk of a fatal illicit opiate overdose.
2. Insufficient doses keep you in discomfort, for no good reason.
3. Since no regulations or addiction medicine groups require or recommend fixed-low-dosing, you may want to consider a switch to a different provider – one that operates based on scientific evidence and is willing to provide you with enough medication to keep you comfortable and to maximize your odds of treatment success.¹¹

Take-Home Message

• Most people do best on a daily dose that ranges from 60 mg to 120 mg per day – some people will require more than this.
• People maintained on lower doses, such as below 60 mg per day, have an increased risk of relapse and accelerated treatment exit.
• There is no one dose that will work for everyone, a number of personal and environmental factors influence your medication needs.
• The right dose of medication is the dose that keeps you withdrawal symptoms and drug cravings free for a full 24 hours, without over-medicating.
• If your clinic operates contrary to established best practices, you should consider a different clinic.