From the Guidelines
Managing severe methadone withdrawals requires a comprehensive approach under medical supervision, with the most effective strategy being a gradual taper of methadone rather than abrupt discontinuation, typically reducing the dose by 5-10% every 1-2 weeks, as recommended by recent guidelines 1.
Key Considerations
- Methadone withdrawal is particularly challenging due to the drug's long half-life, causing withdrawals to last longer (up to 3-4 weeks) than with shorter-acting opioids, with the intensity peaking around days 4-6 but remaining uncomfortable for weeks 1.
- For those already experiencing withdrawals, medications can help manage specific symptoms, including:
- Clonidine (0.1-0.3mg every 6-8 hours) to reduce autonomic symptoms like sweating and anxiety 1.
- Loperamide (4mg initially, then 2mg after each loose stool, maximum 16mg daily) to help with diarrhea 1.
- NSAIDs like ibuprofen (400-600mg every 6 hours) for muscle aches and pain.
- Short-term trazodone (50-100mg at bedtime) or hydroxyzine (25-50mg every 6 hours) for anxiety and insomnia.
Additional Support
- Adequate hydration, nutritional support, and rest are essential during this process.
- Psychological support through counseling or support groups significantly improves outcomes.
- Medical supervision is crucial throughout this process to monitor vital signs, adjust medications as needed, and prevent complications.
Transitioning to Alternative Treatments
- When transitioning from methadone to buprenorphine, caution is required due to the risk of severe and prolonged precipitated withdrawal, and patients should be in active opioid withdrawal before starting buprenorphine 1.
- The use of buprenorphine or methadone can effectively alleviate withdrawal symptoms and may serve to initiate medication for addiction treatment (MAT) for OUD 1.
From the FDA Drug Label
For detoxification and maintenance of opiate dependence methadone should be administered in accordance with the treatment standards cited in 42 CFR Section 8. 12, including limitations on unsupervised administration. Initially, a single dose of 20 to 30 mg of methadone will often be sufficient to suppress withdrawal symptoms The initial dose should not exceed 30 mg. If same-day dosing adjustments are to be made, the patient should be asked to wait 2 to 4 hours for further evaluation, when peak levels have been reached. An additional 5 to 10 mg of methadone may be provided if withdrawal symptoms have not been suppressed or if symptoms reappear The total daily dose of methadone on the first day of treatment should not ordinarily exceed 40 mg.
To manage methadone severe withdrawals, the initial dose of methadone should be 20 to 30 mg, not exceeding 30 mg, and administered under supervision when there are no signs of sedation or intoxication, and the patient shows symptoms of withdrawal.
- The patient should be asked to wait 2 to 4 hours for further evaluation, when peak levels have been reached, before making same-day dosing adjustments.
- An additional 5 to 10 mg of methadone may be provided if withdrawal symptoms have not been suppressed or if symptoms reappear.
- The total daily dose of methadone on the first day of treatment should not ordinarily exceed 40 mg 2.
From the Research
Managing Methadone Severe Withdrawals
- Methadone is a full opioid agonist that can be used to manage opioid withdrawal symptoms 3
- It acts by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids 3
- Oral methadone has the strongest evidence for effectiveness in managing opioid withdrawal 3
Treatment Approaches
- Medication-assisted treatment, including methadone, buprenorphine, and naltrexone, can be effective in managing opioid withdrawal 3, 4, 5
- Clonidine combined with naltrexone can enable abrupt opioid withdrawal in 3-5 days in an outpatient setting 4
- Tapered methadone can be used to manage opioid withdrawal, with evidence suggesting it is similar in effectiveness to other pharmacological treatments 6
Challenges and Future Directions
- Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication 3
- New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and poor treatment adherence 3
- Areas for future research include managing withdrawal in the context of stabilising patients with opioid use disorder to extended-release naltrexone, and transitioning patients with opioid use disorder from methadone to buprenorphine 5