From the Guidelines
For clients entering detox for alcohol while on methadone maintenance, standard medications include benzodiazepines like diazepam (5-10mg every 6 hours as needed), chlordiazepoxide (25-100mg every 6 hours as needed), or lorazepam (1-2mg every 4-6 hours as needed) for managing alcohol withdrawal symptoms. These medications should be administered on a symptom-triggered basis using the CIWA-Ar scale or as a tapered regimen over 3-5 days. The client's prescribed methadone dose should be continued after verification with their maintenance program, as methadone is a crucial component of opioid dependence treatment 1. Supportive medications should include thiamine (100mg daily for 3-5 days), folate (1mg daily), multivitamins, and anti-seizure prophylaxis if indicated. For symptom management, consider clonidine (0.1-0.2mg every 6 hours) for hypertension, ondansetron (4-8mg every 8 hours) for nausea, and trazodone (50-100mg at bedtime) for insomnia. This dual approach addresses alcohol withdrawal while maintaining opioid dependence treatment. Close monitoring is essential as both benzodiazepines and methadone can cause respiratory depression, requiring careful dosing and frequent vital sign checks 1. Liver function should be assessed as both alcohol use and methadone can impact hepatic function. Some studies suggest that acamprosate may be beneficial in maintaining abstinence from alcohol, but the evidence is mostly low quality and more research is needed 1. However, the primary focus should be on managing alcohol withdrawal symptoms and maintaining opioid dependence treatment. Key considerations include:
- Monitoring for respiratory depression and QTc prolongation
- Adjusting methadone doses as needed to manage pain and withdrawal symptoms
- Providing supportive care, including thiamine and folate supplementation
- Managing symptoms such as hypertension, nausea, and insomnia with medications like clonidine, ondansetron, and trazodone.
From the Research
Medications for Alcohol Detoxification with Methadone Maintenance Therapy
- There are no specific studies that directly address medications for clients undergoing alcohol detoxification while receiving daily methadone maintenance therapy 2, 3, 4, 5, 6.
- However, studies suggest that benzodiazepines, such as lorazepam and chlordiazepoxide, are commonly used to manage alcohol withdrawal syndrome 4, 6.
- Phenobarbital has also been shown to be an effective adjunctive therapy for severe alcohol withdrawal syndrome, reducing benzodiazepine use 4.
- Other medications, such as clonidine and non-opiate-based painkillers, may be used to manage withdrawal symptoms during methadone detoxification 3.
- Anticonvulsant drugs, such as carbamazepine and valproic acid, may be useful in the treatment of anxiety, dysphoric mood, and other symptoms of abstinence syndrome, as well as for seizure prophylaxis 5.