From the Guidelines
For clients undergoing alcohol detoxification while on methadone maintenance, benzodiazepines such as lorazepam, diazepam, or chlordiazepoxide are recommended as front-line medications for managing withdrawal symptoms, as supported by the most recent evidence 1. When considering as-needed medications for these clients, it's essential to prioritize benzodiazepines due to their effectiveness in alleviating withdrawal discomfort, preventing and treating seizures, and managing delirium. Some key points to consider when using benzodiazepines in this context include:
- Starting with lower doses to minimize the risk of additive sedative effects, especially when combined with methadone
- Regular monitoring of vital signs, sedation levels, and QTc intervals to ensure safe use
- Individualizing medication choices based on the client's medical history, severity of withdrawal, and concurrent conditions
- Careful documentation of all administered medications to prevent complications Other medications that may be considered as-needed include:
- Antiemetics like ondansetron or promethazine for nausea and vomiting
- Acetaminophen for pain management, with a maximum daily dose of 4g
- Clonidine for autonomic symptoms such as hypertension and tachycardia
- Hydroxyzine for anxiety and insomnia It's crucial to note that antipsychotic medications should not be used as stand-alone treatments for alcohol withdrawal, but rather as an adjunct to benzodiazepines in severe cases that have not responded to adequate doses of benzodiazepines, as recommended by the WHO guidelines 1. Additionally, anticonvulsants should not be used to prevent further alcohol withdrawal seizures after an initial seizure, as stated in the guidelines 1. Overall, the goal is to provide safe and effective management of alcohol withdrawal symptoms in clients on methadone maintenance, while minimizing the risk of complications and promoting the best possible outcomes in terms of morbidity, mortality, and quality of life.
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. The FDA drug label does not answer the question.
From the Research
Standard As-Needed Medications for Alcohol Detoxification with Methadone Maintenance Therapy
- Benzodiazepines are considered the gold standard for treating alcohol withdrawal syndrome, with the largest and best evidence base 2
- Other medications that have been used to treat alcohol withdrawal include anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists 2
- For patients undergoing methadone maintenance therapy, clonidine and benzodiazepines may be used to manage withdrawal symptoms during detoxification from methadone 3
- Non-opiate-based painkillers may also be used to manage pain during detoxification from methadone 3
- Naltrexone may be given to patients after detoxification from methadone to help reduce the risk of relapse 3
Considerations for Methadone Maintenance Therapy
- Methadone maintenance therapy should not necessarily be maintained for life and can be stopped within its prescription setting, including medical, psychological, and social evaluation 4
- The decision to stop methadone maintenance therapy should be based on the client's will to stop, the physician's judgement that the client has been stable for a sufficient period, and the client's motivation to live without maintenance treatment 4
- Slow tapering of the methadone dose, with the ability to go back to the previous dose if needed, is a recommended approach for stopping methadone maintenance therapy 4