1. Late Stabilization & Maintenance Phase of Treatment

2. Challenges in stabilization Management with higher doses “Carries”

3. Dose Adjustment Usual dose is 80-120mg Higher doses sometimes needed Consider a trough blood level if dose is going higher than 120mg or if there is uncertainty about the clinical picture of withdrawal symptoms Trough level - therapeutic range is 100- 400ng/ml

4. Rapid Metabolisers ‘I feel sleepy in the afternoon but I’m in withdrawal by nightime’ Peak blood level drawn 4 hours after witnessed drink Trough level drawn 24 hours after last dose Peak:trough >than 2:1 Dose may need to be split - twice daily dosing

5. Management of High Doses Risk of cardiac effects with doses higher than 140-150mg Prolonged QT interval - risk of arrythmia ECG should be done at this time & should be repeated with subsequent dose increases

6. “Carries” Take - home doses can be given when –At least 2 months in treatment –Clinical Stability is demonstrated –Client is able to store Methadone safely in a locked box Must consider patient safety & public safety when deciding to give carries

7. Clinical Stability This is more than just providing negative urine drug screens Methadone dose is stable Elimination of sustained problematic drug or alcohol use Emotionally stable Housing, employment or school &/or a stable support system Adherence to the treatment agreement

8. Schedule of increasing Carries After the first 2 months in treatment carries can be increased by 1 additional take-home dose/month Maximum of 6 carries/week - only 1 witnessed drink at the pharmacy per week

9. Counseling Once withdrawal symptoms have been controlled, clients can benefit from counseling Residential or out-patient rehab programs, 1:1 counseling & 12 step support groups Clients usually have multiple social & emotional issues to resolve