Methadone Q&A
 Q. A patient on full carries leaves a weekly UDS and has been mostly drug free. I see him once a month and he leaves weekly samples in between our in-person visit. I interpret these tests weekly.
His last test came back positive for cocaine. He was immediately booked for an assessment the following week. He called and stated he couldn’t come in due to a change in his work schedule. He said will lose his job if he is forced to see a physician on an additional day. He works off-site in different northern towns.
How do I manage his carries as he cannot leave a urine sample and was positive for cocaine the previous week?
A. There is justifiable concern that the lack of any intervention regarding carries may lead to future missed appointments when the patient uses cocaine. Even if the patient states he didn't use cocaine, a cancellation of one carry is appropriate because you have evidence of a recent slip.
If the patient was consistently drug-free and was unable to leave a sample due to unforeseen, reasonable circumstances the carries may be left at the same level.
If the patient frequently misses urines and visits on full carries due to work related issues, the carry level or frequency of urines should be re-evaluated.
To promote retention on the methadone program and support the patient's employment circumstances the frequency of UDS may be reduced to biweekly or even monthly for a patient who has been consistently drug-free based on a weekly UDS for at least 6 months.
Q. A patient who has done very well on my methadone program and is on 4 carries reported that he has overused one bottle after he found out his wife was having an affair. He has never done this before and has been a model patient. He is in withdrawal in my office and begging me for a replacement bottle or else he will use heroin.
A. Typically, overused bottles of carries are not replaced. Give the patient support and reassurance that withdrawal will be minimal with only one missed day. Temporarily reduce or cancel carries depending on your assessment of the emotional stability of the patient. Caution should be exercised in reinstating carries. If carries for this individual are considered appropriate, prescribe them non-consecutively to reduce the risk of future misuse. For example, instead of 4 carries Monday through Thursday institute 3 or fewer non-consecutive carries (e.g. Monday, Wednesday and Friday). Once the stressor has resolved, the carries may be reinstated in a limited fashion; however, consecutive carries of more than 3 should be avoided. Exercise good judgement for pregnant patients who have overused a carry bottle. A replacement dose of a reduced volume (50 percent or 30mg) to alleviate withdrawal may be appropriate in these circumstances.
Q. I have a patient who occasionally uses cocaine. He was at CPSO level 4 and stable. I decreased his carries and ended up holding them all. When I next saw the patient, he had not had any use of cocaine and had negative UDS for the last 2 weeks. Can I reinstate two carries (one for each week without use)?
A. In the CPSO Methadone Guidelines, G8.12 states “Take home doses may be reinstated at the same rate, one dose per week without problematic substance use”. The intention of this guideline is to reinstate carries one at a time back to the level they were at prior to the relapse. Assuming sustained stability and no further relapses prescribe one carry initially and then increase at the rate of one carry per week.
Q. I have a patient who is prescribed a daily dose of 120mg of methadone. He continues to use cocaine and opiates due to withdrawals. He is complaining that his dose consistently wears off after 18 hours. Despite a dose of 120mg for about 4 weeks the patient has not stabilized. He only uses opiates once he has withdrawals 18 to 20 hours after his last dose. He is also prescribed a number of other medications. Do I need to do an ECG prior to increasing his dose above 120mg?
A. CPSO Methadone Guideline G6.5 indicates that the MMT physician should identify and manage risk factors for Torsades de Pointes arrhythmias, and should obtain an ECG above 120 mg for patients with any of the following risk factors:
- Older Age
- Structural heart disease
- Myocardial infarction, congestive heart failure, valvular disease, cardiomyopathy
- HIV infection
- Low potassium level
- On drugs that lower potassium (e.g. Diuretics).
- Low prothrombin level
- On medications that inhibit Cytochrome p450 3A4
- HIV antivirals (e.g. indinavir); Antifungals (e.g. Fluconazole, ketoconazole); Calcium channel blockers (e.g. Diltiazem, verapamil); Antimicrobials (e.g. Norfloxacin); Antidepressants (e.g. Fluvoxamine); Contraceptives (e.g. Mifepristone); Foods (e.g. grapefruit juice).
- Alcohol use
- Cocaine use
- Family or past history of long QT syndrome
- History of syncope or sudden cardiac death in the family.
- On medications that prolong QTc
- Cardiac medications (e.g. amiodarone, sotalol); Antipsychotics (e.g. chlorpromazine, haloperidol, pimozide, thioridazine); Antibiotics (e.g. clarithromycin, erythromycin Anti-nausea drugs e.g., domperidone)
If your patient falls into any of these categories that potentially increase the risk of prolonged QTc, then an ECG should be ordered. You should wait for the results to ensure that the QT interval is not prolonged prior to increasing the dose.
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