8
Treatment
Î By regulation, opioid withdrawal management with methadone must be
done in an OTP or an acute care setting (under limited circumstances).
• For patients withdrawing from short-acting opioids the initial dose should
typically be 20–30mg per day, and the patient may be tapered off in approximately
6–10 days.
Î MAJOR REVISION – Opioid withdrawal management with
buprenorphine should not be initiated until there are objective signs of
opioid withdrawal. (See p. 10–11 for more information on the timing of
initiating buprenorphine.)
• Once signs of withdrawal have been objectively confirmed, a dose of
buprenorphine sufficient to suppress withdrawal symptoms is given (an initial dose
of 2–4mg titrated up as needed to suppress withdrawal symptoms).
Î MAJOR REVISION – Alpha-2 adrenergic agonists (e.g., FDA-
approved lofexidine and off-label clonidine) are safe and effective for
management of opioid withdrawal.
• However, methadone and buprenorphine are more effective in reducing the
symptoms of opioid withdrawal, in retaining patients in withdrawal management,
and in supporting the completion of withdrawal management.
Î Opioid withdrawal management using ultra-rapid opioid detoxification
(UROD) is NOT recommended due to high risk for adverse events or
death.
• Naltrexone-facilitated opioid withdrawal management can be safe and effective
but should be used only by clinicians experienced with this clinical method and in
cases in which anesthesia or conscious sedation are not employed.
Methadone
Î Methadone is a recommended treatment for patients with OUD
who are able to give informed consent and have no specific
contraindication to this treatment.
Î MAJOR REVISION – The recommended initial dose of methadone
ranges from 10–30mg with reassessment as clinically indicated
(typically in 2–4 hours).
• Use a lower-than-usual initial dose (2.5–10mg ) in individuals with no or low
opioid tolerance.
Î MAJOR REVISION – Following initial withdrawal stabilization, the usual
daily dose of methadone ranges from 60–120mg.
• Some patients may respond to lower doses and some may need higher doses.
• Methadone titration should be individualized based on careful assessment of the
patient's response and generally should not be increased every day.
• Typically, methadone can be increased by no more than 10mg approximately every
5 days based on the patient's symptoms of opioid withdrawal or sedation.
