Informed consent and treatment planning

Before beginning MMT, the patient must be given enough information for him or her to make an informed decision about commencing treatment. The patient should be told:

• The rationale for methadone maintenance treatment
• The reasons it has been recommended to treat their opioid dependence
• Side effects and risks of treatment
• Expected length of treatment
• Other treatment options

As part of informed consent, tell the patient about the rules that must be follow to receive methadone treatment. For example:

• Patients consume their complete dose in front of dosing staff and do not give or sell any part of their dose to others.
• No violence or threats of violence against staff or other patients
• The patient is to attend consultations with their doctor as required
• Consequences for breaching these rules

The patient should give a patient information statement containing all of the above information and asked to read it. If the patient cannot read, the patient information statement should be read aloud. A sample patient information statement is shown on page 89. If the patient is happy to begin treatment after this process, he or she should sign a consent form to this effect. Mean while a sample consent form is provide on page 90.

After obtaining informed consent from the patient, develop a treatment plan that outlines the patient’s starting dose and the schedule by which doses will increase. See page 28 for more information about treatment plans.

The first dose

The first dose of methadone given to a patient is low. The size of the dose is gradually increase until the maintenance dose is reach. The maintenance dose is the amount of methadone the patient requires to prevent opioid withdrawal symptoms, but does not induce euphoria.

The first dose of methadone should be between 10-30mg. Patients who have recently use opioids can give a first dose at the higher end of this range. The first dose given to a patient who has not recently used opioids should be no greater than 10-20mg. When determining the size of the first dose, keep in mind that deaths from methadone overdose in the first two weeks of treatment have occurred at doses as low as 40-60mg per day.

Observe the patient 3-4 hours after the first dose has been consume. If the patient is showing signs of overdose, continue to monitor the patient at fifteen minute intervals. If the patient enters a coma, administer naloxone as a prolonged infusion.

Provide the same dose daily for three days. The patient will experience increasing effects from the same dose over this time. After the first three days, assess the patient’s withdrawal symptoms. If the patient is experiencing withdrawal, increase the dose by 5-10mg every three days. Dose increases should not be greater than 20mg per week.

Monitor the patient for signs of withdrawal and intoxication and adjust the methadone dose accordingly to find the patient’s maintenance dose. This process may take several weeks. The maintenance dose will usually be between 60-120mg, but may be higher or lower, depending on the patient’s history of opioid use.