I.  Initiate Opioid Agonist Therapy (OAT)

 

OBJECTIVE

 

Provide appropriate dosing and relapse monitoring to promote effective outcomes.

 

ANNOTATION

 

Methadone

For newly-admitted patients, the initial dose of methadone should not exceed 30 mg, and the total dose for the first day should not exceed 40 mg, without provider documentation that 40 mg did not suppress opiate withdrawal symptoms.

 

Under usual practices, a stable target dose is greater than 60 mg/day and most patients will require considerably higher doses in order to achieve a pharmacological blockade of reinforcing effects of exogenously administered opioids.  Effective May 2001, Federal regulations will no longer require the OAT program physician to justify in the patient record doses > 100 mg/day.

 

LAAM

For newly admitted patients, the initial 48-hour dose of LAAM should not exceed 40 mg.  After dose induction, a stable target dose is usually at least 50/50/70 mg administered on Monday/Wednesday/Friday and most patients will require considerably higher doses in order to achieve a pharmacological blockade of reinforcing effects of exogenously administered opioids.  Friday doses are increased 40% to compensate for the 72-hour inter-dose interval.  For patients on established doses of methadone, the relative potency of 48-hour LAAM doses is 1.2-1.3 times the daily methadone dose.

 

Opioid Agonist Therapy

Providers should adjust opioid agonist doses to maintain a therapeutic range between signs/symptoms of overmedication (e.g., somnolence, miosis, itching, hypotension, and flushing) and opioid withdrawal (e.g., drug craving, anxiety, dysphoria, and irritability).

 

Deliver OAT in the context of a complete treatment program that includes counseling or psychotherapy (See Module R: Assessment and Management in Specialty Care).

·         Methadone, combined with weekly counseling for at least four weeks after admission, followed by at least monthly counseling, has been shown to be more effective than methadone alone.

·         Availability of more frequent counseling is associated with less illicit drug use.

·         No specific form of psychosocial intervention has consistently been shown to be more or less efficacious.

·         Programs with high-quality social services show better treatment retention.

§         Programs must provide adequate urine toxicology for drugs of abuse, including a minimum of eight random tests per year per patient.

 

DISCUSSION

 

Effective May 2001, OAT programs must obtain accreditation from an accreditation body that has been approved by the SAMHSA (e.g., JCAHO or CARF) or a state accreditation body, in order to be Federally certified to dispense medications and provide treatment services.

 

To comply with Federal regulations to prevent diversion of opioid medication from legitimate treatment use (42 CFR 8), individual OAT programs have developed a variety of internal procedures with which the patient and provider must comply (e.g., random urine toxicology, policies for “take home” doses, and “call backs” to verify appropriate use of “take home” doses).  Although each OAT program's internal structure and guidelines vary, it would be prudent for the primary physician and/or other health care providers to discuss program rules and expectations with the OAT program physician, so that patient care is appropriately coordinated.

 

OAT programs must provide full and reasonable access to adequate medical, counseling, vocational, educational, and other assessment and treatment services, either at the primary facility or through a documented agreement with other providers.

 

EVIDENCE TABLE

 

	Recommendations	Sources of Evidence	QE		R
1	Methadone target dose is typically > 60 mg/day.	Strain et al., 1999 Preston et al., 2000	I		A
2	Methadone, combined with regular counseling, is more effective than methadone alone.	McLellan et al., 1993	I		A
3	Frequent counseling is associated with less illicit drug use.	Magura et al., 1999	II-2		A
4	High-quality social services show better treatment retention.	Condelli, 1993	I		A
5	LAAM target dose is typically at least 50/50/70 mg on Monday/Wednesday/Friday.	Jones et al., 1998 Eissenberg et al., 1997	I		A

QE = Quality of Evidence; R = Recommendation (See Introduction)