Decide what you want from Opioid Agonist Therapy (OAT) and make sure you’re on the right dose of methadone or buprenorphine.
Methadone & buprenorphine: Getting your dose right
An introduction by Professor Adam Winstock
The optimal dose is one that leaves you free from withdrawal between doses for at least 28 hours*, reduces craving, curbs use of heroin on top and does not cause sedation/toxicity.
Background
For people with opioid dependence, being on the correct (optimal) dose of methadone and buprenorphine is an important factor in treatment efficacy. NICE and the Orange guidelines recommend therapeutic doses of methadone in the range 60’100mg and buprenorphine 8–16mg. Higher doses of methadone are associated with less heroin use (Strain et al 1999) and better retention in treatment (Caplehorn et al 1991). However, people vary and the optimal dose should be titrated based on each individual’s response and to full effect in each individual patient (Traffton et al 2006).
Underdosing OAT leaves people at risk of use and overdose. Many of those receiving OAT have poor understanding of how treatment works including issues relating to dose and effect, which limits the efficacy of treatment. To help patients get the most of treatment they need to have a clear understanding of how treatment works, the benefit of higher dosing and most importantly what the right dose is for them instead of being obsessed by a magic number or focusing on the fact that higher doses will result in a longer period of dose reduction to come off.
In order to help patients get their dose right and based on over 20 years of prescribing OAT I have developed the Stability of Opioid Dose Assessor (SODA). The SODA aims to help patients identify for themselves what the right (optimal) dose is for them. Put simply, the optimal dose of OAT is one that leaves people free from withdrawal between doses (preferably for at least 28 hours so for those on supervised dosing, getting their dose does not become a preoccupation or cause of distress if other activities need to be attended to or they are unable to pick their dose up at their usual time) reduced craving, cessation or significant reduction in regular on top use and does not cause sedation.
SODA has been developed in conjunction with user organisations and treatment services providers as well as focus group tested with a number of my current patients.
*
Why 28 hrs? This is so you don’t have to be tied to being at pharmacy at the exact same time every day. For many people a bigger dose lasts longer and means you have some freedom to do other things in your life before getting your dose without the fear of starting to withdraw if you’re a little late.