Here is a proposed pathway for managing patients who require emergency methadone dosing in the ED (new starts or continuation of treatment):
New Start:
Day 1: Initiate methadone at 30 mg.
Day 2: Increase to 40 mg.
Day 3: Increase to 50 mg.
* If patient is not established at an OTP, you cannot renew or extend emergency dosing beyond 3 consecutive days (3-Day Rule for Methadone). If patient returns to the ED before establishing care at an OTP, you may only provide them with symptomatic medications for opioid withdrawal or consider a transition to buprenorphine. Transitions to buprenorphine should be done with caution since methadone is a long-acting full-opioid agonist and you run the risk of precipitating opioid withdrawal by starting buprenorphine.
In Treatment:
Verification: Always call the patient's methadone clinic (OTP) to confirm the current dose and the last administration time, OR, if receiving treatment at a VA OTP, review the chart/ask ED pharmacist for support. GLA instituted a methadone dispensing note that tracks last dose given and # of take-homes. Don’t just go off what patient tells you.
Missed Doses:
If 1-3 days are missed, administer the last confirmed dose without adjustment.
If 4 days are missed, administer the higher of 50% of the previous dose or 30 mg.
If 5 or more days are missed, treat as a new start.
Unknown Dose: If unable to confirm the dose, treat as a new start (see above).
Follow-up: Refer the patient back to their established methadone clinic for continued follow-up.
Reference:
Methadone Hospital Quick Start. Bridge to Treatment website. https://bridgetotreatment.org/resource/methadone-hospital-quick-start/. Accessed October 5, 2023.