Download SOTA Responses (12) to Query from Florida Regarding What is

SOTA Responses (12) to Query from Florida
Regarding What is Considered a High Dose of Methadone and Prevalence of Split Doses
Received & Compiled by NASADAD Staff by/on October 27, 2009
58. Request from Joel Armstrong, 9/21/09:
I would appreciate getting some feedback from SOTAs on what they would consider a high dose of
methadone. I've read most of the literature I can find on it but would be really interested in others’
opinions about this. I would also like to know generally what the prevalence is of folks getting a split
dose.
Responses to the two questions were summarized separately.
What is considered a high dose of methadone?
Summary: Of the 10 States that responded to this question (CA, IN, MA, MD, NH, NV, NY, OK, RI, VT):
8 noted that appropriate doses vary based on the needs of the individual (CA, IN, MA, MD, NY, OK, RI,
VT) and that for some patients high doses are necessary. Examples given for might be considered a
high dose ranged considerably: 120 mg. (IN); 150 mg. (OK, NV); 180 mg. (VT); 220 mg. (NH); 250 mg.
(MA); 500 mg. (RI). Four States commented that special attention should be paid if too many patients
are receiving relatively high doses (MA, OK, RI, VT).
What is the prevalence of patients getting a split dose?
Summary: Of the 7 States that responded to this question (CA, FL, NH, NV, NY, RI, VT), 6 States
indicated that split doses seem to be rare.
What is considered a high dose of methadone?
CA, Cathy Sorenson:
There is no predetermined “high” milligram dose. It is at the discretion of the program medical director
to determine what dose amount is required to sustain the patient.
IN, Louise Polansky:
I checked with a physician I consider an expert in the field of methadone treatment, and he shared the
following:
1. 'High dose' is an absolute term that is totally meaningless.
2. Doses associated with optimal effectiveness vary from patient to patient, but most patients do best
with a dose range between 80 and 120 mg.
3. Sixty mg or less per day is usually not effective, and dosages above 120 are usually not needed, but
for some patients, doses below and above these doses are effective.
4. There are patients who do 'splendidly,' with no side effects, at 400 mg or more per day and "do lousy
at lower doses".
5. So "it's all relative".
6. If a patient, for whatever reason(s), asks for a lower dose after doing well on that dose for some time,
and the patient is not attempting to totally discontinue the medication, it should be tried, but "watch for
supplemental opiate use".
MA, Hilary Jacobs:
I agree with the comment below (there is no pre-determined high dose). That said, it makes sense to
pay attention to changes in practices and doctors who seem to be outliers. We have a similar situation
to Becky's in MA that concerns me with one OTP consistently prescribing doses in the 300-400 range
and lots of split dosing, with each split in the range of 100+ (mostly plus) mgs that appear outside of the
norm. I have strongly communicated my concerns about this situation after investigating and finding
many irregularities as to how these decisions were arrived at. For example, peak and trough levels are
not done on observed dosing, split dosing given for pregnant women is not changed anytime after
delivery, many patients with split doses got them when this physician came after years of stable dosing
in the clinic and no change in medical status or medications, etc. We have required that the current MD
review all doses above 250 and all split doses with a MD who is Board Certified in Addiction Medicine,
has expertise in opiate treatment, and works as a consultant for the Department.
With all the exception requests we review, we see very few doses over 180. We have about 12,000
people in OTPs in MA.
MD, Suzan Swanton:
In Maryland we do not have any caps on dosing. We tend to think more in terms of the appropriate
dose for each individual. I have known individuals on 200 mg and that was the appropriate dose for
them. I am not sure what our average dose is now. Over the years it has risen for many reasons, not the
least of which are the impact of antiviral and HCV medications that interfere with its bioavailability. I will
ask about our average dose during our provider meeting next month.
NH, Rosemary Shannon:
Hard to say, since I only see dosing amounts for take home exceptions (unless we are doing a site visit),
and the range is all over the place (dosage is not in our client reporting data set).
We have done site visit where we have asked a particular clinic to pull records of clients with doses over
220 mg (just a number I came up with, to see what we would be looking at). The problem with very high
doses is the detox, especially financial detox, which we have seen a fair number of, with the current
economy.
In the past week I have seen ranges of 40 mg to 330 mg. I do wonder, since NH has no reporting
requirement for doses over a certain amount, the street lore is that if you 'want a high dose, go to this
particular facility.'
NV, Pat Chambers:
My opinion is a dose of 150 mg and above would be considered high.
NY, Belinda Greenfield:
NYS leaves it up to the Medical Director’s discretion regarding methadone dosage.
OK, Ray Caesar:
I would consider any dose over 150 as high but, not necessarily problematic. Identifying doses > 150
would be part of a review of dose range by clinic done periodically. If a problem is identified through
the review it has most often been a particular clinic that is dosing all patients at a significantly higher
rate. With that said, we have patients receiving 200+ mgs daily and these appear appropriate. For most
OTPs in Oklahoma dosing seems to fall roughly along a bell curve.
RI, Becky Boss:
I very much agree with Cathy's response. Doses are not high or low - they should be considered as
adequate or not adequate to be effective.
That being said - and after reviewing other's responses, I must admit that I raised my eyebrow a few
years back when I started to get several split dose exception requests for doses in the 400-1000 (yes
1000)mg. range. It was one provider/medical director. Needless to say, I investigated these doses and
found that there was little, if any, real justification for doses to be at that level. And little, if any,
concern for diversion or potential cardiac complications. After bringing this specific Dr. up to the
Medical Review Board (for reasons that went beyond the doses) and continued record review for all split
doses and doses above 500mgs. - he is no longer employed by an OTP. But I did face significant criticism
(and a complaint to my Department Director) from this Dr. and some of his allies for questioning medical
judgment and not being "forward thinking."
VT, Todd Mandell:
Per Tom Payte:
While doses in the 80 to 120 mg range are effective for a majority of patients, the actual range of
individual adequate doses ranges from as little as 10 mg daily to, in rare cases, up to 500 mg, or more.
September 12, 2003
I start raising an eye brow if too many folks are on doses >180mg.
What is the prevalence of patients getting a split dose?
CA, Cathy Sorenson:
The California Department of Alcohol and Drug Programs does not keep records on the number of split
dose patients. California regulations allow split dosing when the patient would benefit, as determined
by the medical director or program physician, from receiving his or her medication in two doses, with
one portion dispensed as a take-home dose.
FL, Darran Duchene responds:
Our experience is very similar to New York’s (35 requests for split doses), with a slightly smaller number
of split dosing requests per year out of 16,000 patients.
MA, Hilary Jacobs:
I agree with the comment below (there is no pre-determined high dose). That said, it makes sense to
pay attention to changes in practices and doctors who seem to be outliers. We have a similar situation
to Becky's in MA that concerns me with one OTP consistently prescribing doses in the 300-400 range
and lots of split dosing, with each split in the range of 100+ (mostly plus) mgs that appear outside of the
norm. I have strongly communicated my concerns about this situation after investigating and finding
many irregularities as to how these decisions were arrived at. For example, peak and trough levels are
not done on observed dosing, split dosing given for pregnant women is not changed anytime after
delivery, many patients with split doses got them when this physician came after years of stable dosing
in the clinic and no change in medical status or medications, etc. We have required that the current MD
review all doses above 250 and all split doses with a MD who is Board Certified in Addiction Medicine,
has expertise in opiate treatment, and works as a consultant for the Department.
In general, we get very few split dosing requests--when we do its usually for pregnant women or people
with medications that affect the absorption of methadone.
NH, Rosemary Shannon:
We have had relatively few requests for split dosing, mostly during the last trimester of a client's
pregnancy, and only a handful of other clients. The clinics do 'peak and trough' levels before requesting
a split dose.
NV, Pat Chambers:
As for split dosing, I only see one or two patients at each of Nevada’s 11 clinics that split dose daily and
only one clinic uses split dosing during the induction phases. All 11 clinics have policies on split dosing,
whether they choose to use it or not.
NY, Belinda Greenfield:
Split dosing requires state approval in both in our existing and our draft regulations so we do track the
#s – at least from those OTPs that seek our approval and don’t do it without such approval! In 2008, we
received 35 requests to approve split dosing – this would be out of our average utilization of 40K
patients. Relatively small # but like I said, 35 represents the # of exemption/approval requests
submitted.
RI, Becky Boss:
I very much agree with Cathy's response. Doses are not high or low - they should be considered as
adequate or not adequate to be effective.
That being said - and after reviewing other's responses, I must admit that I raised my eyebrow a few
years back when I started to get several split dose exception requests for doses in the 400-1000 (yes
1000)mg. range. It was one provider/medical director. Needless to say, I investigated these doses and
found that there was little, if any, real justification for doses to be at that level. And little, if any,
concern for diversion or potential cardiac complications. After bringing this specific Dr. up to the
Medical Review Board (for reasons that went beyond the doses) and continued record review for all split
doses and doses above 500mgs. - he is no longer employed by an OTP. But I did face significant criticism
(and a complaint to my Department Director) from this Dr. and some of his allies for questioning medical
judgment and not being "forward thinking."
It's hard to determine whether I have a high volume of split dose requests as it's all relative. I have to
say that it is less than 5% of the population and most requests are due to pregnancy or medical
conditions/medications that impact methadone metabolism.
VT, Peter Lee:
Vermont has low numbers of split doses-- mostly associated with pregnancy issues.