Methadone & Suboxone

Question 1

Signs of opioid intoxication

Answer 1

-Pupillary constriction, drowsiness, slurred speech, impaired memory/attention
-Euphoria (initially) or dysphoria and apathy (subsequent)
-Impaired judgement and psychomotor retardation

Question 2

Signs of opioid withdrawal

Answer 2

symptoms develop within min-days
-dysphoria, yawning, insomnia
-n/v/d
-muscle aches
-runny nose/eyes
-pupillary dilation
-sweating, fever
COWS scale to assess severity
*pt must be in withdrawal COWS >13 before dosing suboxone otherwise it will precipitate withdrawal abrubtly

Question 3

Signs of opioid overdose

Answer 3

Shallow breathing RR<12bpm
constricted pupils
pale blue cold skin
blue fingernails
Naloxone single 4mg spray may repeat Q2-3min up to 5 doses

Question 4

What is the minimum amount of time between yesterday’s dose and today’s?

Answer 4

16h

Question 5

What is a normal dose titration for methadone?

Answer 5

Higher risk for methadone toxicity: 5-10 mg Every 3-5 days

Recent abstinence from opioids 5 mg or less Every 5 days or more

No risk factors or recent abstinence 10-15 mg Every 3-5 days

Question 6

How many consecutive missed doses before the prescription must be canceled?

Answer 6

3 for methadone (2 if in early stabilization phase ie first 2 weeks)
5 for suboxone

Question 7

Max dose of buprenorphine

Answer 7

24mg

Question 8

Half life of methadone and its significance

Answer 8

55h - risk of bioaccumulation causing insidious onset overdose

Question 9

Early signs of methadone toxicity

Answer 9

ataxia, slurred
speech, “nodding off,” and emotional lability

Question 10

Initial dose recommendations for methadone

Answer 10

Higher risk for methadone toxicity 20 mg or less

Recent abstinence from opioids 10 mg or less

No risk factors or recent abstinence 30 mg or less

Question 11

Risk factors for methadone toxicity

Answer 11

Recent benzodiazepine use
Use of other sedating drugs
Alcohol-dependent patients
Over 60 years old
Respiratory Illnesses
Taking drugs that inhibit methadone metabolism
Lower opioid tolerance
Decompensated hepatic disease
Recent discharge from inpatient rehabilitation facility
Recent incarceration

Question 12

Restarting methadone after missed doses

Answer 12

After
3 consecutive days missed, the dose should be decreased to 50% of the current dose or 30mg.
After 4 or more consecutive days missed, the dose should be decreased to 30 mg or less.

Question 13

ECG monitoring for methadone is recommended beyond what dose?

Answer 13

An ECG shall be done on patients whose dose is greater than150 mg and repeated for doses of 180-200 mg. Patients with known
risk factors for Torsades should have an ECG at a dose above 120 mg.

Question 14

What to ensure before dose increases of methadone?

Answer 14

Do not increase dose until 3
consecutive days at the same
dose