Module 7: The maintenance phase of opioid agonist treatment Flashcards
maintenance phase – what is it?
stable on OAT – titration complete, most cravings gone, no withdrawal
OUD – relapse is expected….
- early in dose titration phase (initiation), but also any time
- brief or prolonged or episodic
considerations for prescribing carries (i.e. when to do it)
- UDT clear
- safe housing with locked storage
- clinical stable (OAT is therapeutic)
- understand risk of diversion
- signed carry agreement
bup/nlx – timeline for prescribing carries
no prescribed timeline
- initiation after stabilisation, and 1 clear week of UDS
- start with 1 carry per week
- increase by 1 carry each week while clear UDS
- to a max 13 carries
can give more carries for compassionate or if long-term stability reasons
when and how to reduce carries - bup/nlx
- reduce by 1 per week if positive UDT or other concerns
methadone – timeline for initiating carries
- initiate carries at 2 months stability + negative UDT (CAMH 2021) or 1 month (Selby 2022)
- increase carries by 1 per week every 2 weeks if stable + negative UDT
- max 6 carries per week
give more carries for compassionate use or long-term stability (up to 13)
SROM – initiating carries
only under exceptional circumstances (case-by-case, very stable or witnessed dosing is impediment)
iOAT – initiating carries
none
Should OAT dose be increased if cravings occur?
Not necessarily. OAT dose should primarily control withdrawal symptoms, but an increase can be tried if cravings are the only concern.
Cravings can occur because of HALT (hungry, angry, lonely, tired) and so should be addressed therapeutically (med increase won’t help)
What are the psychological reasons for cravings (hint: there is an acronym)
Cravings can occur because of HALT (hungry, angry, lonely, tired) and so should be addressed therapeutically (med increase won’t help)
bup/nlx - re-induction after prolonged missed days
|Missed days | Dose | Suggested adjustment | |---------------|-----------------------|-----------------------| | 6–7 days | > 8 mg/2 mg | Restart at 8 mg/2 mg | | > 7 days | > 8 mg/2 mg | Restart at 4 mg/1 mg |
| ≥ 6 days | 6 mg/1.5 mg–8 mg/2 mg | Restart at 4 mg/1 mg |
≥ 6 days | 2 mg/0.5 mg–4 mg/1 mg | No change |
bup/nlx – restarting after missed doses (general points)
during initiation: reassess immediately
during maintenance:
- up to 5 days, then no change
- 6+ days, then re-initiation based on dose
methadone – restarting after missed doses
if 1-2 days missed, no dose change
if 3-4 days missed, then:
- if 30mg: no change
- if 30-60mg: restart at 30mg
- if >60mg: restart at 1/2 previous dose, reassess daily, increase by 10mg/day max
if 5+ days missed, then re-initiation as per guidelines
SROM – restarting after missed doses
- 1 day missed: no change
- 2 days missed: 40% reduction
- 3 days missed: 60% reduction
- 4 days missed: 80% reduction or starting dose if higher
- 5+ days: restart at 60mg
iOAT – restart after missed doses
1 day: no chage
2 days: reduced dose
3 days: retitration
