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Late Stabilization & Maintenance Phase of Treatment • Challenges in stabilization • Management with higher doses • “Carries” Dose Adjustment • Usual dose is 80-120mg • Higher doses sometimes needed • Consider a trough blood level if dose is going higher than 120mg or if there is uncertainty about the clinical picture of withdrawal symptoms • Trough level - therapeutic range is 100400ng/ml Rapid Metabolisers • ‘I feel sleepy in the afternoon but I’m in withdrawal by nightime’ • Peak blood level drawn 4 hours after witnessed drink • Trough level drawn 24 hours after last dose • Peak:trough >than 2:1 • Dose may need to be split - twice daily dosing Management of High Doses • Risk of cardiac effects with doses higher than 140-150mg • Prolonged QT interval - risk of arrythmia • ECG should be done at this time & should be repeated with subsequent dose increases “Carries” • Take - home doses can be given when – At least 2 months in treatment – Clinical Stability is demonstrated – Client is able to store Methadone safely in a locked box Must consider patient safety & public safety when deciding to give carries Clinical Stability • This is more than just providing negative urine drug screens • Methadone dose is stable • Elimination of sustained problematic drug or alcohol use • Emotionally stable • Housing, employment or school &/or a stable support system • Adherence to the treatment agreement Schedule of increasing Carries • After the first 2 months in treatment carries can be increased by 1 additional take-home dose/month • Maximum of 6 carries/week - only 1 witnessed drink at the pharmacy per week Counseling • Once withdrawal symptoms have been controlled, clients can benefit from counseling • Residential or out-patient rehab programs, 1:1 counseling & 12 step support groups • Clients usually have multiple social & emotional issues to resolve