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Safe Methadone Induction and Stabilization: Report of an Expert Panel

Baxter, Louis E. Sr MD, FASAM; Campbell, Anthony DO, RPh; DeShields, Michael MD; Levounis, Petros MD, MS, FASAM; Martin, Judith A. MD; McNicholas, Laura MD, PhD; Payte, J. Thomas MD; Salsitz, Edwin A. MD, FASAM; Taylor, Trusandra MD, MPH; Wilford, Bonnie B. MS

doi: 10.1097/01.ADM.0000435321.39251.d7

Objectives: Methadone is a well-studied, safe, and effective medication when dispensed and consumed properly. However, a number of studies have identified elevated rates of overdose and death in patients being treated with methadone for either addiction or chronic pain. Among patients being treated with methadone in federally certified opioid treatment programs, deaths most often occur during the induction and stabilization phases of treatment. To address this issue, the federal Substance Abuse and Mental Health Services Administration invited the American Society of Addiction Medicine to convene an expert panel to develop a consensus statement on methadone induction and stabilization, with recommendations to reduce the risk of patient overdose or death related to methadone maintenance treatment of addiction.

Methods: A comprehensive literature search of English-language publications (1979-2011) was conducted via MEDLINE and EMBASE. Methadone Action Group members evaluated the resulting information and collaborated in formulating the consensus statement presented here, which subsequently was reviewed by more than 100 experts in the field.

Results: Published data indicate that deaths during methadone induction occur because the initial dose is too high, the dose is increased too rapidly, or the prescribed methadone interacts with another drug. Therefore, the Methadone Action Group has developed recommendations to help methadone providers avoid or minimize these risks.

Conclusions: Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.

From the Methadone Action Group (LEB), American Society of Addiction Medicine, Chevy Chase, MD; Professional Assistance Program of New Jersey (LEB) and University of Medicine and Dentistry of New Jersey (LEB), Princeton; US Public Health Service (AC), and Division of Pharmacologic Therapies (AC), Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD; Medical Affairs (MD), Camden County Health Service Center, Blackwood, NJ; Department of Psychiatry (PL), University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark; Community Behavioral Health Services (JAM) and Substance Abuse Services (JAM), Department of Public Health, City and County of San Francisco, CA; Department of Psychiatry (LM), University of Pennsylvania School of Medicine, Philadelphia; and Behavioral Health (LM), Philadelphia VA Medical Center, Philadelphia, PA; Colonial Management Group, LP (JTP), Wimberly, TX; Albert Einstein Medical Center (EAS) and Beth Israel Medical Center (EAS), New York, NY; JEVS Human Services (TT), Philadelphia, PA; and Center for Health Services and Outcomes Research (BBW), JBS International, Inc, Easton, MD.

Send correspondence and reprint requests to Bonnie B. Wilford, MS, Center for Health Services and Outcomes Research, JBS International, Inc, 210 Marlboro Ave, Ste 31, PMB 187, Easton, MD 21601. E-mail:

Supported by the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services. No funding was accepted from commercial sources. SAMHSA had no role in the data collection, analysis, or manuscript preparation.

All members of the Methadone Action Group had access to the data, participated in its interpretation, and approved the manuscript. The final draft of the consensus statement was reviewed and approved by the members of the Methadone Action Group and by ASAM's Board of Directors.

The views, opinions, and contents of this document are those of the ASAM Methadone Action Group and other referenced sources and do not necessarily reflect the views, opinions, or policies of SAMHSA or any other part of the US Department of Health and Human Services. The authors report no conflicts of interest.

This report is intended to enhance patient care, but it does not supplant clinical judgment. Therefore, the advice given here may not apply to all patients or clinical scenarios. No advice is an adequate substitute for the knowledge and skills of a physician who is engaged in developing a treatment regimen tailored to the needs of an individual patient. Members of the Methadone Action Group recognize that not all treatment providers will be able to conform to each of the strategies recommended here. Instead, physicians and other staff are encouraged to consider these conclusions and strategies to the extent they and their patients are able to do so. Nothing in this document is intended to create a legal standard of care for any physician or to interfere with his or her clinical judgment or practice of medicine.

Received March 06, 2011

Accepted August 30, 2013

© 2013 American Society of Addiction Medicine