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Issue 4 February 2003
A national newsletter on substance misuse management in primary care
Titration: can we make
it work in practice?
Authors: Mark Gabbay, Tom Carnwath, Chris Ford, Kim Wolff
Backround - Before the launch of the 1999 Clinical Practice - Many practitioners aim to increase doses,
few practitioners formally titrated methadone particularly for known, long-term, relatively high-dose
dose at treatment initiation. Many services, particularly users (1gram or more) quite rapidly, to stabilise between
those in general practice still find the titration procedure* 60-120 mg. The aim of higher doses is to limit illicit drug
outlined in the guidelines difficult to organise (*initial dose use once maintenance is established or prior to initiating
10-40 mg, daily review for first few days, maximum methadone detoxification treatment. For those with less
increments of 10mg per day and 30mg per week). We wish established histories or habits, a more cautious dose
to stimulate debate around this issue, in terms of the titration is usually advocated. We need to be confident
underlying evidence, resource implications, and relative though that the best available evidence supports pragmatic
impact compared to other harm and drug related death approaches to titration. An approach that compromises
reduction strategies. between available evidence and practical considerations is
Research findings -
Whilst the evidence is that
methadone overdoses commonly involve other drugs and/or A current common ‘compromise’ practice of starting at 20-
alcohol as well, methadone is potentially lethal to naive 30 mgs of methadone and reviewing later that day or later
adults users at doses over 20 mgs
2, 3
. Additionally it in the week aims to address dose stabilisation issues and the
usually takes 4-5 days for methadone tissue and plasma risk to naive users. However the scientific evidence would
levels to stabilise after dose commencement, though suggest that a series of further assessments should be
accumulation continues beyond this to reach a steady state by made within the first few days to judge the cumulative
10 days
4, 5
. A variety of factors can alter methadone dosing effects. Few general practices currently have the
plasma levels including gastric emptying, pregnancy and liver resources to arrange this, and implications include a
metabolism (affected by disease and drug interactions). restriction of dose initiation appointments to Mondays, a
These factors can increase the risk of overdose during the traditionally busy time, or only prescribing for patients once
early phases of treatment. The Australian National Drug stabilised elsewhere.
Strategy documents adopt approaches which reflect these
It is quite common and acknowledged that illicit drug use
(opiates) may continue during the early stages of
treatment. Facilitation of accurate assessment may rely on
patient co-operation in refraining from other illicit drugs.
Whilst a low starting dose may reduce the immediate risk of
continued overleaf
Alcohol - ideal clinical care for a community detox facility 3
GP views on treating drug users and the GP with
National RCGP Conference:
Special Clinical Interest 4 Management of Drug Users in Primary Care
Classics revisited - Street Drugs -
Primary care management of drug users:
The Facts Explained, The Myths Exploded 5
which way forward.
Paper review - Client regulated methadone dosing
and screening and brief intervention for alcohol use 5
Thursday 15 – Friday 16 May 2003
Relaunch of the drug strategy 5
Hilton Hotel, Sheffield.
Amphetamine 6 Cost: £295 for two-day conference – non residential.
Dr Fixit - Working on amphetamine 6/7
Dr Fixit - Pressure to prescribe 7
Bulletin Board for information, Hot topic on Section 8,
Tel: 020 8541 1399
and View Point on injecting paraphenalia 8 or fax: 020 8547 2300
or email
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