What is 'Safe titration'

[judith yates]

Hi rokki,
You say "Also,please remember that methadone content is twice the amount<I believe thats how it measures> in the UK then the forumla given here in the USA."

Is this right? Our normal mixture in the UK is 1mg in 1ml. The recommended usual maintenance dose range in our National Guidelines is 60mgs-120mgs.  The majority of my patients seem to settle somewhere between those figures.

 If they don't , I make it plain to them that they are welcome to progress gradually to whatever maintenance  dose makes them feel comfortable and well.. I explain I will need them to take it  by  "supervised consumption", until they are happy that they have settled on a stable dose (I explain that this is so that I can demonstrate to anyone who asks, that the whole dose is for their own consumption, and not for friends or relations)  . Above 120mgs I increase the dose by 10mgs daily, each week (ie 130mgs daily for a week, then 140mgs daily for a week) until they tell me enough is enough. I know people do take much larger doses in other places, but so far I have not come across anyone locally wanting more than 160mgs daily.


Most people do not want "too much" methadone, as they tell me it weighs them down. Some people do not even want "enough " methadone,for two main reasons:   either they are  frightenned of the difficulty of getting off it (i try to reassure them that, in my experience, if and when they are ready to come off it, it will be possible) or they want to be able to feel the Hit of the heroin they still think they will need or want to  take on top.

In my inner city practice there are only I would say only about 5% of patients who  want more than 120mgs of methadone daily.

I agree with the diabetes analogy. Patients with diabetes are also struggling with making big changes in their lifestyles and giving up things which trigger powerful cravings (eg chocolate and cream cakes) and arriving at a prescription that people are willing to take every day, and getting some kind of mutual understanding of what is going on in their lives, so that I am able to help, is often a process of gradual discussion and debate.

[judith yates]

PS. I am aware that this is a trans atlantic discussion.

Methadone prescribing in the UK has in recent years been increasingly offered by GPs, Family doctors, taking on this extra area of skill and responsibility. "Research" has shown that our treatment outcomes are comparible with those from more specialist clinics (I work in both settings) .

Many would say that most addiction problems (both alcohol and opiates and other problems) are best treated in primary care, where the person can be offered  all aspects of health care as well as access where needed to other members of the primary health care teams such as helath visitors, midwives adn community nurses.

However you will realise that this is a relatively recent area of expertise for many of these doctors, and prescribing at these higher levels (above the national guideline levels) should probably  be done only after discussion with local GPs whith a special interst (GPSWIs) or other more experenced doctors. Having said that I believe that if undertaken in the way I describe, it is a safe area of prescribing, given a level of training and experience,  and no more complex than others such as hypertension and diabetes which are habitually taken on by the same doctors.

[Rokki]

What I meant,Judith,by the different compound commont was I was under the impression that the strengh of methadone made here in US if half the strengh it is in the UK. It has something extra that the States dont 'use??? I wish I could think of the term I am looking for and am coming up with a big DOH 

   Yes the Uk has made big changes in how it prescribes methadone to patients. We can thank Advocates and those who did research to show that "Nothing Is One Size Fits All" . Bill and Alan have worked hard so patients are a part of their treatment plan and medical care. Hats off to everyone at the Alliance for hangin in there and not letting propaganda get ya down 

 Yes,a lot of patients are afraid to actually get to a theraputic dose for them. This comes from stigma and the way they have been treated in the past. Fear is something that every methadone patient lives with,No Matter where you get your meds. I still have dreams of being stranded someplace and not having my methadone and there has been an earthquake or something that shows some sort of devastation. In my work I have found that these dreams are very common amongst methadone patients,just like the fear we all expierence. When a patient has been compliant and goes to their counseling appointments on time and jumps thru all the hoops put in place by Governing Bodies at what point do they get to grow up and get their meds just like anyone else? Is it 2 yrs. Is it 5 yrs? Well I have ben on methadone for over 20 yrs now,and I realize I am not the norm however there are many patients just like myself. When I was still in the clinic system,the last program I was on was Dr John McCarthys in Sacramanto,Ca. The local program had me going every week to pick up my meds and the reg's state I should have 50 minutes each month of counseling. At what point do we get to be treated like a grown up? Yes,there will be many who will not try to let the meds work for them. Just as we are all individuals so should our medical treatment be. So for those who are not compliant they will stand in those lines each day to be watched as they ingest their meds. Thats just how it is. We can not all be judged by a non-compliant patient or a compliant patient.

I wish I could remember the term I am looking for concerning the difference between the compounds in the UK and here in States. I'll have to call Joyce and ask her 

   Thanks for your replies,Judith 

Love and Respect

Rokki