Mental Health  |  OST Drug Issues Pathway - Method of Withdrawal

Mental Health

OST Drug Issues Pathway - Method of Withdrawal

There is no ideal method of withdrawal from methadone or buprenorphine/naloxone. It is important that any reduction plan is done in consultation with the client, GP and Addiction Liaison Clinician.  Possible approaches to withdrawal are:

1. Fixed
The rate of reduction of methadone or buprenorphine/naloxone is set by the GP in consultation with the patient and can only be altered by the GP. Recommended methadone reduction rate is 2.5mgs per script cycle. Some patients tolerate larger and faster initial reductions. Statistically the faster the reductions, the higher the rate of relapse as smaller reductions are better tolerated and momentum maintained.

2. Flexible
The rate of reduction of methadone or buprenorphine/naloxone is entirely within the control of the client.  The client and GP agree on a rate that is then added to the prescription, for example 1mg per week or 2mg per fortnight AT REQUEST.  It then allows the client to access a reduction from the pharmacy whenever they feel ready. These patient initiated dose changes may only be   reductions, any increase in dose must be renegotiated with the GP and a new prescription written.  The script must then be annotated with "adjust dose for reduction" to allow pharmacist to adjust the dose accordingly.

3. Blind
The patient has the option of requesting a blind reduction, to be arranged by the GP in consultation with the Addiction Liaison Clinician and Pharmacist and the script to be appropriately annotated by the GP. The details of the dose reductions and administration are arranged by the GP with the pharmacist.

Decisions must be made after assessment of the patient's needs and preferences, and in consultation with the patient.

Rate of withdrawal:

The following guidelines are recommended:

Current methadone or buprenorphine/naloxone dose/day

Weekly or fortnightly or monthly reduction

Above 50mg

5mg or less


2.5mg or less

Less than 30mg

1-2mg or less

The rate of withdrawal should be reviewed each time a patient is seen. If there is evidence that a patient's treatment outcomes are compromised by the rate of withdrawal, a slowing or cessation of the dose reduction, or even a temporary increase in the dose is recommended, rather than introducing ancillary medication.

Note:  Once down to 20mg per day or less, consider changing to the Biodone 2mg/ml substance to enable small reductions to be made more easily. The pharmacy will need to be notified in advance so that they can order this in.

If clients struggle with the reduction off lower doses of methadone, they could be offered a transfer to Buprenorphine/naloxone, as this might be better tolerated.

*See Section 3.9.1 Planned Withdrawal page 29 of  " New Zealand Practice Guidelines for Opioid Substitution Treatment 2014"

Last updated : Thursday, January 09, 2020
Next review date : Friday, January 08,2021

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