Optimal dosing

Most medications have recommended doses which will ensure that the medicine can be effective and used safely with minimum side effects. In the case of OST medications there are recommended optimal doses. However, this area has become contentious and drawn into a wider controversy around OST and specifically methadone prescribing (see OST).

The purpose of OST is to stop someone having to use street opiates because they are in withdrawal. One benefit of substitution with methadone is that methadone lasts at least 24 hours and so it can be consumed once a day and the person is then free to build a daily routine around other activity and not around avoiding withdrawal, seeking drugs and consuming drugs. To achieve this, a person must be on a dose that prevents any withdrawal symptoms for over 24 hours. For them this is a minimum optimal dose.

People have different optimal doses due to tolerance and how well their body metabolises substances (see tolerance). Unfortunately, a focus on the comparative size of doses has made this controversial in some instances. People who have been on suboptimal doses can view an increase in dose as a step back in their progress; people on higher doses than other people (because they experience withdrawal at a different dose) can view themselves as ‘more addicted’ than others. People in these situations need support and good quality information about their medication and may benefit from a wider conversation about the purpose of treatment and the potential role of other forms of substitution – diamorphine, methadone, buprenorphine should all be available – or the potential role of a reducing their prescription and detoxification.

One of the benefits of focussing on achieving an optimal dose that is defined as a dose that prevents any feeling of withdrawal until the next dose is consumed and prevents or greatly reduces ‘topping up’ with other drugs is that a patient can be experience these situations for themselves. This approach is far more person-centred than a fixation only on the size of the dose or prescribers naming a dose they are prepared to describe. A lot of unnecessary concern arises from a fixation on whether a dose is ‘high’ or ‘low’.