A 30-year-old heroin-dependent man is started on methadone maintenance therapy. After 2 weeks on a stable dose, he reports craving reduction but is discovered to have used heroin once. The urine toxicology confirms heroin use. According to opioid use disorder deaddiction principles, what is the CORRECT action?
- A Immediately discontinue methadone and refer for naltrexone
- B Continue methadone at the same dose and counsel without punitive measures ✓
- C Increase methadone dose and add urine monitoring
- D Switch to buprenorphine-naloxone
Explanation
Relapse during opioid agonist therapy (OAT) is not a treatment failure but part of the chronic relapsing nature of opioid use disorder. A single lapse should be addressed with non-punitive counselling, review of triggers, and reinforcement of harm reduction strategies—not abrupt cessation of methadone (which risks precipitated withdrawal and return to illicit use). Punitive discontinuation increases overdose risk. If dose is adequate and the patient is engaged, dose adjustment is not necessarily warranted for a single lapse; however, increased monitoring may be added. Switching to buprenorphine without a clear rationale is not evidence-based.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.