An opioid-naive patient with heroin use disorder is started on methadone maintenance. According to standard induction guidelines, what is the maximum recommended total methadone dose on the first day?
- A 10 mg
- B 20 mg
- C 30 mg ✓
- D 60 mg
Correct answer: C. 30 mg
Explanation
Because methadone has a long and variable half-life of 24 to 36 hours with delayed peak respiratory depression, conservative induction is mandatory. Standard guidelines recommend an initial dose of 10 to 20 mg with a maximum first-day total of 30 mg, since deaths during induction occur from accumulation rather than the initial dose. Doses above this in opioid-naive patients risk fatal respiratory depression before tolerance develops. Higher maintenance doses such as 60 to 100 mg are reached only gradually over subsequent days.
Reference: Substance Abuse and Mental Health Services Administration, TIP 63, 2018 revision ed.
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