I would start off by saying that methadone definitely doesn’t have a sense of humor. I think as a practitioner, you have to not only understand the literature for methadone but also the limitations of what we know of methadone. It can be very unforgiving, and so really having a respect for those limitations when you’re dosing a patient can help push off some safety issues.
And then to further reduce their dose. It’s important to remember when using methadone to not dose adjust more than once a week. There are Department of Defense and Department of Veterans Affairs guidelines that talk about methadone Mondays, if you will, as an easy way to remember how frequently you should adjust the dose. We ask patients to keep a pain diary and to keep track of how much medication they’re using so we can re-evaluate that as clinicians and do the appropriate dose adjustment when we see them in the office. Also, don’t neglect patient and family education about keeping medication locked up and out of reach.