The use of plasma levels to optimize methadone maintenance treatment

The question of the optimal methadone dose during maintenance therapy is controversial. For both philosophical and practical reasons, therapeutic drug monitoring has not been generally used. Some therapists prescribe low doses of methadone more for psychological than pharmacological reasons. This study examines, in 104 methadone patients, the relation between self-rating, observer-rating, urine tests, HIV-1 sero-status, daily methadone doses and plasma levels of methadone. No differences were found between HIV-1 infected and seronegative patients in these respects. The optimal methadone plasma level as judged by self- and observer-rating was more than 150 ng/ml. For oral methadone, the best results are obtained in patients receiving more than 90 mg daily. We found a significant relationship between methadone dose and plasma levels, also in patients who also used illicit drugs. We conclude that therapeutic drug monitoring should become routine in methadone treatment to achieve optimum results, especially in patients who complain of withdrawal symptoms and continue high-risk behaviour.