At a planned prescribing review, a patient who has received methadone 80 mg once daily for four weeks requests an increase to 100 mg. He reports

Question

At a planned prescribing review, a patient who has received methadone 80 mg once daily for four weeks requests an increase to 100 mg. He reports using heroin most evenings, particularly when he feels the methadone effect is wearing off. No further clinical assessment has yet been undertaken. Which is the most appropriate approach before deciding whether to increase the dose?

Accepted Answer

Review adherence and dose timing, withdrawal or intoxication, other opioid and sedative use, and overdose risk; use toxicology selectively if it would inform management.

Answer

Withhold any increase until an ECG is normal because moving from 80 mg to 100 mg/day mandates ECG monitoring even without additional QT-risk factors.

Answer

Require urine confirmation of recent heroin use before considering an increase because self-report cannot support optimisation or establish continuing opioid tolerance.

Answer

Interpret the continued heroin use as failure of methadone maintenance and reduce the dose while intensifying psychosocial and relapse-prevention interventions.

Answer

Treat the admitted heroin use as sufficient evidence of underdosing and increase directly to 100 mg because this remains within the usual therapeutic range.

Methadone Dose Increase Assessment — MRCPsych Paper B MCQ