Synopsis
Use methadone or buprenorphine safely and collaboratively to reduce illicit opioid use, overdose and treatment dropout, with evidence-based induction, therapeutic dosing, supervision, monitoring, naloxone and continuity across care settings.
- Opioid substitution treatment is usually long-term treatment, not simply a bridge to detoxification; retention itself reduces exposure to illicit supply and mortality risk.
- Current DHSC guidance requires both oral methadone and buprenorphine to be available and usually offered as a shared choice with risks and benefits explained.
- Prefer buprenorphine when tolerance is low or uncertain, sedative use is concerning, important cardiac or respiratory disease exists, or supervised consumption is not feasible, while individual exceptions remain possible.
- Start buprenorphine only when objective opioid withdrawal is present to avoid precipitated withdrawal; current national guidance supports 4–8 mg on day 1 for most adults and reassessment the next day for up to a further 8 mg if required.
- Evidence-based therapeutic ranges are commonly methadone 60–120 mg once daily and buprenorphine 8–16 mg once daily, up to 32 mg, but the correct dose is the individual dose that suppresses withdrawal and non-prescribed opioid use without intoxication.
- A current methadone 1 mg/mL SmPC gives an initial oral dose of 10–20 mg once daily with cautious 10–20 mg daily increases; accumulation means every increment requires assessment and this product schedule is not automatic.
- Methadone supervision is usual at treatment start until stability; current guidance allows individualized early take-away or unsupervised buprenorphine when assessed benefits outweigh diversion and safety risks.
- Provide take-home naloxone, safe-storage advice and seamless prescribing across hospital, prison, pharmacy and community services; an administrative gap can be fatal.
Key red flags
Sedation, respiratory slowing or intoxication before observed consumption requires the dose to be withheld and urgently assessed rather than automatically administered.
Uncertain or low opioid tolerance, recent abstinence, missed doses or prison or hospital transition substantially increases induction and restart risk.
Concurrent alcohol, benzodiazepine, gabapentinoid or other sedative use raises fatal oversedation risk with both methadone and buprenorphine.
Syncope, palpitations, major QT prolongation, severe respiratory disease or important hepatic impairment requires specialist medicine review.
Pregnancy, acute pain, planned surgery, admission or release from custody needs rapid coordination to avoid an unintended prescription interruption or unsafe withdrawal.
Investigation priorities
Establish dependence, tolerance, current supply, route, last use, overdose and previous treatment.
Management branches
Opioid dependence is established and substitution treatment is clinically appropriate.
- Discuss methadone and buprenorphine effects, induction, supervision, interactions, prior experience and the person's goals.
- Prefer buprenorphine where low tolerance, sedatives, cardiac or respiratory disease or supervision barriers make its safety profile advantageous.
- Agree a rapid but adequately assessed start, naloxone supply, pharmacy arrangement and clear contact route for early problems.