Active intoxication or unclear dependence: do not dose. Confirm dependence objectively and arrange safe monitoring before induction. Deaths cluster in the first 2 weeks of treatment.
Before starting
- Confirm opioid dependence: history, examination, and a urine drug screen (objective withdrawal, for example COWS, before buprenorphine)
- Pregnancy test, LFTs, and a blood-borne virus screen; offer hepatitis B vaccination
- Consider an ECG before higher-dose methadone (QT)
- Explain the risks, benefits and the plan
Consent and advice
- Driving and operating machinery
- Safe storage (lethal to children) and not sharing or diverting
- Interactions with alcohol, benzodiazepines and other sedatives
- What to do about missed doses (tolerance falls after a few days)
Assessment
- Confirm dependence (history, tests)
- Discuss options and goals
- Baseline ECG if methadone risk
Induction
- Methadone 10 to 30 mg start, titrate
- Buprenorphine once in withdrawal
- Supervised consumption
High-risk period
- First 2 weeks: overdose risk
- Lost tolerance after a break
- Involve family, provide naloxone
Checklist
1
1. Diagnose
Establish physical dependence before prescribing; do not prescribe on history alone if uncertain.
Establish physical dependence before prescribing; do not prescribe on history alone if uncertain.
↓
2
2. Plan the dose
Use national and local induction tables: a low, cautious starting dose with review before increases.
Use national and local induction tables: a low, cautious starting dose with review before increases.
↓
3
3. Supervise
Daily supervised consumption initially; relax only as the person stabilises.
Daily supervised consumption initially; relax only as the person stabilises.
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4
4. Holistic care
Address mental health, housing, social needs and blood-borne virus care; provide take-home naloxone.
Address mental health, housing, social needs and blood-borne virus care; provide take-home naloxone.
Highest-risk period
- The first 2 weeks, especially with methadone accumulation
- Concurrent sedative use
- Lost tolerance after a recent break or release from custody
Pitfalls
- Dosing an intoxicated patient
- Starting without confirming dependence
- Rapid dose increases during induction
- No naloxone or safe-storage advice
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026