TABLE 1.

Methadone initiation and titration guideline for hospitalized patients with opioid withdrawal.

Day 1	Initiate methadone at 20–30 mg, unless there is concern for oversedation. Give up to 10 mg every 4 h as needed for opioid withdrawal or cravings. Traditionally, 40 mg has been the maximum total daily dose on Day 1; however, patients using fentanyl commonly need higher doses.
Day 2	Start with the total methadone dose you prescribed on Day 1 and give up to 10 mg every 4 h as needed for opioid withdrawal or cravings. Traditionally, 50 mg has been the maximum total daily dose on Day 2; however, patients using fentanyl commonly need higher doses.
Day 3	Start with the total methadone dose you prescribed on Day 2 and give up to 10 mg every 4 h as needed for opioid withdrawal or cravings. Traditionally, 60 mg has been the maximum total daily dose on Day 3; however, patients using fentanyl commonly need higher doses.
Day 4 and beyond	Start with the total methadone dose on Day 3. Uptitrate until patients reach 60 mg or stop at a lower dose based on relief of withdrawal, cravings, and patient preference. Traditionally, we have waited 72 h after reaching 60 mg/day to allow methadone to reach steady state. However, patients using fentanyl may need faster uptitration to effectively manage withdrawal and cravings.

Note: This table is adapted from OTP guidelines for OUD and opioid withdrawal management primarily developed for patients with pill- and heroin-based OUD.¹ Methadone titration guidelines are rapidly evolving due to increased opioid tolerance in patients who use potent opioids, including fentanyl.¹⁸ Many patients may need more rapid methadone titrations and/or additional opioid agonists to relieve opioid withdrawal. In these instances, hospitalists can involve an addiction consultant if possible. When patients have acute pain, consider splitting the methadone dose to leverage methadone’s analgesic effects. However, consolidate methadone prior to discharge as most patients cannot continue split dosing at an OTP.

Abbreviations: OTP, Opioid Treatment Program; OUD, opioid use disorder.