What actually happens in your first week on methadone

Most written information about methadone describes how it works pharmacologically. Very little of it describes what the week feels like. That gap matters, because the most common reason people leave methadone treatment is not side effects or cost. It is quitting in the first ten days, convinced the medication is not working, when in fact it is working exactly as designed.

Day one

Your first appointment takes longer than you expect, usually ninety minutes or more. There is a history to take, a physical assessment, a urine drug screen and a conversation about which pharmacy you want to use. Bring identification if you have it, and come anyway if you do not.

Your first dose is deliberately low. Most people start somewhere in the range of ten to thirty milligrams, and if you have been using large amounts of fentanyl that number will sound absurd. Here is why it is not.

Methadone has a long half life, which means it accumulates. The dose you take on Monday is still in your system on Thursday, adding to Tuesday and Wednesday doses. A dose that feels inadequate on day one can become dangerous by day four if it was set to feel adequate immediately. Every death in early methadone treatment comes from starting too high or going up too fast. So we start low, and we tell you in advance that it will feel low.

That first dose usually takes the edge off within two to four hours. It will not hold you for a full day. Expect to feel some withdrawal by evening.

Days two and three

This is the hard part, and it is where most people give up.

You are attending the pharmacy daily for witnessed dosing. The dose is still building. You are probably still in some withdrawal for part of each day: restless legs at night, poor sleep, sweating, stomach trouble, and a low flat mood that is harder to describe than the physical symptoms and often worse.

Day three is commonly the low point. Enough time has passed that the initial relief has worn off, but not enough for accumulation to have done its work. If you are also cutting down on other substances at the same time, it compounds.

What we want you to know before you get there is that this is expected. It is not evidence that methadone does not work for you, that your dose is wrong for good, or that you have failed. It is the shape of the first week for almost everybody.

The rest of the first week

By days four and five, most people notice that the gaps are shortening. The dose holds a little longer. Sleep improves before mood does, which can be disorienting, since you may find yourself sleeping properly for the first time in months while still feeling emotionally flat.

You will normally be reviewed around the end of the first week. The question we are asking is not whether you feel good. It is how many hours each dose holds you before withdrawal starts creeping back. If a dose covers you for sixteen hours, we need to go up. If it covers twenty four but leaves you sedated, we need to look at that too.

Increases are usually small, commonly five to ten milligrams at a time, with several days between changes. Reaching a dose that holds you comfortably for a full day typically takes two to four weeks in total.

What helps during the first week

• Clear your schedule where you can. Treat this like recovering from an operation. If you can avoid a job interview or a court date in week one, do.
• Ask about symptom medication. There are effective treatments for nausea, cramps, diarrhoea and sleeplessness during induction. Many people endure these unnecessarily because nobody mentioned they could be treated.
• Eat and drink something, even without appetite. Dehydration makes every withdrawal symptom worse and is easy to overlook.
• Have naloxone in the house. The first two weeks carry the highest risk, particularly if you use on top. This is precaution, not pessimism.
• Tell one person what you are doing. Day three is much harder alone.

When to call us rather than wait

Some things should not wait for your next scheduled appointment. Contact us the same day if you feel drowsy or find yourself nodding off after a dose, if you are still in significant withdrawal more than twelve hours after dosing, if you have missed two or more doses, or if you have been prescribed a new medication by anyone else.

That last one catches people out. Methadone interacts with a long list of common medications, including some antibiotics and antidepressants. A prescription from a walk in clinic that nobody connected to your methadone is a genuine risk.

If you are three days into treatment and thinking about stopping, please call us before you do. That conversation takes ten minutes and it changes outcomes more than almost anything else we do.