Patient evaluation before starting MATOD

Consider indications for specialist advice on MATOD.

Before prescribing MATOD therapy, perform a thorough assessment of the patient’s general physical and mental health over a number of extended appointments.

Ask about use of medications that induce or inhibit hepatic cytochrome P450 enzymes; these metabolise buprenorphine and methadone, and dose adjustment may be required (particularly for methadone).

Assess liver function and test for viral hepatitis. For patients with liver impairment (eg Child–Pugh class B or C cirrhosis), lower starting doses, slower rates of dose adjustments and closer monitoring for sedation may be required to reduce risk of fatal overdose. Particularly for methadone, also consider these ‘start low, go slow’ measures if the patient has respiratory or central nervous system depression, or if they are using alcohol, benzodiazepines, gabapentinoids or other sedatives.

An electrocardiogram (ECG) is recommended before starting methadone for patients who are at increased risk of QTc prolongation; see Methadone for medication-assisted treatment of opioid dependence.