Description

EP 03

🎙 Special Series: ASAM's 57th Annual Conference

This episode is part of a special three-part series spotlighting key sessions from ASAM’s 57th Annual Conference.

 

In this episode of ASAM Practice Pearls, In this episode of ASAM Practice Pearls, Dr. Elizabeth Salisbury-Afshar is joined by Drs. Ruth Potee and Ari Kriegsman to explore highlights from their session, The Right Dose, Every Day. Together, they challenge the algorithmic, punitive approaches to methadone treatment, instead promoting individualized, patient-centered care. They share their clinical and philosophical approaches to methadone treatment, including split dosing, missed-dosing protocols, and expanded take-home medications, offering practical insights to help you advocate for your patients and collaborate across care settings.

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Host

Elizabeth Salisbury-Afshar, MD, MPH, FAAFP, FACPM, DFASAM

Dr. Elizabeth Salisbury-Afshar is a family medicine, public health and general preventive medicine, and addiction medicine physician. Her work focuses on expanding access to evidence-based addiction treatment and harm reduction services, and she has over 14 years of experience practicing in medically underserved settings. Dr. Salisbury-Afshar is a Professor at the University of Wisconsin-Madison where she works clinically on an inpatient addiction consult team and is the Medical Director of a low-barrier walk-in clinic for people who use substances. Dr. Salisbury-Afshar is the Vice Chair of ASAM’s Medical Education Council and the Vice Chair of the Conference Program Planning Committee.

Expert

Ruth Potee, MD, DFASAM, FAAFP

Dr. Ruth Potee is a board-certified Family Physician and Addiction Medicine physician who works across Massachusetts. She attended Wellesley College, Yale University School of Medicine, and did her residency at Boston University, where she remained an assistant professor of Family Medicine for eight years. She is currently the Medical Director for Behavioral Health Network and the Franklin County House of Corrections. She oversees 10 methadone clinics, including the first county jail-based methadone clinic in the United States. She was named Franklin County Doctor of the Year by the Massachusetts Medical Society in 2015 and has won multiple teaching awards from medical students and residents. 

Expert

Ari Kriegsman, MD, FASAM

Dr. Ari Kreigsman is the Medical Director of the Carlson Recovery Center, an ASAM 3.7 Level Facility in Springfield, MA. He is also the Medical Director of the BHN Springfield OTP. He is board-certified in Internal Medicine and Addiction Medicine. He is a graduate of Weill Cornell Medical College, and completed his residency in Social Internal Medicine at Montefiore/Albert Einstein College of Medicine. 

📖 Show Segments

• 00:05 - Introduction 
• 02:30 - Philosophy of Methadone Treatment 
• 06:42 - Training Gaps & Need for Individualized Clinical Decision-Making
• 08:29 - Caring for Patients with Unique Clinical Needs
• 10:13 - Rethinking Missed Dose Protocols
• 14:58 - Split Dosing Considerations
• 17:04 - Take-Home Medications
• 22:21 - Practice Pearls
• 25:36 - Conclusion and Additional Learning Opportunity 

📋 Key Takeaways

• Patients choosing methadone choose life: Orient care around the patient's own goals, which is often staying alive and getting their life back. Clinical decisions should align with the patient’s goals and be tailored to each individual.
• Promote individualized dosing over rigid protocols: Clinicians should feel empowered to use clinical judgment for methadone dosing. There is no single protocol, and each patient's history, comorbidities, pain, and life circumstances should guide the dosing plan.
• Non-punitive missed dose approaches are safe and evidence-based: In most cases, patients who miss doses and continue using opioids can safely resume their previous (or nearly previous) methadone dose. Steep dose reductions can increase the patient's risk of overdose or worsen their substance use disorder.
• Split dosing is underused and often essential: Pregnant patients, those with chronic pain, shift workers, and anyone experiencing side effects at peak dosing are strong candidates for split doses.
• Take-home medications should be the default, not the reward: No other medication requires a patient to travel daily just to receive it. Methadone take-home medication should be treated as a right unless there's a specific safety concern that outweighs the benefits.
• Break down the silos between OTPs and the broader healthcare system: All providers, including hospital and ER clinicians, should familiarize themselves with their local OTP medical directors, establish warm handoff relationships, and feel confident advocating for patients, including requesting that aggressive induction doses or split doses be continued upon transfer to an OTP.

🔗 Resources

• The Right Dose Every Time Annual Conference Session: Register HERE
• ASAM 55th Annual Conference Session: Clinicians Advocating for Methadone Reform: Community Engagement and Empowerment
• 8.12 Federal Opioid Use Disorder Treatment Standards: 42 CFR 8.12
• Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation - Gomes T, Campbell TJ, Kitchen SA, et al. JAMA. 2022;327(9):846-855. doi:10.1001/jama.2022.1271
• Evaluation of a Novel Patient-Centered Methadone Restart Protocol - Christine PJ, Blum J, Tillman AR, et al. JAMA Netw Open. 2025;8(8):e2529393. Published 2025 Aug 1. doi:10.1001/jamanetworkopen.2025.29393
• Individualizing Methadone Treatment with Split Dosing: An Underutilized Tool - Braun HM, Potee RA. J Subst Use Addict Treat. 2023;152:209096. doi:10.1016/j.josat.2023.209096
• Treatment Retention, Return to Use, and Recovery Support Following COVID-19 Relaxation of Methadone Take-Home Dosing in Two Rural Opioid Treatment Programs: A Mixed Methods Analysis - Hoffman KA, Foot C, Levander XA, et al. J Subst Abuse Treat. 2022;141:108801. doi:10.1016/j.jsat.2022.108801

📢 Join the Discussion

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In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.