Methadone Safety

When considering initiation of methadone, the panel recommends that clinicians perform an individualized medical and behavioral risk evaluation to assess risks and benefits of methadone, given methadone’s specific pharmacologic properties and adverse effect profile. (L, S)

The panel recommends that clinicians educate and counsel patients prior to the first prescription of methadone about the indications for treatment and goals of therapy, availability of alternative therapies, and specific plans for monitoring therapy, adjusting doses, potential adverse effects associated with methadone, and methods for reducing the risk of potential adverse effects and managing them. (L, S)

The panel recommends that clinicians obtain an ECG prior to initiation of methadone in patients with risk factors for QTc interval prolongation, any prior ECG demonstrating a QTc >450 ms, or a history suggestive of prior ventricular arrhythmia. An ECG within the past 3 months with a QTc <450 ms in patients without new risk factors for QTc interval prolongation can be used for the baseline study. (L, S)

The panel recommends that clinicians consider obtaining an ECG prior to initiation of methadone in patients not known to be at higher risk for QTc interval prolongation; an ECG within the past year with a QTc <450 ms in patients without new risk factors for QTc interval prolongation can be used for the baseline study. (L, W)

The panel recommends against use of methadone in patients with a baseline QTc interval >500 ms. (L, S)

The panel recommends that clinicians consider alternate opioids in patients with a baseline QTc interval ≥450 ms but <500ms. If methadone is considered in a patient with a baseline QTc interval ≥450ms but <500ms, the clinician should evaluate for and correct reversible causes of QTc interval prolongation before initiating methadone. (L, W)

The panel recommends that clinicians consider buprenorphine as a treatment option for patients treated for opioid addiction who have risk factors for or known QTc interval prolongation when an agonist/partial agonist is indicated. (I, W)

The panel recommends that clinicians initiate methadone at low doses individualized based on the Chou et al. The Journal of Pain indication for treatment and prior opioid exposure status, titrate doses slowly, and monitor patients for sedation. (I, M)

The panel recommends that clinicians consider those patients previously prescribed methadone, but who have not currently taken opioids for 1 to 2 weeks, opioid-naÏve for the purpose of methadone reinitiation. (L, S)