Methadone Safety

Publication Date: April 1, 2014

Recommendations

Initiation of Methadone

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

The panel recommends that for patients prescribed methadone, clinicians perform follow-up ECGs based on baseline ECG findings, methadone dose changes, and other risk factors for QTc interval prolongation. (L, S)
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The panel recommends that clinicians switch methadone-treated adults with a QTc interval ≥500 ms to an alternative opioid or immediately reduce the methadone dose. In all such cases, the panel recommends that clinicians evaluate and correct reversible causes of QTc interval prolongation and repeat the ECG after the methadone dose has been decreased. (L, S)
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The panel recommends that clinicians consider switching methadone-treated adults with a QTc interval ≥450 ms but <500 ms to an alternative opioid or reducing the methadone dose. In patients in whom there are barriers to switching to alternative opioids, or who experience decreased treatment effectiveness with methadone dose reductions, the panel recommends that clinicians discuss with patients the potential risks of continued methadone. In all cases, the panel recommends that clinicians evaluate and correct reversible causes of QTc interval prolongation, and repeat the ECG after the methadone dose has been decreased. (L, S)
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Monitoring for and Management of Adverse Events

The panel recommends face-to-face or phone assessment with patients to assess for adverse events within 3 to 5 days after initiating methadone, and within 3 to 5 days after each dose increase. (L, S)
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Urine Drug Testing

The panel recommends that clinicians obtain urine drug screens prior to initiating methadone and at regular intervals in patients prescribed methadone for opioid addiction. (L, S)
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The panel recommends that patients prescribed methadone for chronic pain who have risk factors for drug abuse undergo urine drug testing prior to initiating methadone and at regular intervals thereafter. It recommends that clinicians consider urine drug testing in all patients regardless of assessed risk status. (L, S)
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Methadone Use in Pregnancy

The panel recommends monitoring of neonates born to mothers receiving methadone for neonatal abstinence syndrome and treatment for neonatal abstinence syndrome when present. (I, S)
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Recommendation Grading

Disclaimer

Overview

Title

Methadone Safety

Publication Month/Year

April 1, 2014

Document Type

Guideline

Country of Publication

US

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Diseases/Conditions (MeSH)

D010146 - Pain

Source Citation

Roger C et al. Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society. The Journal of Pain, Vol 15, No 4 (April), 2014: pp 321-337.