A recording of this presentation is available HERE.
Deep gratitude for our two Addiction Medicine Fellows, Drs. Bianka Aguilar and Anna Bowen, for an important and concrete presentation this week on Methadone in Hospitalized patients. They will be back in the spring with another Addiction Medicine presentation!
Here are my favorite pearls:
1) Starting methadone in the hospital decreases self-directed (AMA) discharges (30% vs. 59.6%), reduces all-cause readmission rates (27% vs. 41%), and decreases risk of endocarditis, osteomyelitis, and septic arthritis. I was taught that we should be "cautious" in the hospital about starting methadone if there wasn't a long-term plan for follow-up, but this is no longer true. If a patient is motivated to start methadone and it is indicated, we should do it. There are many new algorithms that can cross taper people easily from methadone to buprenorphine IF they are unable to get methadone through an outpatient treatment center.
2) Fentanyl in our drug supply has changed the treatment of opioid use disorder (OUD). Recent studies are showing the methadone may be superior to buprenorphine in terms of treating OUD in fentanyl users. Methadone for OUD also appears to have higher retention rates.
3) Traditional methadone induction involved weeks of up titrating doses until methadone was at therapeutic levels; newer studies, particularly in the fentanyl era, have found that quick starts-- higher starting doses, 30-40mg on D#1, and quicker up-titrating, increasing by 10-15mg, per day is safe and effective.
4) While methadone is known to lengthen the QT interval, not everyone on methadone needs serial or even baseline EKG monitoring. Most guidelines recommend an EKG at initiation of methadone only for patients with other cardiac risk factors (e.g. known prolonged QT, CAD, CHF, etc.) AND once methadone doses near 100mg daily. This is a dose response side effect. We should remember to look at other medications that can also prolong QTc to see if those can be altered/discontinued. A QTc of >500 is not an absolute contraindication to treating with methadone, but the clinical scenario merits review (e.g. medication review)
4) Some people are "rapid metabolizers", meaning that single daily dose of methadone may be insufficient to help with cravings and treat their opiate use disorder. This is known to be true in pregnancy, but can also occur in some patients. Rapid metabolizing most often manifest as someone who appears appropriately treated by a certain methadone dose by 2-4 hours after their dose (maybe even a little sedated), but then 12 hours later is experiencing s/sx of withdrawal or cravings. We can potentially help their case to receive methadone BID by checking "peak" (2-4 hours after the dose) and "trough" (right BEFORE their dose) serum level of methadone.
Practical tips for methadone in hospitalized patients:
- Consult the addiction medicine fellows (on call schedule on Epic)
- Document a 1 year history of OUD
- Use the COWS score to monitor s/sx of withdrawal
- We have 2 Methadone clinics in Santa Rosa: DAAC and SRTP. When initiating methadone, contact one of these clinics ASAP to arrange intake.
- There is a federal 3 day exception for patients being discharged from the hospital, to whom we can prescribe methadone. Current local help is available via Creekside Pharmacy vs. SSRRH ER.
- Offer all patients naloxone on discharge.
- Use the California Bridge website for help, including guidelines and algorithms.
- Keep your eye out for newer studies showing quick start algorithms
Toronto Perinatal Addiction Medicine Team
No comments:
Post a Comment