Download Methadone Madness - Pennsylvania Society of Health

For Pain or Not for Pain:
Methadone Madness
Maria Foy, PharmD, BCPS, CPE
Clinical Specialist Palliative Care
Abington Memorial Hospital
[email protected]
Objectives
Differentiate the use of methadone
for pain vs. addiction management
Explain information needed to verify
a methadone dose for addiction
management
Methadone History
1939: developed in Germany to be used as an analgesic in
WWII
1949: US obtained methadone from the manufacturing
company following the war
Early 1960’s: heroin epidemic following WWII
1964: research project was conducted studying methadone
for addiction treatment to try to combat the increase abuse
of heroin
Patient Case:
LO is a 27 year old female who enters the emergency
department. She is currently addicted to heroin and
recently found out she was pregnant. Currently,
patients cannot be admitted to an inpatient facility for
heroin detoxification without a special license. Would
you allow this patient to be admitted for detoxification
in your institution?
Key Policy Elements
Define ordering and dispensing processes based
on indication of use
• Analgesia
• Maintenance therapy for patients enrolled
in an Outpatient Treatment Program
(OTP)
• Short term treatment of acute withdrawal
in a current opioid abuser if admitted for
an alternate medical diagnosis
Key Policy Elements
Restrict pain indication use to experts trained
and experienced with analgesic use
• Exception: Unrestricted ordering allowed
for patients receiving methadone prior to
admission
Key Policy Elements
Assure compliance to regulatory agency
standards
• Drug Enforcement Agency (DEA)
• Substance Abuse and Mental Health
• Services Administration (SAMSHA)
• Commonwealth of Pennsylvania
Monitoring Data
Time frame: 6 months
Total orders reviewed: 105
Clarifications: 11
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
Published, April 2014: Key Recommendations
Patient Assessment:
•
Patient selection should be based on a thorough history, review of medical records
and physical examination.
•
Use assessment results to stratify patients based on their risk for substance abuse,
co-morbidities, and drug interactions.
Education and Counseling:
•
Counsel patients about potential risks and benefits prior to beginning therapy.
•
Advise patients to take methadone as prescribed and comply with follow up monitoring.
•
Notify caregivers about risks for respiratory depression.
Baseline Electrocardiograms:
•
Perform ECG exams prior to initiating methadone therapy due risk for QTc interval
prolongation.
Guidelines, cont.
Alternative Medications:
•
Consider buprenorphine as an option for patients being treated for
opioid addiction with risk factors for prolonged QTc intervals.
Low Beginning Dose:
•
Methadone treatment should be started at low doses (no more than
30-40 mg daily) and titrated slowly.
Urine Drug Testing:
•
Urine drug testing should be performed before initiating therapy and
at regular intervals for patients treated for opioid addiction.
Conclusions

Development of an institutional methadone policy and
order set with decision support has promoted safe and
effective use of methadone at our institution

Daily review of methadone orders by a pain specialist led
to early identification of potential errors
References
•
Pasero C, McCaffrey M. Pain Assessment and Pharmacologic Management. St.
Louis, Missouri. Elsevier. 2011. 339-349
•
McPherson M. Demystifiying Opioid Conversion Calculations. Bethesda, MD.
American Society of Health Systems Pharmacists. 2010. 137-143
•
Federal Narcotic Addict Treatment Act of 1974 (P.L. 93-281) Title 21, Code of
Federal Regulations, Section 1306 [39 FR 37986, October 25, 1974).
•
Chou R, Cruciani R, Fiellin D, 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. 2014. 15(4): 321-337
•
Boutwell A, Rich J. Inpatient Management of the Active Heroin User. Resident
and Staff Physician. 2007. 53(3) 1-5