Download ED Management of Opioid Use Disorders

ED Management of
Opioid Use Disorders
Educational Rounds for
ED Physicians
META:PHI 2015
About META:PHI
Mentoring, Education, and Clinical Tools for Addiction:
Primary Care–Hospital Integration
•
Goals:
– Promote evidence-based addiction medicine treatment
– Implement care pathways between the ED, hospital, WMS, primary care, and
rapid access addiction medicine clinics
•
Seven sites in Ontario are currently involved, with plans to expand the spread of
the project in the future
•
Funding and support provided by the Adopting Research to Improve Care (ARTIC)
program (Council of Academic Hospitals of Ontario & Health Quality Ontario)
https://www.porticonetwork.ca/web/meta-phi
META:PHI 2015
Baseline Survey
The baseline survey is anonymous and entirely optional. You may skip any
question that you do not wish to answer. We will not ask you for any
personal information.
Please tear off and keep the front page with contact information, should
you have any questions about the survey or the META:PHI project.
Please return the completed or incomplete survey face down to the
facilitator when you leave the presentation.
OVERVIEW
META:PHI 2015
Management Goals for
OUD Patients in the ED
1. Treat presenting problem (overdose, withdrawal,
infection, pain etc.).
2. Initiate bup/nx treatment in the ED when
appropriate
3. Prevent overdose through patient education and
naloxone
4. Provide rapid access
to an outpatient addiction
medicine clinic for long-term medication-assisted
treatment
META:PHI 2015
IDENTIFYING AND DIAGNOSING AN
OPIOID USE DISORDER
META:PHI 2015
Identifying & Diagnosing an OUD (1)
• Difficult to diagnose if patient doesn’t disclose
use
• Maintain high index of suspicion with risk factors:
– Younger, male, psychiatric comorbidity, concurrent
addiction to other drugs, on high prescribed opioid
doses
• Common presentations:
– Overdose, withdrawal, drug seeking, infections from
injection drug use, depression and suicidal ideation,
trauma
META:PHI 2015
Identifying & Diagnosing an OUD (2)
Indications of an OUD
1. Check for physical signs: track marks, pinpoint
pupils, slurred speech, nodding off (intoxication),
restlessness (withdrawal)
2. Check pharmacy dispensing record for patients
on Ontario Drug Benefits
3. Ask about opioid use and withdrawal symptoms
META:PHI 2015
TREATING OPIOID OVERDOSE
META:PHI 2015
Treating Opioid Overdose in the ED (1)
• Provide naloxone drip and respiratory support
• Monitor for at least six hours after respiratory
support discontinued
– Monitor patients for 10 hours if the patient has had a
methadone overdose
• Resume respiratory support and naloxone drip if
signs of toxicity return during the six- to ten-hour
interval
• Most sensitive indicator of toxicity: Slurred
speech or ‘nodding off’ while engaged in
conversation over several minutes
META:PHI 2015
Treating Opioid Overdose in the ED (2)
• Initiate bup/nx if the patient experiences
withdrawal (after naloxone is discontinued)
• Do not prescribe opioids during ED/hospital stay
• If the patient demands to leave while still
intoxicated and you feel they are at high risk for
overdose death or injury, inform them you will
complete a Form I
– Indicate on the Form I that the patient is suffering
from an opioid use disorder, which puts them at
imminent risk of self-harm
META:PHI 2015
OPIOID WITHDRAWAL
META:PHI 2015
Clinical Features of Opioid
Withdrawal
• Time course
Symptoms start six hours after last use of IR opioid, peak at 2-3
days, and begin to resolve by 5-7 days (psychological symptoms,
can last for weeks)
• Physical symptoms
Flu-like (myalgias, chills, nausea and vomiting, abdominal cramps,
diarrhea, rhinorrhea, lacrimation, piloerection)
• Psychological symptoms
Insomnia, extreme anxiety/irritability, dysphoria, drug craving
• Complications
Exacerbation of psychiatric conditions, suicide, overdose if opioids
taken after a period of abstinence, gastric or duodenal ulcer, acute
exacerbation of cardiorespiratory illnesses, miscarriage or
premature labour in pregnancy
META:PHI 2015
Treatment of withdrawal
1. Buprenorphine/naloxone (bup/nx)
2. Clonidine
META:PHI 2015
What is Buprenorphine/naloxone
(bup/nx)?
• Sublingual tablet, with long duration of action
• Partial opioid agonist with a ceiling effect
– Doses beyond 24 mg - 32 mg do not have any additional
opioid effects
– Therefore bup/nx is much less likely to cause overdose
than methadone or other potent opioids
• Binds very tightly to receptor
– Displaces other opioids
(displacement of fentanyl is
slower and less complete)
– Can precipitate withdrawal when
taken shortly after opioid use
META:PHI 2015
Opioids replaced and blocked by buprenorphine
(Image from naabt.org)
Bup/nx for the Treatment of
Withdrawal (1)
• To avoid precipitating withdrawal, don’t give bup/nx until
at least 12 hours have elapsed since last opioid use and
patient has withdrawal symptoms
• A score of 12 or more on the Clinical Opioid Withdrawal
Scale (COWS) indicates that it is safe to administer
bup/nx
• If the patient is not in withdrawal but will likely be in 2-3
hours, keep in ED until safe to give bup/nx
• If more than 2-3 hours before onset of withdrawal,
discharge and give referral card for RAAM
• Or send to WMS, with instructions to return to ED when
in withdrawal
META:PHI 2015
Clinical Opioid Withdrawal Scale
Interval
Date
Time
Resting heart rate (measure after lying or sitting for 1 minute)
0 HR 80 or below
1 HR 81-100
2 HR 101-120
4 HR greater than 120
Sweating (preceding 30 mins and not related to room temp /activity)
0 No report of chills/flushing
1 Subjective report of chills/flushing
2 Flushed or observable moistness on face
3 Beads of sweat on brow or face
4 Sweat streaming off face
Restlessness (observe during assessment)
0 Able to sit still
1 Reports difficulty sitting still but able to do so
3 Frequent shifting or extraneous movements
of legs/arm
5 Unable to sit still for more than a few seconds
Pupil size
0 Pupils pinned or normal size for room light
1 Pupils possibly larger than normal for room
light
2 Pupils moderately dilated
5 Pupils so dilated that only the rim of the iris is
visible
Bone or joint aches (not including existing joint aches)
0 Not present
1 Mild diffuse discomfort
2 Patient reports severe diffuse aching of
joints/muscles
4 Patient is rubbing joints / muscles plus unable
to sit still due to discomfort
META:PHI 2015
0
30m
2h
4h
Interval
Date
Time
Runny nose or tearing (not related to URTI or allergies)
0 Not present
1 Nasal stuffiness or unusually moist eyes
2 Nose running or tearing
4 Nose constantly running or tears streaming down
cheeks
GI upset (over last 30 minutes)
0 No GI symptoms
1 Stomach cramps
2 Nausea or loose stool
3 Vomiting or diarrhoea
5 Multiple episodes of vomiting or diarrhoea
Tremor
0 No tremor
1 Tremor can be felt, but not observed
2 Slight tremor observable
4 Gross tremor or muscle twitching
Yawning (observe during assessment)
0 No yawning
1 Yawning once or twice during
assessment
2 Yawning three or more times during assessment
4 Yawning several times/minute
Anxiety or irritability
0 None
1 Patient reports increasing irritability or
anxiousness
2 Patient obviously irritable or anxious
4 Patient so irritable or anxious that participation in
the assessment is difficult
Gooseflesh skin
0 Skin is smooth
3 Piloerection (goosebumps) of skin can
be felt or hair standing up on arms
5 Prominent piloerection
5-12 Mild withdrawal
13-24 Moderate withdrawal
25-36 Moderately severe withdrawal
> 36 Severe withdrawal
META:PHI 2015
TOTAL
INITIALS
0
30m
2h
4h
Bup/nx for the Treatment of
Withdrawal (2)
• Initial dose: 4 mg SL (takes several minutes to dissolve)
– Give only 2 mg SL if patient is elderly or on a high
benzodiazepine dose, or if you’re unsure if the patient is in
withdrawal
• Reassess in 1-2 hours
– If substantial improvement of withdrawal, give 2-4 mg SL
to take-home for later in day, plus an outpatient script
– If still in significant withdrawal, give another 4 mg SL in the
ED and reassess again in 1-2 hours
• Treatment complete when 4-12 mg have been
dispensed and withdrawal symptoms are minimal
META:PHI 2015
Outpatient Prescription
• Prescribe the total amount given in ED as a single dose, dispensed
daily under observation
• LU 437 or 438
– 437 – high risk for methadone toxicity (elderly, on benzodiazepines,
heavy drinker, non-daily opioid use or codeine use)
– 438 – no methadone prescriber in community or waiting list 3+
months
• Script should last until next RAAM clinic; advise patient to attend
clinic (give referral card) for additional bup/nx treatment
• Refer patient to WMS if: has transient housing, lack of social
supports, and/or at high risk for relapse
– Find out what pharmacy uses
– put pharmacy name on script and fax
– write note to WMS informing them of the bup/nx script and advising
them that patient should attend next RAAM clinic
META:PHI 2015
Sample bup/nx Prescription
Patient
Health card number
Date of birth
Pharmacy
Address
Fax number
Date:
Buprenorphine/naloxone 8/2 mg 1 tab SL OD
February 12 – February 16, 2018 inclusive
Dispense daily observed
LU 437/438
Physician signature
CPSO number
META:PHI 2015
Bup/nx use in Methadone Patients
• Bup/nx can trigger very severe withdrawal when
given to methadone patients, even if 72 hours or
more have elapsed since last methadone dose
• Therefore, give bup/nx only under supervision of
a methadone prescriber
• If methadone patient requires admission and has
no access to methadone, don’t use bup/nx; use
oral controlled-release morphine titrated to
relieve withdrawal symptoms
META:PHI 2015
Bup/nx Versus Methadone
Methadone
Bup/nx
Effectiveness as
maintenance treatment
Very effective
Effective but less than
methadone
Overdose risk
Very high
Low
Who can prescribe
Need a special licence
Any MD
Rx of acute withdrawal
Not safe or practical (takes
weeks to reach optimal
dose)
Very effective
Optimal dose reached
within 1-3 days
META:PHI 2015
CPSO Stance on Bup/Nx Prescribing
& Training
• Previously, the CPSO had a policy outlining expectations for
physicians who wished to prescribe buprenorphine
– This policy recommended advanced training and education in
order to prescribe the medication
• This has recently changed!
• The CPSO has maintained that physicians do not need a
methadone license to prescribe bup/nx and has removed
its recommendation that physicians have specialized
bup/nx prescribing training
– Recommendation has been replaced with a reminder that ‘as
with any drug the College expects that all physicians who wish
to use buprenorphine will have the requisite knowledge about
its intended impacts, side effects and role in addiction
treatment’
META:PHI 2015
Clonidine Treatment of Withdrawal
• Not as effective as bup/nx for symptom relief or
treatment retention
• Clonidine 0.1 mg PO qid PRN; increase to 0.2 mg if able
to check BP prior to dose (hold if BP < 90/60)
• Discharge home or WMS with prescription for 3-5 days
• Additional meds for symptom relief: anti-emetics, e.g.,
gravol; trazodone for sleep; Naprosyn for myalgias
• Warn patients that they are at high risk for overdose if
they relapse to usual opioid dose
• Refer to RAAM clinic (give referral card if available)
META:PHI 2015
DISCHARGING PATIENTS WITH AN
OPIOID USE DISORDER
META:PHI 2015
Advice on Discharge
• Advise patient that they have lost tolerance and
that they could overdose again if they use their
usual dose
• Inform patient of overdose prevention strategies
and provide with 1-2 vials of naloxone
• Refer the patient to the RAAM clinic (give referral
card)
• If bup/nx prescribed during ED visit, give bridging
script until patient can be seen at RAAM clinic
• Inform patient’s family doctor, especially if the
doctor has been prescribing opioids
META:PHI 2015
Case Scenario – Karen Part 1
Karen is a 30 year old woman who was brought
by her friends to the ED after an accidental
overdose after injecting fentanyl purchased from
a ‘friend’. She was given a naloxone drip and
respiratory support. These were discontinued a
half hour ago. Her O2 saturation is currently
normal. The physician is requesting that Karen
stay for several more hours of observation, but
Karen is very angry and wants to go home.
META:PHI 2015
Question
• What medical intervention would you do in
the ED prior to discharge?
META:PHI 2015
Medical Intervention
• Treat withdrawal with
buprenorphine/naloxone in the ED
• Start bup/nx when:
– Patient is not on naloxone
– Patient is in withdrawal
– 12 hours have passed since last fentanyl dose
META:PHI 2015
Case Scenario - Karen Part 2
Karen is feeling better after taking 8mg of
bup/nx . After six hours of observation she
shows no signs of opioid toxicity and is now
ready for discharge.
META:PHI 2015
Question
• What would be your discharge plan for Karen?
META:PHI 2015
Discharge Plan
- Provide bridging prescription for bup/nx until
patient can be seen at RAAM
- Provide RAAM referral
- Give advice on overdose prevention
- Provide patient with naloxone kit
META:PHI 2015
Who is at Risk for Opioid Overdose?
• Opioid-addicted patients who inject, smoke, or
snort opioids
• Recently abstinent opioid-addicted patients
– E.g., patients discharged from a treatment program,
withdrawal management, prison, or hospital
• Binge opioid users
• Patients on very high prescribed doses (eg > 400
mg MED)
• Patients who use opioids and also take
benzodiazepines or drink heavily
META:PHI 2015
Advice to Patients on
Preventing Overdose (1)
• If you relapse after being abstinent for a few
days or longer, you have lost tolerance and
could die if you take your usual dose.
• To avoid overdose:
– do not inject
– take a much smaller opioid dose than usual.
– Take a ‘test dose’ unless you got the drug directly
from a doctor’s prescription.
– Don’t mix opioids with alcohol/benzos.
– Always have a friend with you if you inject or snort
opioids.
META:PHI 2015
Advice to Patients on
Preventing Overdose (2)
• If one of your friends appears drowsy, has
slurred speech, or is “nodding off” after taking
opioids:
 Shake/talk to them to keep them awake.
 If they can’t be woken up, call 911 and start
chest compressions.
 Don’t let your friend ‘sleep it off,’ even if
someone watches them overnight.
META:PHI 2015
Advice to Patients on
Preventing Overdose (3)
• The best way to avoid an overdose is to get
treatment for your addiction. Please attend
the next rapid access addiction medicine
clinic.
 Give referral card and tell them when and where
the clinic is.
 Tell them that they don’t need an appointment;
they can just show up during clinic hours.
 Carry naloxone
META:PHI 2015
Distribute Take-Home Naloxone to
Patients at High Risk of Overdose
• Not on methadone or bup/nx, on these medications but
started in the past two weeks, or on these medications
but continuing to use substances
• On high dose opioids for chronic pain
• Treated for overdose (or reports a past overdose)
• Injects, crushes, smokes or snorts potent opioids
(fentanyl, morphine, hydromorphone, oxycodone)
• Buys methadone or other opioids from the street
• Recently discharged from an abstinence-based treatment
program, WMS, hospital, or prison
• Uses opioids with benzos and/or alcohol
META:PHI 2015
Contents of Naloxone Kit
– One to two naloxone vials
– Two syringes
– Alcohol wipes
– ID card explaining why
patient is carrying
medication and syringes
META:PHI 2015
Administering Naloxone
Instruct patient on naloxone use:
- Shake the overdose
victim, call their name
- If they cannot be fully
woken up, call 911
- Inject a full naloxone vial
into an arm or leg muscle
- Start chest compressions
- Inject another vial if they
don’t wake up in 3-4
minutes
META:PHI 2015
Outpatient Psychiatry Referral
• Refer patient to outpatient psychiatry if
patient:
 Has major symptoms of anxiety, depression, etc.
 Is not at imminent risk of self-harm
META:PHI 2015
MANAGEMENT OF COMMON
PRESENTING PROBLEMS OF OPIOID
USERS
META:PHI 2015
Infections: Outpatient Treatment
• Use oral antibiotics that cover staph and strep
– Avoid PIC lines if possible
• Ask about injection drug use and look for
indicators
• Offer bup/nx treatment and refer to RAAM clinic
(using ED referral card)
• If patient agrees to bup/nx treatment but is not in
withdrawal, refer to WMS with instructions to
send back to ED upon onset of withdrawal
• Offer advice on overdose prevention and give
naloxone if indicated
META:PHI 2015
Infections: Inpatient Treatment
• Ask for telephone or in-person consult
from RAAM physician
• Start bup/nx treatment ASAP
• Avoid PIC line if possible
• Refer to RAAM clinic on discharge
META:PHI 2015
Musculoskeletal Injuries and Trauma
• Most minor injuries (muscle strains,
contusions, etc.) do not require
opioids
• Combination of acetaminophen and
NSAIDs is at least as effective as
opioids and much safer
META:PHI 2015
Opioid Prescribing for Minor Injuries
*Protocol for ALL patients (not just opioid users)
• When opioids are indicated:
 Use IR low-dose opioids rather than high-dose CR
formulations
 Codeine preparations are effective for acute pain
 Prescribe for no more than 3-5 days
 Do not prescribe fentanyl for acute pain
 Do not prescribe benzodiazepines along with
opioids
 Warn patients not to drink heavily or take sedating
drugs when taking opioids
 Warn patients not to drive for two to three hours
after taking the opioid, for at least the first week
META:PHI 2015
Patients Admitted with Trauma
• Suspect opioid addiction if:
 Patient requests higher doses than
normally required for their degree of
injury
 Patient requests a specific opioid
 Patient demands dose immediately, uses
all PRNs
 Patient has risk factors for addiction
 Patient was on a high opioid dose prior to
admission
META:PHI 2015
Inpatient trauma patient and OUD
• If addiction is suspected yet opioids required:
 Avoid PCA pumps and high doses of short-acting
parenteral opioids
 Total daily dose will probably be higher than usual
 Breakthrough doses should be 10-30% of total daily
dose
 Contact patient’s family doctor for further information
 Ask for phone or in-person consult from RAAM physician
 Initiate bup/nx or methadone therapy if indicated
 Or refer to RAAM clinic on discharge
META:PHI 2015
Chronic Non-Cancer Pain:
Requests for Opioid Refills in the ED (1)
• If you do not suspect an OUD:
 Ask the patient the date and dose of last script
 Contact the patient’s pharmacy
 If history is consistent and sounds legitimate, and
you chose to write a script:
 write a note to the pharmacist: “Do not dispense if you
receive an alert from NMS [Narcotic Monitoring
System].”
 Inform the patient that this is a one-time-only
prescription, and document this in the chart
META:PHI 2015
Chronic Non-Cancer Pain:
Requests for Opioid Refills in the ED (2)
 Prescribe no more than 3-5 days
 Send a record of the visit to the family physician
 Prescribe a reasonable daily dose that you are
comfortable with
 No more than 120-200 mg MED regardless of patient’s
usual dose
 Prescribe no more than one patch of fentanyl even if
patient is prescribed more than that
• If OUD is suspected: Don’t prescribe opioids
META:PHI 2015
Morphine Equivalent Doses
Opioid
Equivalent oral dose
Morphine
30 mg
Hydromorphone
5 mg
Oxycodone
20 mg
Codeine
200 mg
Fentanyl
25 ucg = 60-100 mg morphine
META:PHI 2015
Drug Seeking by Patients with OUD
• Patients with OUD sometimes use the ED as a
source of opioids
• Can be difficult to diagnose
• Clinical features:
 Make aggressive demands for a specific opioid
 Not satisfied with non-opioid treatments
 Often return to the same ED with the same
presenting complaint
 Often on high prescribed doses yet runs out early
 Has risk factors for addiction
META:PHI 2015
Management of
Suspected Drug Seeking
• Contact the patient’s pharmacy
• Do not prescribe opioids
• Tell patient you suspect they may have an OUD, and
prescribing opioids will increase their risk of
overdose while worsening their pain and distress
• Inform patient that addiction is a treatable
condition
• If the patient is in withdrawal, prescribe bup/nx
• If patient is not yet in withdrawal, refer to WMS with
instructions to return to the ED when in withdrawal
• Refer them to the RAAM clinic
META:PHI 2015
Case Scenario – Christie Part 1
Christie is a 35 year old woman with neck pain
from a motor vehicle accident years ago. She is
on Hydromorph Contin 12 mg tid and
hydromorphone 8 mg 1-2 tabs qid PRN for
breakthrough. She reports that her prescription
ended and her family doctor is not available to
refill the prescription. She says she has not had
medication in two days and that she is in severe
pain.
META:PHI 2015
Question
• How would you manage Christie’s request?
– What further information would you want to
gather?
META:PHI 2015
Management Plan
• Check patient’s chart to see if she has
presented with similar requests previously
• Call pharmacy and verify amount and date of
last prescription
• Call physician in case they are available to
speak
META:PHI 2015
Case Scenario – Christie Part 2
You call the pharmacy and they inform you that
Christie received a prescription for 240
hydromorphone tabs and 90 Hydromorph
Contin tabs 2 weeks ago. You calculate that she
has run out 2 weeks early. You review the
hospital chart and note that she has made four
similar requests for hydromorphone in the last
six months.
META:PHI 2015
Question
• What is your diagnosis
• What is your management plan?
META:PHI 2015
Management Plan
Tell patient you suspect she is addicted to
hydromorphone and she needs treatment.
Tell patient you will not prescribe her
hydromorphone or Hydromorph Contin but can
offer bup/nx instead
META:PHI 2015
Case Scenario – Christie Part 3
Christie is reluctant to try bup/nx, citing fears
around: worsening pain if she stops her
prescription opioids, switching from one
addictive substance to another, and being
unable to attend the pharmacy everyday. She
wants to leave with her regular prescription.
META:PHI 2015
Question
• What would be your discharge plan for
Christie?
META:PHI 2015
Discharge Plan
a) Do not prescribe hydromorphone as this is
harming the patient
b) Provide bup/nx in the ED (patient has been off
hydromorphone for two days)
c) Give a prescription for a few days until patient
can be seen in the rapid access clinic
d) Emphasize to the patient that stopping
hydromorphone and starting bup/nx will
improve her pain, mood and function
e) Tell patient to discuss ‘carries’ and going to the
pharmacy every day with the RAAM physician
META:PHI 2015
Depression and Suicidal Ideation
• Regardless of whether patient sees psychiatry or
is admitted:
 Inform patient that opioid addiction treatment will
likely rapidly improve their mood and functioning
 Initiate bup/nx treatment if patient goes into withdrawal in
the ED or in hospital
 If patient agrees to bup/nx treatment but is not in
withdrawal, send to WMS with instructions to send back to
ED with onset of withdrawal
 On discharge, refer patient to RAAM clinic (give referral card)
and community addiction treatment with a bridging script
for bup/nx if started in the ED
META:PHI 2015
Urgent Psychiatry Referral
• Refer patient to psychiatry if patient:
 Has recently attempted suicide
 Refuses bup/nx treatment or remains severely
depressed despite bup/nx treatment
 Has major risk factors for suicide (e.g., recent loss,
has feasible suicide plan)
META:PHI 2015
MANAGING PAIN IN ED PATIENTS
ON METHADONE OR BUP/NX
META:PHI 2015
Addressing Misconceptions about Pain
Patients on Methadone or Bup/nx
• Stable doses of methadone or bup/nx do not
relieve acute pain
 Patients have developed tolerance to analgesic
effects of methadone or bup/nx
 Often require higher opioid doses to overcome
tolerance
• Treating acute pain will not trigger a relapse
• Patients on methadone or bup/nx who are in
acute pain are rarely drug-seeking
META:PHI 2015
Protocol for Acute Pain Management
• Maintain patient on their usual dose of
methadone or bup/nx
• Prescribe standard non-opioid analgesia
• Prescribe opioids if the patient’s pain
condition warrants it
• Start with usual dose for that pain condition
• Titrate rapidly if that dose is inadequate
META:PHI 2015
Discharge for Patients on Methadone
or Bup/nx
• Prescribe opioids as you would for other
patients (generally no more than 3-5 days)
• Have patient follow up with their methadone
or bup/nx prescriber and family physician
• Fax prescription to patient’s bup/nx or
methadone pharmacy with the request
“Dispense with bup/nx or methadone”
META:PHI 2015
PATIENTS ADMITTED TO HOSPITAL
ON METHADONE
META:PHI 2015
On Admission
• Only doctors with an exemption from the
CPSO to prescribe methadone can write
methadone orders for hospital inpatients
• Hospitals should identify methadone
prescribers on staff who can write these
orders
– Methadone is usually not initiated in hospital
whereas bup/nx can be safely initiated
META:PHI 2015
Protocol for Admitted Methadone
Patients
• Cancel patient’s methadone at outpatient pharmacy
• Ask pharmacy for dates methadone was dispensed in the
past week
• Lower dose if 72 hours or more have elapsed since last
dose
• If pharmacy or prescriber cannot be reached, give small
amount of methadone (e.g., 15 mg)
• If patient about to be admitted and methadone not
available:
 Prescribe oral controlled release morphine qid; initial daily dose
should probably not exceed 45 mg qid (180 mg)
 Do not co-prescribe benzodiazepines
 Titrate daily to relieve withdrawal symptoms; hold if drowsy
META:PHI 2015
Risk Factors for Methadone Toxicity in
Hospitalized Patients
• Prescribing benzodiazepines or atypical
antipsychotics
• Prescribing medications that inhibit
methadone metabolism (e.g., quinolone
antibiotics)
• Hepatic failure
• Renal failure
• Respiratory impairment
META:PHI 2015
Avoiding Methadone Toxicity
• Avoid or use low doses of benzodiazepines
and atypical antipsychotics
• Closely monitor patient daily for signs of
toxicity
• Observe patient for slurred speech or
‘nodding off’ while engaged in conversation
over several minutes
• Monitor QT interval
– High serum methadone concentration can cause QT
prolongation
META:PHI 2015
Management of Toxicity
• If signs of toxicity, hold methadone until clear,
then resume at a much lower dose
• Discontinue sedating drugs
• If rapidly developing hepatic, renal, or
respiratory failure, reduce dose even if no
obvious signs of toxicity
META:PHI 2015
ICU Patients on Methadone
• Intubated, obtunded patients will still go
through severe withdrawal if their methadone
is abruptly discontinued
• Provide regular doses of hydromorphone,
titrated to relieve agitation
• When patient is awake and alert, methadone
can be resumed (at a lower dose, via G tube)
META:PHI 2015