Development and Implementation of a Pharmacist-Managed, Neonatal and Pediatric, Opioid-Weaning Protocol

Abstract

OBJECTIVES: To compare the length of wean and abstinence severity in neonatal and pediatric patients with neonatal abstinence syndrome or iatrogenic opioid dependence treated with a pharmacist-managed, methadone-based protocol compared with physician-managed patients treated with either methadone or dilute tincture of opium (DTO). METHODS: This was a prospective, single-centered, interventional evaluation of 54 pharmacist-managed patients versus 53 retrospective, physician-managed patients. Wean duration and severity of neonatal abstinence syndrome were compared between groups using the Student t test. RESULTS: Significantly shorter wean duration in in utero-exposed pharmacist-managed patients compared with patients on physician-managed DTO (11.7 days vs 24.2 days, p < 0.001), but not compared with patients on physician-managed methadone (11.7 days vs 47 days, p = 0.101). No statistically significant difference was seen in wean duration in iatrogenic-exposed pharmacist-managed patients compared with patients on either physician-managed DTO or methadone (8.69 days vs 14 days, p = 0.096) and (8.69 days vs 9.82 days, p = 0.34), respectively. There were significantly fewer abstinence scores >12 in pharmacist-managed patients versus physician-managed DTO, but not physician-managed methadone (2.05 vs 17.3, p = 0.008 and 2.05 vs 74.3, p = 0.119, respectively). Significantly fewer abstinence scores ≥8 × 3 consecutively were seen in pharmacist-managed patients compared with patients on either physician-managed DTO or methadone (2.89 vs 11.9, p = 0.01 and 2.89 vs 24, p < 0.001, respectively). CONCLUSIONS: Use of a pharmacist-managed, methadone-based weaning protocol standardizes patient care and has the potential to decrease abstinence severity and shorten duration of wean versus physician-managed patients exposed to opioids in utero. Additionally, a methadone wean of 10% to 20% per day was well tolerated in both neonatal and pediatric patients.

Shortened Taper Duration after Implementation of a Standardized Protocol for Iatrogenic Benzodiazepine and Opioid Withdrawal in Pediatric Patients: Results of a Cohort Study

“…Steineck et al 14 showed similar results in their study; a pharmacist-managed methadone taper reduced the average taper length from 24.7 days to 15 days. However, research by Johnson et al 17 did not find a difference in taper length between pharmacist-managed and physician-managed children with methadone use for iatrogenic opioid withdrawal, although pharmacist-managed patients had fewer elevated withdrawal scores. 17 Additionally, Abdouni et al 25 reported a reduction in methadone taper length from 15.3 days to 9.5 days with the use of a standardized withdrawal guideline, though this was not a pharmacist-managed protocol.…”

Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies

“…Of the 13 studies, 10 were NRSI [31][32][33][34][35][36][37][38][39][40], and 3 were randomised controlled trials (RCTs) [41][42][43] (Table 1). Nine studies were conducted in North American ICUs [31,33,34,[37][38][39][40][41][42] and 12 were single-centre studies [43].…”

“…Heterogeneity was found in the type of patients included (Table 1). Only two studies involved adult patients [35,43], while the rest involved neonatal and paediatric patients [31][32][33][34][36][37][38][39][40][41][42]. Nine studies included only patients at risk of IWS based on opioid and/or benzodiazepine exposure of at least 5 days in six studies [32,33,[40][41][42][43] and at least 7 days in three studies [31,37,38].…”

“…Nine studies included only patients at risk of IWS based on opioid and/or benzodiazepine exposure of at least 5 days in six studies [32,33,[40][41][42][43] and at least 7 days in three studies [31,37,38]. Other studies included patients based on previous experience of IWS [35,41], exposure to treatment for IWS [34,39], or use of mechanical ventilation for ≥ 24 h [36]. One of the studies included both patients at risk of IWS (pre-emptive enrolment) and patients experiencing IWS (rescue enrolment) [41].…”

“…One of the studies included both patients at risk of IWS (pre-emptive enrolment) and patients experiencing IWS (rescue enrolment) [41]. Another study included neonates with in-utero exposure to opioids, in addition to patients at risk for IWS [34].…”