Iatrogenic Opiate Withdrawal in Pediatric Patients: Implementation of a Standardized Methadone Weaning Protocol and Withdrawal Assessment Tool

Abstract

Methadone is frequently used to prevent withdrawal symptoms secondary to intended therapeutic opiate exposure. Absence of a standardized dose weaning strategy potentially results in increased exposure to narcotics and/or withdrawal symptoms. We sought to quantify the effect of implementing a standardized methadone weaning protocol and withdrawal assessment tool on methadone exposure and opiate withdrawal in pediatric patients receiving 5 or more days of continuous morphine or fentanyl infusions. The preintervention phase included patients weaned off of opiate infusions before implementation of a standardized weaning protocol and withdrawal symptom scoring tool. Patients in the postintervention phase were started on a standardized methadone wean based on total duration and dose of continuous opiate infusion exposure in the 24 hours preceding methadone initiation. Patients received either a 5- or 10-day wean, with the total daily methadone dose reduced by 20% daily or every other day, respectively. Patients in the postintervention phase were monitored for withdrawal using the withdrawal assessment tool (WAT-1). Postintervention patients were compared to preintervention patients treated with methadone. Total methadone duration decreased significantly from a median of 17 (13-22 interquartile range [IQR]) to 5 (5-10 IQR) days ( P = .00001) after implementation of the methadone weaning protocol. Number of morphine boluses administered increased from a median of 3 (0-6 IQR) to 4 (0-5 IQR) doses per patient ( P = .45). Demographic data were similar between both groups. Patients in the postintervention phase had significant reductions in methadone exposure after implementation of a standardized methadone weaning protocol and assessment tool.

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].…”

“…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]. 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].…”

“…Interventions and comparators described were heterogeneous (Table 1) and may be broadly categorised in two main categories: multifaceted protocolised care targeting IWS (n = 8) as compared to usual practices [31,33,34,[36][37][38][39][40] or interventions focusing on individual aspects of IWS management (n = 5) [32,35,[41][42][43] (see Table 2 for a detailed description of interventions). Multifaceted protocolised care included more than one implementation component (e.g.…”

“…Individual interventions involved using a specific drug for IWS (clonidine or methadone) against placebo in two studies, both of which were conducted in adult patients [35,43]; or testing various dosages [42], routes of administration [32] or durations of tapering [41], in three studies, all of which were conducted in the paediatric/neonatal setting. Studies involving multifaceted protocolised care were all conducted in paediatric/neonatal populations [31,33,34,[36][37][38][39][40]. Task shift to nurses (n = 5) [31,34,36,38,40] or pharmacists (n = 3) [34,37,39] (vs physician-managed standard of care) was an element of most of these interventions.…”

“…Studies involving multifaceted protocolised care were all conducted in paediatric/neonatal populations [31,33,34,[36][37][38][39][40]. Task shift to nurses (n = 5) [31,34,36,38,40] or pharmacists (n = 3) [34,37,39] (vs physician-managed standard of care) was an element of most of these interventions. One study involved incorporation of the protocol's order sets in electronic health records [40].…”