Safety of rapid inpatient methadone initiation protocol: A retrospective cohort study

Racha, Savitha; Patel, Sapan; Harfouch, Layal  T. Bou; Berger, Olivia; Buresh, Megan

doi:10.1016/j.josat.2023.209004

Cited by 6 publications

(8 citation statements)

References 16 publications

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“…Prior experiences or fear of precipitated withdrawal may lead some patients to delay or decline buprenorphine. Moreover, methadone initiation with traditional outpatient doses is often insufficient . In these circumstances, clinicians should consider novel dosing approaches (Figure 3) or other opioid agonist medications .…”

Section: Methodsmentioning

confidence: 99%

“…The traditional methadone initiation approach was developed decades ago in ambulatory settings and is often insufficient to manage severe withdrawal and craving from regular fentanyl use. Clinical experience and early evidence from hospital addiction consultation services has demonstrated that patients, especially those using fentanyl, can undergo more rapid dose titration while hospitalized . Clinicians should consider harms of untreated or undertreated OUD with potential harms of rapid methadone titration.…”

Section: Methodsmentioning

confidence: 99%

“…Moreover, methadone initiation with traditional outpatient doses is often insufficient. 58 In these circumstances, clinicians should consider novel dosing approaches (Figure 3) or other opioid agonist medications. 55 Clinicians can also use short-acting opioids safely, feasibly, and legally to treat withdrawal, 59 typically while titrating methadone or as a bridge to buprenorphine via low-dose 60,61 or traditional initiation.…”

Section: Opioid Withdrawalmentioning

confidence: 99%

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Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl

Englander,

Thakrar,

Bagley

et al. 2024

JAMA Intern Med

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ImportanceThe rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.ObservationsClinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl’s high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl’s unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians’ understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.Conclusions and RelevanceThe findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Opioid Withdrawalmentioning

confidence: 99%

See 1 more Smart Citation

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl

Englander,

Thakrar,

Bagley

et al. 2024

JAMA Intern Med

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“…Risk of overdose is highest in the first 2 weeks, frequently due to concurrent use of other depressants [20]. Outpatient protocols were developed in the prefentanyl era based on expert opinion, with conservative initial and subsequent doses to prevent overdose [21]. However, these guidelines lack flexibility for individual opioid tolerance, especially in the fentanyl era where effective maintenance doses far exceed previous experiences [22].…”

Section: Methadonementioning

confidence: 99%

“…For inpatient initiation, no specific titration guidelines exist. Multiple studies of nonpregnant patients suggest rapid inpatient initiation is well tolerated to successfully reach higher effective doses [21,22,24]. For patients initiating methadone treatment during pregnancy with confirmed fentanyl use, the authors offer a high-dose inpatient protocol that rapidly achieves doses of 100 mg or more within 4 days based on previously published reports and expert consensus (Table 1) [25,26].…”

Section: Methadonementioning

confidence: 99%

Pharmacotherapy for opioid use disorder in pregnancy

Trammel,

Whitley,

Kelly

2024

Current Opinion in Obstetrics &Amp; Gynecology

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Purpose of review Opioid use disorder (OUD) in pregnancy has significantly in the last decade, impacting 8.2 per 1000 deliveries. OUD carries significant risk of morbidity and mortality for both the birthing person and neonate, but outcomes for both are improved with opioid agonist treatment (OAT). Here, we describe the recommended forms of OAT in pregnancy, updates to the literature, and alternate OAT strategies, and share practical peripartum considerations for patients on OAT. Recent findings Recent studies comparing buprenorphine and methadone have reaffirmed previous findings that buprenorphine is associated with superior outcomes for the neonate, without clear differences in morbidity or mortality for the birthing person. Optimal initiation and dosing of OAT remains unclear, with several recent studies evaluating methods of initiation, as well as a potential role for higher and more rapid dosing in the fentanyl era. Alternative products such as buprenorphine-naloxone and extended-release buprenorphine are of significant research interest, though randomized prospective data are not yet available. Summary Buprenorphine and methadone are standard of care for treatment of OUD during pregnancy, and multiple patient factors impact the optimal choice. Insufficient data exist to recommend alternative agents as a primary strategy currently. All patients with OUD in pregnancy should be counseled regarding OAT. Video http://links.lww.com/COOG/A94

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Safety and Efficacy of Rapid Methadone Titration for Opioid Use Disorder in an Inpatient Setting: A Retrospective Cohort Study

Klaire,

Fairbairn,

Ryan

et al. 2023

J Addict Med

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Objectives Inpatient guidelines for methadone titration do not exist, whereas outpatient guidelines lack flexibility and do not consider individual opioid tolerance. The evaluation of rapid, adaptable titration protocols may allow more patient-centered and effective treatment for opioid use disorder in the fentanyl era. Methods This study performed a retrospective chart review of patients 18 years or older with opioid use disorder who were initiated on methadone at a single academic urban hospital using a rapid divided dose protocol between November 2019 and November 2020. The primary outcome was adverse events associated with methadone, specifically opioid toxicity or sedation requiring increased medical observation or intervention. The secondary outcome was total daily dose of methadone received on day 7 of titration. Results Ninety-eight patients were included for a total of 168 visits. Sixty-five (66%) were male, with a median age of 38 years (interquartile range, 31–42 years). Sedation occurred in 2 patients (1%), who required either naloxone administration or transfer to an intensive care unit for monitoring. Of the 135 visits where patients received at least 7 days of methadone, the mean dose on day 1 was 41 mg (SD, 9.6 mg) and on day 7 was 65 mg (SD, 20.9 mg). Conclusions In this inpatient cohort, rapid methadone titration was well tolerated and resulted in patients reaching higher doses of methadone than would be possible with a standard schedule, with few adverse events. Given the known effective dose range, this approach may result in shorter time to clinical stabilization and suggests that alternative methadone titration schedules may be safe and effective in appropriately selected patients.

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Safety of rapid inpatient methadone initiation protocol: A retrospective cohort study

Cited by 6 publications

References 16 publications

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl

Pharmacotherapy for opioid use disorder in pregnancy

Safety and Efficacy of Rapid Methadone Titration for Opioid Use Disorder in an Inpatient Setting: A Retrospective Cohort Study

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