Safety of Rapid Inpatient Methadone Initiation Protocol: A Retrospective Cohort Study

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.

Section: Discussionmentioning

confidence: 99%

“…Multiple titration protocols that increase the frequency or quantity of doses have been suggested 12–14 . To date, formal evaluation of these strategies remains limited, with this study building on a case report that presents the rationale for such a dosing approach 15 …”

Section: Discussionmentioning

confidence: 99%

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

“…Traditional inpatient methadone initiation protocols do not exceed 40 mg methadone on day 1, 50 mg methadone on day 2, and 60 mg methadone on days 3-6. [7][8][9][10] This shortens the time to reach an effective dose compared with the OTP setting, but may still be inadequate to control withdrawals and cravings, which can lead to higher rates of patient directed discharge.…”

mentioning

confidence: 99%

“…Currently, there is little empiric evidence to guide addiction medicine providers. 8,9,11 Our interprofessional addiction medicine consult service, 12 the Improving Addiction Care Team (IMPACT), 5 developed a rapid methadone initiation protocol based on previously described rapid methadone protocols from St. Paul Hospital in British Columbia and case reports. 9,13 This report describes our experience during the first 9 months following protocol implementation.…”

mentioning

confidence: 99%

Piloting a Hospital-Based Rapid Methadone Initiation Protocol for Fentanyl

Liu,

Chan,

Sokolski

et al. 2024

Objectives Treating acute opioid withdrawal and offering medications for opioid use disorder (OUD) is critical. Hospitalization offers a unique opportunity to rapidly initiate methadone for OUD; however, little clinical guidance exists. This report describes our experience during the first 9 months following introduction of a hospital-based rapid methadone initiation protocol. Methods We conducted a retrospective chart review of hospitalized patients with OUD seen by our interprofessional addiction medicine consult service at an urban academic center between December 2022 and August 2023. We identified patients who initiated methadone using the rapid methadone initiation protocol, which includes dose recommendations (maximum 60 mg day 1, 70 mg day 2, 80 mg day 3, 100 mg days 4–7) and strict inclusion and exclusion criteria (end organ failure, arrhythmia, concurrent benzodiazepine or alcohol use, age >65). Results There were 171 patients that received methadone for OUD during the study period. Of those, 25 patients (15%) received rapid methadone initiation. The average total daily dose of methadone on days 1–7 was 53.0 mg, 69.2 mg, 75.4 mg, 79.5 mg, 87.1 mg, 92.2 mg, and 96.6 mg, respectively. There were no adverse events requiring holding a dose of scheduled methadone, naloxone administration, or transfer to higher level of care. Conclusions A rapid methadone initiation protocol for OUD can be implemented in the inpatient setting. Patients up-titrated their methadone doses quicker than with traditional induction methods, and there were no serious adverse events. Appropriate patient selection may be important to avoid harms.

“…Initiating methadone and titrating it to an effective dose on an outpatient basis can take several weeks. Alternatively, rapid methadone initiation conducted in an acute inpatient setting can help people safely reach a stable dose in a matter of days, which may increase the likelihood of successful methadone initiation in the era of more potent opioids like fentanyl 10 or in populations for whom time is of the essence like pregnancy 11 . The hospital stay also allows for coordination of postdischarge care.…”

mentioning

confidence: 99%

Maternal Perspective of Inpatient Methadone Initiation: Opportunities to Increase Retention in Treatment

Gannon,

Hand,

Short

et al. 2023

Objectives Recent trends demonstrate increases in the rates of opioid use among pregnant and parenting women. Treatment for pregnant people with opioid use disorder (OUD) includes medications for OUD, like methadone, as well as comprehensive support services. Still, inpatient treatment engagement is suboptimal and treatment drop out is common. There is little research examining the maternal perspective of the inpatient methadone initiation experience. The primary aim of this qualitative methods study was to explore patient experience and perspective of the inpatient methadone initiation period. Methods All participants were recruited from a single urban university affiliated hospital and OUD treatment program. Data were collected from 30 maternal participants in OUD treatment about their inpatient methadone initiation experience while pregnant using semistructured interviews. Thematic analyses were conducted using an inductive approach after an iterative process of code development and application among a multidisciplinary team of 3 coders. Validity was accounted for through 2 participant feedback interviews and study team review and discussion of findings. Results Four themes emerged from the maternal interview data: (1) Barriers to Inpatient Methadone Initiation, (2) Facilitators to Inpatient Methadone Initiation, (3) Transition From Hospital Inpatient to Outpatient or Residential OUD Treatment Services, and (4) Opportunities for Enhanced Clinical Support. Conclusion Maternal participants reported multiple barriers and facilitators to inpatient care during methadone initiation, highlighting opportunities for improvement to effectively engage pregnant individuals in treatment.