Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration with the Heart Rhythm Society

Authors

Roger Chou, Oregon Health & Science UniversityFollow
Ricardo Cruciani, Beth Israel Medical Center
David A. Fiellin, Yale Center for Interdisciplinary Research on AIDS
Peggy Compton, UCLA School of Nursing
John Farrar, University of Pennsylvania
Mark C. Haigney, Uniformed Services University of the Health Sciences
Charles Inturrisi, Weill Cornell Medical College
John Knight, Children’s Hospital Boston
Shirley Otis-Green, City of Hope National Medical Center
Steven Marcus, School of Biomedical and Health Sciences, New Jersey Medical School, Rutgers University
Davendra Mehta, Departments of Medicine and Cardiology, Icahn School of Medicine at Mount Sinai
Marjorie Meyer, University of Vermont
Russell Portenoy, Beth Israel Medical Center
Seddon Savage, Dartmouth Medical School
Eric Strain, Johns Hopkins University School of Medicine
Sharon Walsh, College of Pharmacy, University of Kentucky College of Medicine
Lonnie Zeltzer, Mattel Children’s Hospital at UCLA

Date of this Version

2014

Citation

The Journal of Pain, Vol 15, No 4 (April), 2014: pp 321-337

Comments

This article is a U.S. government work, and is not subject to copyright in the United States.

Abstract

Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence. Perspective: This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.