1. For Pain or Not for Pain: Methadone Madness
Maria Foy, PharmD, BCPS, CPE
Clinical Specialist Palliative Care
Abington Memorial Hospital

2. Objectives
Differentiate the use of methadone for pain vs. addiction management
Explain information needed to verify a methadone dose for addiction management

3. Methadone History
1939: developed in Germany to be used as an analgesic in WWII
1949: US obtained methadone from the manufacturing company following the war
Early 1960’s: heroin epidemic following WWII
1964: research project was conducted studying methadone for addiction treatment to try to combat the increase abuse of heroin

4. Patient Case:
LO is a 27 year old female who enters the emergency department. She is currently addicted to heroin and recently found out she was pregnant. Currently, patients cannot be admitted to an inpatient facility for heroin detoxification without a special license. Would you allow this patient to be admitted for detoxification in your institution?

5. Key Policy Elements
Define ordering and dispensing processes based on indication of use
Analgesia
Maintenance therapy for patients enrolled in an Outpatient Treatment Program (OTP)
Short term treatment of acute withdrawal in a current opioid abuser if admitted for an alternate medical diagnosis

6. Key Policy Elements
Restrict pain indication use to experts trained and experienced with analgesic use
Exception: Unrestricted ordering allowed for patients receiving methadone prior to admission

7. Key Policy Elements Assure compliance to regulatory agency standards
Drug Enforcement Agency (DEA)
Substance Abuse and Mental Health
Services Administration (SAMSHA)
Commonwealth of Pennsylvania

13. Monitoring Data Time frame: 6 months Total orders reviewed: 105
Clarifications: 11

14. 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 Published, April 2014: Key Recommendations
Patient Assessment:
Patient selection should be based on a thorough history, review of medical records and physical examination.
Use assessment results to stratify patients based on their risk for substance abuse, co-morbidities, and drug interactions.
Education and Counseling:
Counsel patients about potential risks and benefits prior to beginning therapy.
Advise patients to take methadone as prescribed and comply with follow up monitoring.
Notify caregivers about risks for respiratory depression.
Baseline Electrocardiograms:
Perform ECG exams prior to initiating methadone therapy due risk for QTc interval
prolongation.

15. Guidelines, cont. Alternative Medications:
Consider buprenorphine as an option for patients being treated for opioid addiction with risk factors for prolonged QTc intervals.
Low Beginning Dose:
Methadone treatment should be started at low doses (no more than mg daily) and titrated slowly.
Urine Drug Testing:
Urine drug testing should be performed before initiating therapy and at regular intervals for patients treated for opioid addiction.

16. Conclusions
Development of an institutional methadone policy and order set with decision support has promoted safe and effective use of methadone at our institution
Daily review of methadone orders by a pain specialist led to early identification of potential errors

17. References
Pasero C, McCaffrey M. Pain Assessment and Pharmacologic Management. St. Louis, Missouri. Elsevier
McPherson M. Demystifiying Opioid Conversion Calculations. Bethesda, MD. American Society of Health Systems Pharmacists
Federal Narcotic Addict Treatment Act of 1974 (P.L ) Title 21, Code of Federal Regulations, Section 1306 [39 FR 37986, October 25, 1974).
Chou R, Cruciani R, Fiellin D, et.al. 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. The Journal Of Pain (4):
Boutwell A, Rich J. Inpatient Management of the Active Heroin User. Resident and Staff Physician (3) 1-5