#1 Methadone for OUD w/Dr. Ruth Potee

July 7, 2022 | By Carolyn Chan

Find Your Rage

Supercharge your knowledge on using methadone for the treatment of opioid use disorder! We discuss treatment goals, and how to start or continue methadone in the hospital.  We’re joined by guest Dr Ruth Potee, addiction medicine physician, full-scope family medicine doc, feminist, and expert composter.  She inspires us to be strong advocates for our patients. 

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Credits

• Producer, Writer: Kenneth Morford, MD
• Show Notes, Infographic, Cover Art: Zina Huxley-Reicher, MD
• Hosts: Matthew Watto MD, FACP; Carolyn Chan, MD; Kenneth Morford, MD 
• Reviewer: Shawn Cohen MD
• Showrunner: Carolyn Chan, MD
• Technical Production: Castos
• Guest: Dr. Ruth Potee

Production Partner: ACAAM

The Curbsiders Addiction Medicine are proud to partner with  The American College of Addiction Medicine (ACAAM) to bring you this mini-series.  ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. 

Show Segments

• Intro, disclaimer, guest bio 0:46
• Guest one-liner 3:23
• Case from Kashlak 5:00
• Methadone for OUD 5:47
• Methadone Dosing 16:35
• 72 hour Rule 25:35
• What is a methadone clinic  31:00
• Methadone Checklist 35:44
• QTc Prolongation and Methadone 39:15
• Confirming Methadone Dose 43:17
• Managing Missed Methadone doses: 45:20
• Outro 50:40

Methadone for OUD Pearls

1. Methadone is a long-acting full opioid agonist medication that is safe and effective for treating patients with opioid use disorder (OUD). 
2. A typical therapeutic methadone dose for OUD has a wide range, and doses between 80mg-120mg once daily are common.
3. A common first dose of methadone for OUD is often 30mg for individuals with opioid tolerance. 
4. Titrating methadone in the hospital setting can often be increased more rapidly than in the outpatient setting as a patient can be monitored closely. In Dr. Potee’s expert opinion, it can be increased in 10mg a day increments up to 60-70mg as long as there is no evidence of sedation or other side effects.
5. Use a“Methadone Checklist” to ensure your patient is a candidate for a methadone clinic:  1) Has OUD for at least 1 year, 2) Is geographically close to a clinic, 3) Has transportation to clinic, 4) Is at least 18 years old, and 5) Has a government issued photo ID.
6. In the hospital setting, there is no specific training or certification needed to start a patient on methadone in the hospital, nor specific regulations about how to initiate or escalate doses. 
7. Patients on methadone for OUD can have their acute pain managed by full opioid agonists, though they will often need a higher dose of opioids due to underlying opioid tolerance.

Methadone for OUD Show Notes

What is methadone? 

Methadone is a full opioid agonist treatment used to treat opioid use disorder (OUD) since the 1960s (Dole, Nyswander, Kreek, 1966). It is effective in treating OUD due to its long half-life, high bioavailability, and ability to stabilize the mu opioid receptor, thus preventing opioid withdrawal and cravings for up to 24 hours.

Of note, its analgesic benefits are much shorter (6-8 hours). Patients who metabolize methadone faster either due to pregnancy or because of their baseline physiology may benefit from twice daily (or more frequent) dosing.

Methadone is a life saving medication. There is robust data that it reduces mortality by 50%!!! (Larochelle, 2018. Sordo, 2017. Pearce, 2020). In the fentanyl era, methadone has become increasingly important in the treatment of OUD. Dr. Potee encourages us to consider this medication more readily, especially in the hospital setting. 

Importantly, methadone for the treatment of OUD cannot be prescribed in the outpatient setting and must be dispensed by a federally-certified opioid treatment program (OTP), commonly called a “methadone clinic.” Conversely, methadone for the treatment of chronic pain can be prescribed in the outpatient setting and filled at a pharmacy. In the US, methadone for chronic pain is typically prescribed as a pill whereas methadone for OUD is dispensed in a liquid formulation at an OTP.  

Methadone Regulations

Methadone dosing in OTPs is regulated by the federal government (Federal Guidelines for Methadone OTP). These regulations were written in 1973 and most recently updated in 2015. 

OTPs are regulated in terms of methadone starting doses, speed of titration, and how long patients must be enrolled in methadone treatment before qualifying for “take home” doses (Federal Guidelines for Methadone OTP). During the first 90 days of treatment, the take home supply is limited to a single dose each week with all other doses being dispensed daily at a methadone clinic. These regulations were temporarily relaxed during the COVID-19 pandemic (SAMHSA, 2022). 

In the US, methadone for OUD can only be initiated by an OTP, hospital, or correctional facility. 

All this to say, despite how clearly effective methadone is, it is the most regulated medication in the United States making it often inaccessible to people who need it! Other countries allow methadone to be safely prescribed by PCPs and dispensed at pharmacies. For more on methadone regulation and how we can advocate for needed change, check out this lecture by Dr Potee (lecture on Methadone Regulations).

Goals of Treatment

Patients with OUD may have a variety of goals for starting methadone that can include reducing or abstaining from unregulated (“illicit”) opioid use.  From a clinical perspective, the primary goal of methadone treatment is to stabilize individuals with OUD and allow them to feel normal and healthy throughout the day (that is – without opioid cravings, withdrawal symptoms, or sedation). For most patients, this therapeutic dose falls between 80-120mg but for others it may be lower or higher. The therapeutic dose is where most people stabilize and begin to decrease their use of unregulated opioids (Strain, 1999) (Faggiano, 2003). Uptitrating to the therapeutic dose often takes time, which should be discussed with your patients. 

Some people may need methadone to be dosed twice daily (“split dosing”). In order to provide twice-daily dosing of methadone, OTPs must apply for an exemption from the federal government to allow it.. Dr. Potee mentions two specific populations who benefit from twice-daily dosing: pregnant patients (McCarthy, 2015) and those with concurrent pain contributing to opioid use (expert opinion). 

For patients who don’t have the current goal of abstinence from unregulated opioids, methadone can still be helpful for stabilization and harm reduction. However, there is wide variability across OTPs as to whether ongoing use of unregulated opioids excludes patients from continued dosing. 

Methadone in the Hospital Setting

In the hospital setting, there is no specific training or certification needed to start a patient on methadone, nor specific regulations about how to initiate or escalate doses (Noska, 2015). The hospital is a monitored environment and thus Dr. Potee recommends that you can be more aggressive with dose titration in this setting than in the outpatient setting.  Dr. Potee mentions that patients using fentanyl may require a more rapid uptitration.  In the outpatient setting this may look like dose escalations of 10-15 mg every 3-5 days as suggested in new recommendations from Canadian colleagues, with possibly faster titration in the hospital setting.  Additionally, she suggests considering faster titration for patients who have been treated with methadone in the past. 

While there is no standard accelerated protocol for hospital settings, for patients using non-prescribed opioids, one reasonable approach is the following:

• Order COWS [clinical opioid withdrawal scale] scoring
• If opioid tolerant with OUD, start 30 mg of methadone. Order an additional dose of 10 mg, to be given at least 2-4 hours after the first dose for any additional withdrawal symptoms.
• Day 2-4: Give the total dose from the prior day in the morning, and provide an additional 5-15 mg PRN as needed for withdrawal symptoms or cravings.
• Once at 60-70 mg daily (depending on prior experiences with methadone, opioid tolerance, and response), Dr. Potee’s recommends slowing down dose titration to increase by no more than 10mg every 3 days until a therapeutic dose is reached

It is important to partner with your patient and explain the plan for their methadone titration.

“You will do harm to people if you can’t take care of people’s needs fast enough.” – Dr. Ruth Potee

Once you’ve stabilized your patient on methadone, it’s important to determine if they can continue methadone treatment after discharge using the Methadone Checklist below.  If your patient can’t continue methadone after discharge, you’ll need to consider tapering the methadone or transitioning to buprenorphine-naloxone.

Methadone Checklist

Dr. Potee recommends a “Methadone Checklist” to ensure your patient is a candidate for an OTP/methadone clinic:

• Has OUD for at least 1 year
• Is geographically close to an OTP
• Has transportation to a clinic daily, or can have transportation arranged
• Is at least 18 years old
• Has a government issued photo ID

Hospitalists Tips for Patients On Methadone

If a patient comes to the hospital reporting they are on methadone, the standard of care is to call the patient’s clinic to confirm the dose. Ask patients for the name of their OTP on admission and document it in your notes.  Methadone does NOT show up on Prescription Drug Monitoring Programs. 

A team member should call the clinic EARLY IN THE MORNING: “Hi I’m __________ calling from __________ about __________ to confirm their methadone dose, and the date of their last dose. .

If you cannot confirm the dose but the patient is having withdrawal symptoms, give them something (30-40mg of methadone) and provide any other comfort meds (e.g. clonidine, hydroxyzine, as needed short acting opioids) until you are able to confirm the dose with the clinic.

What if a patient has missed a dose?

Expert opinion (Dr Potee)- If patients have missed fewer than 4 days, there is no need to adjust the dose. If a patient has gone 5 days without a dose, most OTPs will decrease the dose by 20-40% and then get them back to their stable dose as quickly as possible. In the inpatient setting, this is probably appropriate as well. 

What is the risk of torsades de pointes?

The risk of torsades de pointes is small. The risk of opioid overdose is high. Screening EKGs for patients without significant cardiac history, family history of sudden cardiac death, or known prolonged QTC should not limit methadone initiation or dosing (Clinical Practice Guidelines on Methadone Safety, 2014). 

Expert opinion (Dr Potee) You can get a baseline EKG (although most OTPs don’t get screening EKGs when starting methadone), but  there is no need for daily EKGs in a patient without other cardiac concerns. She reminds us to consider other QT prolonging medications such as fluoroquinolones, macrolides, TCAs, and certain SSRIs that may have an additive impact on a patient’s QT. These patients should have their EKGs monitored. 

Pain

We shouldn’t shy away from treating patients with full opioid agonists, such as oxycodone or hydromorphone, for adequate pain control along with non-opioid analgesics while they are in the hospital (Alford, 2006). Inadequate pain control can contribute to premature discharges and not receiving needed medical care. It’s important to know that we are using methadone to treat their OUD not their pain; thus, additional medications to treat pain should be provided when needed. You will need to use higher doses than usual due to opioid tolerance in many of these patients. 

DEA 72-Hour Rule 

The 72-hour or 3 day rule is an often misunderstood DEA regulation that allows for outpatient dispensing of methadone for OUD outside the OTP setting. It does NOT apply to using methadone in the hospital setting.

It allows non-OTP clinicians to dispense/administer (not prescribe) methadone for up to 3 days as a patient is being connected to an OTP. In lay terms this means a clinician can give a patient an observed dose of methadone daily for up to 3 days to bridge them to care at an OTP. Recently this rule was expanded to allow for the 3 days of doses to be given all at once (one observed dose, and two doses to take home). 

This is most often used in the ED, but recently has been implemented by low barrier clinics to help lower barriers to begin people on methadone. (Taylor, 2022)

Links

1. Dr. Potee lecture on Methadone Regulations. 
2. Methadone Treatment for People Who Use Fentanyl Recommendations (Canadian)

Goal

Listeners will counsel patients on the benefits of methadone for opioid use disorder, dispel common myths, and recognize how to initiate and access methadone treatment. 

Learning objectives

After listening to this episode listeners will…  

1. Explain the pharmacology of methadone
2. Educate patients on common myths about methadone treatment 
3. Develop a plan to initiate and titrate methadone for a patient with OUD
4. Describe how patients access methadone and the potential barriers they face

Disclosures

Dr. Ruth Potee reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Potee, R, Morford, K, Watto MF, Huxley-Reicher Z, Cohen S, Chan CA “#1 Methadone for Opioid Use Disorder – Find your Rage with Dr. Ruth Potee”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/episode-list Julu 7th, 2022.