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Trytell A, Osekowski M, Zentner D, Nehme Z, James P, Pflaumer A, Semsarian C, Ingles J, Stub D, La Gerche A, Paratz ED. Prevalence of illicit drug use in young patients with sudden cardiac death. Heart Rhythm 2023; 20:1349-1355. [PMID: 37295741 DOI: 10.1016/j.hrthm.2023.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/21/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Illicit drug use may accelerate coronary disease and cardiac hypertrophy or stimulate arrhythmias. Rates of illicit drug use in young patients with sudden cardiac death (SCD) are uncertain. OBJECTIVE The purpose of this study was to identify rates of illicit drug use in young patients with SCD. METHODS A prospective statewide registry identified out-of-hospital patients with cardiac arrest aged 18-50 years from April 2019 to April 2021. Clinical characteristics were compared between patients with and without illicit drug use (defined by toxicological results or reported regular use). Illicit drugs included amphetamine-type substances, cocaine, heroin, cannabis, and other drugs. RESULTS A total of 554 (40.2%) of 1378 patients had confirmed cardiac cause of out-of-hospital cardiac arrest, with 523 undergoing toxicological assessment. There were 170 patients (32.5%) having either positive toxicology for illicit drugs (n = 138) or negative toxicology but reported regular drug use (n = 32). Patients with SCD and illicit drug use were more commonly male (81.2% vs 72.3%; P = .028), smokers (38.8% vs 19.8%; P ≤ .0001), and excess alcohol drinkers (30.6% vs 20.6%; P = .012) and had a psychiatric diagnosis (38.8% vs 25.7%; P = .002), lower body mass index (29.4 kg/m2 vs 31.7 kg/m2; P = .0063), and lower rates of hypertension (10.6% vs 18.6%; P = .019). Death commonly occurred while sedentary (47.5%) or during sleep (45.8%). Accounting for these baseline differences, there were no differences in rates of coronary disease or cardiomyopathy. Cannabis (n = 106) was the most common illicit drug identified and polysubstance abuse occurred frequently (n = 25). CONCLUSION Approximately one-third of young patients with SCD have positive toxicology at the time of death or reported frequent use of illicit drugs, with high rates of polysubstance abuse.
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Affiliation(s)
- Adam Trytell
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Michael Osekowski
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital Clinical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia; Department of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Paul James
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andreas Pflaumer
- Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Chris Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Jodie Ingles
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Dion Stub
- Ambulance Victoria, Doncaster, Victoria, Australia; Department of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia
| | - Andre La Gerche
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia; Baker Heart and Diabetes Institute, Prahran, Victoria, Australia; Department of Medicine, Dentistry and Health Sciences, Melbourne University, Parkville, Victoria, Australia
| | - Elizabeth D Paratz
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia; Baker Heart and Diabetes Institute, Prahran, Victoria, Australia; Department of Medicine, Dentistry and Health Sciences, Melbourne University, Parkville, Victoria, Australia.
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Yue Y, Zou L, Tao J, Yin L, Xie Z, Xia Y, Zhang Z, Wang K, Zhu M. Transcriptomics and metabolomics together reveal the underlying mechanism of heroin hepatotoxicity. Toxicology 2023; 483:153393. [PMID: 36502556 DOI: 10.1016/j.tox.2022.153393] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
Researches on heroin are more about addiction and some infectious diseases it causes, but liver fibrosis caused by heroin abuse and the mechanism of heroin hepatotoxicity in addicts are ignored. To explore the mechanism of heroin hepatotoxicity, mice in heroin group were intraperitoneally injected by heroin (10 mg/kg) once a day for 14 consecutive days, while mice in heroin withdraw group underwent another 7 days without heroin administration after the same treatment as heroin group. The levels of alanine aminotransferase (ALT)and aspartate aminotransferase (AST) in serum, as biochemical indexes, were applied to evaluate liver damage. H & E staining and oil red O staining were used to observe the pathological changes of liver. Transcriptomics and metabolomics were applied to detect genes and metabolites in livers. The results of biochemical analysis and pathological examination showed that heroin induced liver damage and lipid loss in mice, and these mice did not return to normal completely after a short-term withdrawal. A total of 511 differential genes and 78 differential metabolites were identified by transcriptomics and metabolomics. These differential genes and metabolites were significantly enriched in pathways like lipid metabolism, arachidonic acid metabolism, glutathione metabolism, TCA cycle. And after undergoing 7-day withdrawal of heroin, most of the above differential genes and metabolites did not return to normal. Our study revealed the hepatotoxicity of heroin and that short-term withdrawal of heroin did not fully restore liver function. In addition, transcriptomics and metabolomics revealed that lipid metabolism and arachidonic acid metabolism may be potential therapeutic targets of heroin hepatotoxicity, providing a basis for the treatment of heroin addiction patients in the future.
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Affiliation(s)
- Yingbiao Yue
- National Health Commission Key Laboratory of Drug Addiction Medicine, Kunming Medical University, Kunming 650032, Yunnan, China
| | - Lei Zou
- Department of Hepatobiliary Surgery, The First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, China
| | - Jie Tao
- Drug Rehabilitation Center of Kunming Public Security Bureau, Kunming 650032, Yunnan, China
| | - Lin Yin
- Drug Rehabilitation Center of Kunming Public Security Bureau, Kunming 650032, Yunnan, China
| | - Zhenrong Xie
- The Medical Biobank, the First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan, China
| | - Yu Xia
- Peking University Health Science Center, Beijing 100191, China
| | - Zunyue Zhang
- School of Medicine, Yunnan University, Kunming 650032, Yunnan, China.
| | - Kunhua Wang
- School of Medicine, Yunnan University, Kunming 650032, Yunnan, China.
| | - Mei Zhu
- First Affiliated Hospital of Kunming Medical University, Kunming 650032, Yunnan, China.
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3
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Modi V, Krinock M, Desai R, Stevens S, Nanda S. Loperamide-Induced Cardiac Events: Case Reports and Review. Cureus 2021; 13:e20744. [PMID: 35111436 PMCID: PMC8792126 DOI: 10.7759/cureus.20744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 11/05/2022] Open
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Greenwald MK, Lundahl LH, Shkokani LA, Syed S, Roxas RS, Levy PD. Effects of cocaine and/or heroin use on resting cardiovascular function. INTERNATIONAL JOURNAL OF CARDIOLOGY CARDIOVASCULAR RISK AND PREVENTION 2021; 11:200123. [PMID: 34927171 PMCID: PMC8652009 DOI: 10.1016/j.ijcrp.2021.200123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 12/05/2022]
Abstract
Background Regular cocaine and/or heroin use is associated with major health risks, especially cardiovascular disease, but confounded by other factors. We examined effects of chronic (years regular use) and recent (past-month) cocaine and heroin use, controlling for other factors, on resting cardiovascular function. Methods In a sample of 292 cocaine and/or heroin users, we assessed demographics, body mass index (BMI), substance use history, electrocardiogram, heart rate (HR) and blood pressure (BP). Three-block (1: demographics, BMI; 2: tobacco, alcohol, cannabis; 3: cocaine, heroin) regression analyses were conducted to predict cardiovascular measures. Results Higher BMI predicted increased systolic and diastolic BP (as did older age), increased supine HR, and longer QRS duration, QTc interval, PR interval, and P-wave duration. Past-month cannabis-use days predicted higher systolic BP, lower supine HR, and greater likelihood of early repolarization and ST elevation; average daily cannabis use predicted shorter QTc interval. Average daily alcohol use predicted higher diastolic BP, higher supine HR and lower likelihood of sinus bradycardia (HR < 60 bpm). Past-month tobacco-use days predicted shorter QTc interval and lower lower likelihood of profound bradycardia (HR < 50 bpm). Past-month heroin-use days predicted lower seated HR, greater likelihood of sinus bradycardia and lower likelihood of left ventricular hypertrophy. More years of regular cocaine use and past-month cocaine-use days predicted longer QTc interval. Conclusions Cocaine and heroin use incrementally predicted modest variance in resting bradycardia and QTc interval. Clinicians should first consider demographics and recent use of tobacco, alcohol and cannabis before assuming cocaine and heroin affect these measures.
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Kelty E, Hulse G, Joyce D, Preen DB. Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality. CNS Drugs 2020; 34:629-642. [PMID: 32215842 DOI: 10.1007/s40263-020-00719-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.
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Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia.
| | - Gary Hulse
- Division of Psychiatry, Medical School, The University of Western Australia, Perth, WA, Australia.,Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
| | - David Joyce
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia
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Keseg DP, Augustine JJ, Fowler RL, Scheppke KA, Farcy DA, Pepe PE. Annotated Guidance and Recommendations for the Role and Actions of Emergency Medical Services Systems in the Current Opioid and Drug-Related Epidemics. J Emerg Med 2019; 57:187-194.e1. [DOI: 10.1016/j.jemermed.2019.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 11/30/2022]
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Fatal and non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:54-60. [PMID: 28609749 DOI: 10.1016/j.drugpo.2017.05.039] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 12/16/2016] [Accepted: 05/12/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Illicit opioid use is associated with high rates of fatal and non-fatal opioid overdose. This study aims to compare rates of fatal and serious but non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone, and to identify risk factors for fatal opioid overdose. METHODS Opioid dependent patients treated with methadone (n=3515), buprenorphine (n=3250) or implant naltrexone (n=1461) in Western Australia for the first time between 2001 and 2010, were matched against state mortality and hospital data. Rates of fatal and non-fatal serious opioid overdoses were calculated and compared for the three treatments. Risk factors associated with fatal opioid overdose were examined using multivariate cox proportional hazard models. RESULTS No significant difference was observed between the three groups in terms of crude rates of fatal or non-fatal opioid overdoses. During the first 28days of treatment, rates of non-fatal opioid overdose were high in all three groups, as were fatal opioid overdoses in patients treated with methadone. However, no fatal opioid overdoses were observed in buprenorphine or naltrexone patients during this period. Following the first 28 days, buprenorphine was shown to be protective, particularly in terms of non-fatal opioid overdoses. After the cessation of treatment, rates of fatal and non-fatal opioid overdoses were similar between the groups, with the exception of lower rates of non-fatal opioid overdose in the naltrexone treated patients compared with the methadone treated patients. After the commencement of treatment, gender, and hospitalisations with a diagnosis of opioid poisoning, cardiovascular or mental health problems were significant predictors of subsequent fatal opioid overdose. CONCLUSIONS Rates of fatal and non-fatal opioid overdose were not significantly different in patients treated with methadone, buprenorphine or implant naltrexone. Gender and prior cause-specific hospitalisations can be used to identify patients at a high risk of fatal opioid overdose.
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Rates of Hospital and Emergency Department Attendances in Opiate-dependent Patients Treated With Implant Naltrexone, Methadone, or Buprenorphine. ADDICTIVE DISORDERS & THEIR TREATMENT 2017. [DOI: 10.1097/adt.0000000000000101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The recreational use of illicit drugs remains an enormous and growing problem throughout the United States of America and around the world. Cocaine is most frequently thought of when considering the cardiovascular toxicity of illicit drugs. The association of cocaine use with sudden death due to myocardial ischaemia and infarction is well recognised, and this risk appears to be amplified by concomitant cigarette smoking and alcohol consumption. Like cocaine, amphetamine and its derivatives lead to indirect stimulation of the autonomic nervous system through the release of norepinephrine, dopamine, and serotonin in nerve terminals of the central and autonomic nervous systems. However, amphetamine lacks the ion channel-blocking properties of cocaine. Also similar to cocaine, coronary artery spasm may be induced in individuals with or without atherosclerotic disease and may lead to myocardial infarction. With the movement across the United States of America to legalise marijuana, or cannabis, for medicinal and recreational purposes, it is important to consider its potential deleterious effects. Marijuana has long been thought to have very few adverse effects with the exception of long-term dependence. There are, however, scattered reports of acute adverse events up to and including sudden death. These appear to be due to myocardial infarction. In conclusion, the incidence of sudden death associated with the use of these drugs varies from rare in the case of marijuana use to not infrequent with some drugs such as cocaine. It is important for care providers to recognise the potential for drug abuse when caring for a sudden cardiac arrest survivor.
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10
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Shimomura SK, Watanabe AS. Adverse Drug Reactions: Illustrated by Clinical Case Studies. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/106002807500900402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Pavlidis P, Deftereou TE, Karakasi MV, Papadopoulos N, Zissimopoulos A, Pagonopoulou O, Lambropoulou M. Intravenous Heroin Abuse and Acute Myocardial Infarction. Am J Forensic Med Pathol 2016; 37:95-8. [DOI: 10.1097/paf.0000000000000224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Loperamide Induced Torsades de Pointes: A Case Report and Review of the Literature. Case Rep Med 2016; 2016:4061980. [PMID: 26989420 PMCID: PMC4775784 DOI: 10.1155/2016/4061980] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 02/01/2016] [Indexed: 01/08/2023] Open
Abstract
Abuse of over the counter drugs often gets overlooked by health care providers. Loperamide is one such over the counter drug that is often abused by drug addicts. We present here a case of a young male attaining euphoria from taking massive doses of loperamide. He developed Torsades de Pointes and subsequent cardiac arrest. We found similarities in the progression of myocardial electrical conduction abnormalities among loperamide and other previously known arrhythmogenic drugs. We intend to raise concern over the ease of availability of such drugs over the counter and increase the index of suspicion for over the counter drug abuse from our experience.
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Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Donnino MW. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S501-18. [PMID: 26472998 DOI: 10.1161/cir.0000000000000264] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Weimer MB, Chou R. Research gaps on methadone harms and comparative harms: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. THE JOURNAL OF PAIN 2014; 15:366-76. [PMID: 24685460 DOI: 10.1016/j.jpain.2014.01.496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/10/2023]
Abstract
UNLABELLED Methadone-associated overdose deaths have dramatically increased. In order to inform an evidence-based clinical practice guideline to improve safety of methadone prescribing, the American Pain Society commissioned a systematic review on various aspects related to methadone safety. We searched Ovid MEDLINE, Cochrane Library, and PsycINFO databases through July 2012 to identify studies that addressed 1 or more of 17 Key Questions related to methadone safety; an update search was performed in 2014 for new studies related to methadone-related overdose and risks related to cardiac arrhythmias. A total of 168 studies met inclusion criteria for the review. The purpose of this article is to highlight critical research gaps in the literature related to methadone safety. These include lack of evidence on risk factors associated with methadone-overdose deaths and adverse events, limited evidence to evaluate the comparative mortality of methadone versus other opioids, insufficient evidence to fully understand the harms associated with methadone use during pregnancy, and insufficient evidence to determine effects of risk mitigation strategies such as electrocardiogram monitoring, strategies for managing patients with prolonged QTc intervals on screening, urine drug testing, alternative dosing regimens for initiation and titration of therapy, and timing of follow-up. Therefore, most guideline recommendations are based on weak evidence. More research is needed to guide safe methadone prescribing practices and decrease the adverse events associated with methadone. PERSPECTIVE This article summarizes critical research gaps in the literature related to methadone safety, based on a systematic review commissioned by the American Pain Society. Critical research gaps were identified in a number of areas, highlighting the need for additional research to guide safer prescribing and risk mitigation strategies.
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Affiliation(s)
- Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon.
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Chou R, Cruciani RA, Fiellin DA, Compton P, Farrar JT, Haigney MC, Inturrisi C, Knight JR, Otis-Green S, Marcus SM, Mehta D, Meyer MC, Portenoy R, Savage S, Strain E, Walsh S, Zeltzer L. 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 2014; 15:321-37. [PMID: 24685458 DOI: 10.1016/j.jpain.2014.01.494] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/08/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Roger Chou
- Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, and Pacific Northwest Evidence-based Practice Center, Portland, Oregon.
| | - Ricardo A Cruciani
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York
| | - David A Fiellin
- School of Public Health, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark C Haigney
- Cardiology Uniformed Services, University of the Health Sciences, Baltimore, Maryland
| | - Charles Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, New York, New York
| | - John R Knight
- Center for Adolescent Substance Abuse Research, Children's Hospital Boston, Boston, Massachusetts
| | - Shirley Otis-Green
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Steven M Marcus
- School of Biomedical and Health Sciences, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Davendra Mehta
- Departments of Medicine and Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marjorie C Meyer
- Departments of Gynecology and Maternal Fetal Medicine, University of Vermont, Burlington, Vermont
| | - Russell Portenoy
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York
| | - Seddon Savage
- Department of Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire
| | - Eric Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon Walsh
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Lonnie Zeltzer
- Pediatric Pain Program, Mattel Children's Hospital at UCLA, Los Angeles, California
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Chou R, Weimer MB, Dana T. Methadone overdose and cardiac arrhythmia potential: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. THE JOURNAL OF PAIN 2014; 15:338-65. [PMID: 24685459 DOI: 10.1016/j.jpain.2014.01.495] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 12/01/2022]
Abstract
UNLABELLED The number of deaths associated with methadone use increased dramatically in parallel with marked increases in its use, particularly for treatment of chronic pain. To develop a clinical guideline on methadone prescribing to reduce potential harms, the American Pain Society commissioned a review of various aspects related to methadone safety. This article summarizes evidence related to unintentional overdose due to methadone and harms related to cardiac arrhythmia potential. We searched Ovid MEDLINE, the Cochrane Library, and PsycINFO databases through January 2014 for studies assessing harms associated with methadone use; we judged 70 studies to be relevant and to meet inclusion criteria. The majority of studies on overdose and cardiac arrhythmia risk are observational and provide weak evidence on which to base clinical guidelines. In patients prescribed methadone for treatment of opioid dependence, data suggest that mortality benefits related to reduction in illicit drug use outweigh harms. Despite epidemiologic data showing marked increases in the numbers of methadone-related deaths that have been primarily attributed to increased use of methadone for chronic pain, evidence on methadone and mortality risk in this population has been somewhat contradictory. There is some evidence that recent initiation of methadone, psychiatric admissions, and concomitant use of benzodiazepines are associated with a higher risk for overdose. Evidence on cardiac risks is primarily limited to case reports of torsades de pointes, primarily in patients on high doses of methadone, and to studies showing an association between methadone use and prolongation of QTc intervals. Research is needed to understand the effectiveness of dosing methods, electrocardiogram monitoring, and other risk mitigation strategies in patients prescribed methadone. PERSPECTIVE This systematic review synthesizes the evidence related to methadone use and risk for overdose and cardiac arrhythmia. Findings regarding the association between methadone use and QTc interval prolongation and risk factors for methadone-associated overdose suggest potential targets for risk mitigation strategies, though research is needed to determine the effectiveness of such strategies at reducing adverse outcomes.
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Affiliation(s)
- Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon.
| | - Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon
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Hajj A, Ksouda K, Peoc'h K, Curis E, Messali A, Deveaux LL, Bloch V, Prince N, Mouly S, Scherrmann JM, Lépine JP, Laplanche JL, Drici MD, Vorspan F. KCNH2 polymorphism and methadone dosage interact to enhance QT duration. Drug Alcohol Depend 2014; 141:34-8. [PMID: 24875677 DOI: 10.1016/j.drugalcdep.2014.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 04/25/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many drugs increase the duration of the QT interval of patients, potentially leading to harmful effects such as polymorphic ventricular arrhythmias. Most of these drugs do so by inhibiting the rapid component IKr of the delayed rectifier potassium current IK. Methadone is the most prescribed heroin maintenance treatment and is known to inhibit the cardiac potassium channel hERG, which recapitulates IKr. In order to evaluate if any polymorphism of potassium channels' genes could explain some of the "idiosyncratic" QT prolongations observed in patients treated with methadone, we tested the association between KCNE1, KCNE2, and KCNH2 polymorphism and the QT interval prolongation in those patients, controlling for other variables associated with a decrease of the repolarizing reserve. METHODS A cohort of 82 patients treated with stable dosage of methadone (mean dosage 65 mg/d) for at least three months was genotyped for five polymorphisms in KCNE1, KCNE2 and KCNH2 genes and had their corrected QT (QTc) assessed. RESULTS The mean QTc interval was 415±34ms. In a linear regression model, longer QTc interval was associated with methadone dosage and with one genetic factor. Each copy of a Lys allele at codon 897 of KCNH2, the gene that encodes the cardiac potassium voltage-gated channel hERG, was associated with a 15.4ms longer QTc (95% CI [4.6-26.2]; p=0.001). CONCLUSION KCNH2 genotyping may be relevant in the analysis of cumulative risk factors for QT prolongation in patients on methadone maintenance treatment.
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Affiliation(s)
- Aline Hajj
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; AP-HP, Hôpital Lariboisière, Service de Biochimie et Biologie moléculaire, 2 rue Ambroise Paré, 75010 Paris, France; Pharmacology Unit, Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, Saint Joseph University, Beirut, Lebanon
| | - Kamilia Ksouda
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; AP-HP, Hôpital Fernand Widal, Service de Psychiatrie, 200 rue du Fg St Denis, 75010 Paris, France
| | - Katell Peoc'h
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; AP-HP, Hôpital Lariboisière, Service de Biochimie et Biologie moléculaire, 2 rue Ambroise Paré, 75010 Paris, France
| | - Emmanuel Curis
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; Université Paris Descartes, Faculté de Pharmacie, Département de Biostatistiques, 4 avenue de l'Observatoire, 75006 Paris, France
| | - Anne Messali
- AP-HP, Hôpital Lariboisière, Service de Cardiologie, 2 rue Ambroise Paré, 75010 Paris, France
| | - Laurence Labat Deveaux
- AP-HP, Hôtel Dieu Service de Pharmacie - Pharmacologie - Toxicologie, 1 place du Parvis Notre Dame, 75004 Paris, France
| | - Vanessa Bloch
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France
| | - Nathalie Prince
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France
| | - Stéphane Mouly
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France
| | - Jean-Michel Scherrmann
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France
| | - Jean-Pierre Lépine
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; AP-HP, Hôpital Fernand Widal, Service de Psychiatrie, 200 rue du Fg St Denis, 75010 Paris, France
| | - Jean-Louis Laplanche
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; AP-HP, Hôpital Lariboisière, Service de Biochimie et Biologie moléculaire, 2 rue Ambroise Paré, 75010 Paris, France
| | | | - Florence Vorspan
- INSERM UMR-S 1144, Variabilité de la Réponse aux Psychotropes, Université Paris Descartes, Université Paris Diderot, PRES Sorbonne Paris Cité, Hôpital Fernand Widal, 200 rue du Fg St Denis, 75010 Paris, France; AP-HP, Hôpital Fernand Widal, Service de Psychiatrie, 200 rue du Fg St Denis, 75010 Paris, France.
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Rambod M, Elhanafi S, Mukherjee D. Brugada phenocopy in concomitant ethanol and heroin overdose. Ann Noninvasive Electrocardiol 2014; 20:87-90. [PMID: 24903622 DOI: 10.1111/anec.12171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Brugada phenocopy describes conditions with Brugada-like ECG pattern but without true congenital Brugada syndrome. We report a case of 44-year-old man with no known medical history who presented with loss of consciousness. Toxicology screening was positive for opiates and high serum alcohol level. His initial ECG showed Brugada type 1 pattern which resolved after several hours of observation and treatment with continuous naloxone infusion. Patient regained his consciousness and disclosed heroin abuse and drinking alcohol. This case highlights the heroin overdose as a possible cause of Brugada phenocopy.
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Affiliation(s)
- Mehdi Rambod
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas
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20
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Modest increase in risk of acute coronary syndrome associated with morphine use in cancer patients: A population-based nested case-control study. Eur J Oncol Nurs 2014; 18:295-8. [DOI: 10.1016/j.ejon.2014.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 11/20/2022]
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Sudden cardiac arrest in a patient on chronic methadone after the addition of azithromycin. Am J Med Sci 2013; 345:160-2. [PMID: 23103438 DOI: 10.1097/maj.0b013e318266e7af] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Corrected QT-interval (QTc) prolongation with increased risk of fatal arrhythmia is a well-established toxicity of methadone. In this study, a case of sudden cardiac arrest in a patient on chronic methadone therapy is presented. A 47-year-old man presented unresponsive to the emergency department after pulseless arrest at his home. The patient's wife revealed he was taking methadone as part of an ongoing opioid dependency treatment and that he was prescribed azithromycin for an upper respiratory tract infection 3 days before his presentation. A 12-lead electrocardiogram at the time of presentation showed sinus tachycardia and a QTc of 490 milliseconds. It was concluded that the patient experienced a fatal arrhythmia because of QTc prolongation, precipitated by azithromycin in the setting of ongoing methadone use.
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Nerantzis CE, Couvaris CM, Pastromas SC, Marianou SK, Boghiokas ID, Koutsaftis PN. Histological Findings of the Atrioventricular Conductive System in Street Heroin Addicts, Victims of Sudden Unexpected Death. J Forensic Sci 2012; 58 Suppl 1:S99-104. [DOI: 10.1111/j.1556-4029.2012.02304.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 12/13/2011] [Accepted: 12/17/2011] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | - Ilias D. Boghiokas
- Forensic Medical Service of Athens; Mikras Asias 75; GR-115 27; Athens; Greece
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Emamhadi M, Sanaei-Zadeh H, Nikniya M, Zamani N, Dart RC. Electrocardiographic manifestations of tramadol toxicity with special reference to their ability for prediction of seizures. Am J Emerg Med 2012; 30:1481-5. [DOI: 10.1016/j.ajem.2011.12.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/09/2011] [Accepted: 12/09/2011] [Indexed: 12/01/2022] Open
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Faa A, Senes G, Locci A, Pampaloni P, Pais ME, Piras B, d'Aloja E, Faa G. S100B protein expression in the heart of deceased individuals by overdose: a new forensic marker? Clinics (Sao Paulo) 2012; 67:821-6. [PMID: 22892929 PMCID: PMC3400175 DOI: 10.6061/clinics/2012(07)19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 03/22/2012] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The evaluation of S100B protein expression in the human heart and its correlation with drug-related death. METHOD Left ventricular samples were collected from 74 serial forensic autopsies (15 overdose-related deaths; 59 non-overdose-related deaths) from 2007 to 2010. Tissue sections from each sample were immunostained for S100B protein by a commercial antibody. RESULTS The S100B protein was detected in the heart samples of all 15 cases of drug-related deaths; S100B immunoreactivity was mainly observed in the cytoplasm of cardiomyocytes and as globular deposits in the interstitial spaces. No reactivity or weak reactivity was found in the cardiomyocytes of the 59 subjects who died of other causes. CONCLUSION Our preliminary data show that the S100B protein accumulates in injured cardiomyocytes during drug-related sudden death. Given the near absence of S100B protein in the heart of subjects who died from causes other than drug overdose, S100B immunopositivity may be used as a new ancillary screening tool for the postmortem diagnosis of overdose-related cardiac death.
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Affiliation(s)
- Armando Faa
- University of Cagliari, Department of Pathology, Cagliari, Italy.
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26
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Bart G. CSAT's QT interval screening in methadone report: outrageous fortune or sea of troubles? J Addict Dis 2012; 30:313-7. [PMID: 22026522 DOI: 10.1080/10550887.2011.610707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Gavin Bart
- University of Minnesota, Minneapolis, MN, USA.
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Martin JA, Campbell A, Killip T, Kotz M, Krantz MJ, Kreek MJ, McCarroll BA, Mehta D, Payte JT, Stimmel B, Taylor T, Haigney MCP, Wilford BB. QT interval screening in methadone maintenance treatment: report of a SAMHSA expert panel. J Addict Dis 2011; 30:283-306. [PMID: 22026519 PMCID: PMC4078896 DOI: 10.1080/10550887.2011.610710] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Saervices Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patient's risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.
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[Ischemic strokes in young adults and illegal drugs]. Rev Med Interne 2011; 33:35-40. [PMID: 21616567 DOI: 10.1016/j.revmed.2011.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 04/14/2011] [Accepted: 04/20/2011] [Indexed: 11/20/2022]
Abstract
One out of four ischemic strokes in France occurs in adults under 65 years old. About a third of them remain unexplained even after an extensive etiological assessment. A large part of these unexplained strokes could be linked to illegal drug abuse, and 10 % are estimated to be directly linked to illegal drugs in some international studies. The most frequently incriminated recreational drug remains cocaine, via several mechanisms. However, several other illegal drugs, some very commonly used such as cannabis, are suspected to have an important role in neurovascular diseases. In this article, we reviewed the epidemiological, pathophysiological and clinical studies, published in the international literature over the past 30 years. The drug-caused stroke epidemiology needs to be more precisely studied, as well as the underlying mechanisms depending on each drug. This is a public health issue that affects an economically active population, as stroke is the first cause of acquired handicap in adults.
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Nerantzis CE, Koulouris SN, Marianou SK, Pastromas SC, Koutsaftis PN, Agapitos EB. Histologic Findings of the Sinus Node and the Perinodal Area in Street Heroin Addicts, Victims of Sudden Unexpected Death. J Forensic Sci 2011; 56:645-8. [DOI: 10.1111/j.1556-4029.2011.01717.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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MAYET SORAYA, GOSSOP MICHAEL, LINTZERIS NICHOLAS, MARKIDES VIAS, STRANG JOHN. Methadone maintenance, QTc and torsade de pointes: Who needs an electrocardiogram and what is the prevalence of QTc prolongation? Drug Alcohol Rev 2010; 30:388-96. [DOI: 10.1111/j.1465-3362.2010.00237.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reddy S, Hui D, El Osta B, de la Cruz M, Walker P, Palmer JL, Bruera E. The effect of oral methadone on the QTc interval in advanced cancer patients: a prospective pilot study. J Palliat Med 2010; 13:33-8. [PMID: 19824814 DOI: 10.1089/jpm.2009.0184] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recent reports suggest that high doses of methadone may prolong QTc interval and occasionally cause torsades de pointes; however, few of these studies involved the palliative care population. OBJECTIVE The purpose of this study was to determine the effect of initiation of methadone on QTc interval in patients with cancer pain seen at the palliative care setting. METHODS We enrolled 100 patients with cancer in this prospective study. Patients were followed clinically and electrocardiographically for QTc changes at baseline, 2, 4, and 8 weeks. Contributing factors for QTc prolongation such as medications, cardiovascular diseases, and electrolytes disturbances were documented. QTc prolongation was defined as greater than 430 ms in males and greater than 450 ms in females, and significant QTc prolongation was defined as QTc interval greater than 25% increase from baseline or 500 ms or more. RESULTS Electrocardiographic (ECG) assessments were available for 100, 64, 41, and 27 patients at baseline, 2-, 4-, and 8-week follow-up, respectively. At baseline prior to initiation of methadone, 28 (28%) patients had QTc prolongation. Clinically significant increase in QTc occurred in only 1 of 64 (1.6%) patients at week 2, and none at weeks 4 and 8. There was no clinical evidence of torsades de pointes, ventricular fibrillation, or sudden death. QTc prolongation was more frequent among patients with increased baseline QTc interval. CONCLUSIONS Baseline QTc prolongation was common, whereas significant QTc interval 500 ms or more after methadone initiation rarely occurred, with no evidence of clinically significant arrhythmias. This study supports the safety of methadone use for pain control in patients with advanced cancer in the palliative care setting.
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Affiliation(s)
- Suresh Reddy
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Modesto-Lowe V, Brooks D, Petry N. Methadone deaths: risk factors in pain and addicted populations. J Gen Intern Med 2010; 25:305-9. [PMID: 20087676 PMCID: PMC2842557 DOI: 10.1007/s11606-009-1225-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 05/06/2009] [Accepted: 12/10/2009] [Indexed: 10/20/2022]
Abstract
Methadone is highly effective in treating opioid dependence, and it is also used as an analgesic for second-line management of chronic pain. However, recent increases in methadone-related deaths have instigated controversy about the use of this medication. In this paper, we evaluate risk factors for methadone mortality in opioid dependent and pain populations and present guidelines for initiating methadone treatment in these two populations to minimize the risk of death. Early research with methadone-maintained patients revealed that methadone fatalities occur primarily due to respiratory arrest during methadone induction and in the context of polysubstance use. Recent reports of methadone deaths emphasize chronic pain populations, methadone-related QTc prolongation, and the possibility of inducing Torsade de pointes (TdP), a potentially fatal ventricular arrhythmia. Retrospective analyses of these deaths show that patients who develop TdP often present with multiple risk factors, including high methadone doses, use of other medications that cause QTc prolongation, and electrolyte abnormalities. To minimize fatalities, guidelines are presented for initiating methadone in opioid treatment and pain populations that consider the drug's pharmacology along with behavioral, medical and psychiatric risk factors.
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Affiliation(s)
- Vania Modesto-Lowe
- Addiction Services Division, Connecticut Valley Hospital, Middletown, CT 06457, USA.
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Reinhold JA, Sanoski CA, Russo AM, Cooper JM, Spinler SA. Torsades de pointes associated with methadone and voriconazole. BMJ Case Rep 2009; 2009:bcr07.2009.2119. [PMID: 22190985 DOI: 10.1136/bcr.07.2009.2119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This report concerns a case of torsades de pointes (TdP) associated with the concomitant administration of methadone and voriconazole in a patient with comorbid medical conditions. A 57-year-old man, with a medical history of human immunodeficiency virus, infective endocarditis, hepatitis C and orbital Aspergillus infection, was admitted to the intensive care unit following several episodes of TdP. The patient was being treated with methadone for opioid addiction and had started taking voriconazole 2 weeks prior for orbital Aspergillosis. He experienced multiple episodes of TdP with a prolonged QTc interval (>600 ms). The pronounced inhibitory impact of voriconazole on methadone metabolism via the cytochrome P450 (CYP)2B6 isoenzyme was identified as a probable cause of the arrhythmia. Voriconazole was subsequently temporarily withheld and the methadone dose was significantly reduced. The patient received an implantable cardioverter-defibrillator, did not experience additional episodes of TdP during hospitalisation, and was discharged from the hospital on day 13.
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Affiliation(s)
- Jennifer A Reinhold
- Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Pharmacy Practice and Pharmacy Administration, 600 S 43rd Street, Philadelphia, Pennsylvania, 19104, USA
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Guay DR. Cardiotoxicity of Oral Methadone as an Analgesic–-Recommendations for Safe Use. ACTA ACUST UNITED AC 2009. [DOI: 10.4137/cmt.s3041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Once used only as third-line therapy in the management of chronic pain states, methadone is now being used as first- and second-line therapy. Most risks and the stigma associated with methadone use have been known for years. Only over the past decade or so have the unique pharmacokinetic-pharmacodynamic properties and methods for conversion from other opioids to methadone been established. Pertinent English-language literature was obtained from MEDLINE/PUBMED and EMBASE searches (1966-June 2009). This paper provides an overview of the cardiotoxicity of oral methadone, with an emphasis on its use as an analgesic. Cardiotoxicity during its use in the maintenance of opioid addiction has also been reviewed due to the wealth of epidemiologic, risk factor, and correlative analytic data contained therein. A series of recommendations are provided to improve the cardiac safety profile of oral methadone used for analgesia. In addition, there is a discussion of settings and patient types which may impact upon these recommendations.
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Affiliation(s)
- David R.P. Guay
- College of Pharmacy, University of Minnesota and HealthPartners Geriatrics, HealthPartners Inc., Minneapolis, Minnesota, USA
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Stringer J, Welsh C, Tommasello A. Methadone-associated Q-T interval prolongation and torsades de pointes. Am J Health Syst Pharm 2009; 66:825-33. [PMID: 19386945 DOI: 10.2146/ajhp070392] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The association of methadone with Q-T interval prolongation and torsades de pointes (TdP) is reviewed, and recommendations for preventing Q-T interval prolongation in methadone users are provided. SUMMARY Abnormalities in voltage-gated potassium channels have been shown to lead to prolonged action potentials that are expressed as long Q-T intervals, and methadone has been found to interact with the voltage-gated potassium channels of the myocardium. While cardiac arrhythmias in methadone users have been reported for several decades, specific reports of methadone-associated Q-T interval prolongation and TdP did not appear in the literature until the early part of the 21st century. Because not every patient experiences Q-T interval prolongation with methadone, recent research has elucidated risk factors that predispose patients to this adverse effect, including female sex, hypokalemia, high-dose methadone, drug interactions, underlying cardiac conditions, unrecognized congenital long Q-T interval syndrome, and predisposing DNA polymorphisms. Given the high mortality rates seen in untreated illicit opioid users and the clear efficacy of methadone in treating opioid addiction, the risk of using methadone, even in a patient with other risk factors for Q-T interval prolongation, may outweigh the alternative of no pharmacologic treatment. A baseline electrocardiogram (ECG), personal and family history of syncope, and a complete medication history should be obtained before a patient begins treatment with methadone. Given the apparent synergistic effects of parenteral methadone and chlorobutanol, oral methadone should be used whenever possible. CONCLUSION Q-T interval prolongation and TdP associated with the use of methadone are potentially fatal adverse effects. A thorough patient history and ECG monitoring are essential for patients treated with this agent, and alterations in treatment options may be necessary.
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Affiliation(s)
- John Stringer
- Pharmacy, Saint Barnabas Behavioral Health Center, Toms River, NJ 08754, USA.
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Athanasos P, Farquharson AL, Compton P, Psaltis P, Hay J. Electrocardiogram Characteristics of Methadone and Buprenorphine Maintained Subjects. J Addict Dis 2008; 27:31-5. [DOI: 10.1080/10550880802122596] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | - Peter Psaltis
- c Royal Adelaide Hospital , University of Adelaide , Adelaide, Australia
| | - Justin Hay
- a University of Adelaide , Adelaide, Australia
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Case files of the Drexel University Medical Toxicology Fellowship: methadone-induced QTc prolongation. J Med Toxicol 2008; 3:190-4. [PMID: 18072176 DOI: 10.1007/bf03160939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Puri R, Roberts-Thomson KC, Young GD. HIV and Long QT syndrome--cause or coincidence. Int J Cardiol 2007; 133:e9-10. [PMID: 18068238 DOI: 10.1016/j.ijcard.2007.08.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Accepted: 08/04/2007] [Indexed: 11/29/2022]
Abstract
The Long QT syndrome is a disorder characterized by abnormalities of cardiac repolarisation, resulting in a propensity to polymorphic ventricular tachycardia (torsades de pointes) and sudden cardiac death. It remains unclear whether cardiac involvement with the HIV virus itself can cause QT prolongation. We report a case of a HIV infected young female presenting with recurrent syncope due to torsades de pointes.
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Ehret GB, Desmeules JA, Broers B. Methadone-associated long QT syndrome: improving pharmacotherapy for dependence on illegal opioids and lessons learned for pharmacology. Expert Opin Drug Saf 2007; 6:289-303. [PMID: 17480178 DOI: 10.1517/14740338.6.3.289] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Methadone is used as the pharmacologic mainstay for substitution for illegal opiates and as analgesic for chronic or cancer-related pain. Given the benefits of methadone substitution for illicit opioids, the finding of an association between methadone and prolongation of cardiac depolarization (QT prolongation) and torsades de pointes is of great concern. QT prolongation can occur with many drugs and is a potentially lethal adverse drug reaction, necessitating risk monitoring and therapeutic alternatives in some patients. Recent studies suggest that QT prolongation with methadone is context dependent: occurrence is more frequent with high doses of methadone, concomitant administration of CYP3A4 inhibitors, hypokalemia, hepatic failure, administration of other QT prolonging drugs and pre-existing heart disease. The valued benefit of methadone substitution therapy on the one hand and the increased cardiovascular risk in particular situations on the other illustrate the difficulties in dealing with drug-induced QT prolongation in general.
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Affiliation(s)
- Georg B Ehret
- Johns Hopkins University School of Medicine, McKusick Nathans Institute of Genetic Medicine, Baltimore, MD 21205, USA.
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Peles E, Bodner G, Kreek MJ, Rados V, Adelson M. Corrected-QT intervals as related to methadone dose and serum level in methadone maintenance treatment (MMT) patients: a cross-sectional study. Addiction 2007; 102:289-300. [PMID: 17222284 DOI: 10.1111/j.1360-0443.2006.01668.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To determine and evaluate QTc intervals in electrocardiograms (ECGs) of former heroin addicts, currently in methadone maintenance treatment (MMT), as previous reports suggest that methadone may prolong QTc intervals, thus possibly increasing the risk for Torsade de pointes (TdP). DESIGN Cross-sectional study. SETTING Between January 2003 and September 2004, patients on a steady dose of methadone for at least 2 weeks were studied. PARTICIPANTS This study is a subset of 153 patients, of whom 151 patients participated in a study of high methadone doses and serum levels. A total of 138 patients in MMT for a minimum of 100 days up to 10.7 years, receiving 40-290 mg/day methadone dose, participated. MEASUREMENTS Patients had an ECG at the time when blood was drawn for determination of serum methadone levels at around 24 hours after the last oral methadone dose. Corrected-QT intervals (QTc) were calculated using the Bazett formula. FINDINGS Of 138 patients studied, 98 (71%) were male. Mean QTc interval was 418.3 +/- 32.8 milliseconds (ms). Mean methadone dose was 170.9 +/- 50.3 mg/day and mean serum methadone level was 708.2 +/- 363.1 ng/ml. Methadone dose and serum levels did not correlate with QTc. Three patients had QTc intervals above 500 ms ('prolonged'). After 2 +/- 0.4 years of follow-up, two patients died; they were two of three patients with very prolonged QTc. Causes of death were not attributed to cardiac origin. An additional 19 patients had QTc intervals of between 450 and 499 ms ('possibly prolonged'). None of these QTc > or = 450 ms patients had any cardiac problems. Methadone doses of all 22 patients were > 120 mg/day. CONCLUSIONS Methadone maintenance is generally safe; however, the possible toxicity of high dose (> 120 mg/day) should be monitored for QTc.
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Affiliation(s)
- Einat Peles
- Dr Miriam and Sheldon G Adelson Clinic for Drug Abuse, Treatmentand Research,, Tel-Aviv, Israel.
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Ashwath ML, Ajjan M, Culclasure T. Methadone-induced bradycardia. J Emerg Med 2005; 29:73-5. [PMID: 15961013 DOI: 10.1016/j.jemermed.2004.10.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2003] [Revised: 09/08/2004] [Accepted: 10/21/2004] [Indexed: 11/18/2022]
Abstract
Methadone is commonly used in opiate detoxification in high dose. It has a molecular structure similar to verapamil and has been reported to cause similar side effects with continuous high-dose infusion. We report the case of a patient with a history of addiction and abuse of alprazolam and hydrocodone who developed sinus bradycardia after being started on oral methadone for detoxification. The potential of methadone to cause side effects similar to verapamil must be considered in any patient taking methadone.
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Abstract
Information concerning acute myocardial infarctions (AMI) after heroin injection is limited. Only one report has described the association between heroin injections and AMI in a young woman. AMI after heroin injection in a patient with a normal coronary angiogram has not been reported. We report a 38-year-old man who developed AMI after heroin injection. He is probably the first case of AMI with normal coronary artery angiograms associated with heroin abuse. The heroin-induced toxic effect and/or coronary spasm are highly suspected to be the causes of the infarction episode.
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Affiliation(s)
- Sung-Lin Yu
- Intensive Care Unit, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang-Ming University, School of Medicine, Taipei, Taiwan 813, ROC
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Teichtahl H, Wang D, Cunnington D, Kronborg I, Goodman C, Prodromidis A, Drummer O. Cardiorespiratory function in stable methadone maintenance treatment (MMT) patients. Addict Biol 2004. [DOI: 10.1111/j.1369-1600.2004.tb00540.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Decerf JA, Gressens B, Brohet C, Liolios A, Hantson P. Can methadone prolong the QT interval? Intensive Care Med 2004; 30:1690-1. [PMID: 15185068 DOI: 10.1007/s00134-004-2335-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2004] [Indexed: 11/29/2022]
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Gil M, Sala M, Anguera I, Chapinal O, Cervantes M, Guma JR, Segura F. QT prolongation and Torsades de Pointes in patients infected with human immunodeficiency virus and treated with methadone. Am J Cardiol 2003; 92:995-7. [PMID: 14556883 DOI: 10.1016/s0002-9149(03)00906-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Four patients infected with human immunodeficiency virus receiving antiretroviral treatment and high doses of methadone (>200 mg/day) presented with several syncopal episodes. A significant prolongation of the QTc interval was detected in all of them, and in 3 patients, > or =1 episode of Torsades de Pointes was recorded. The sequence of events in these cases suggests that high doses of methadone caused QT prolongation and provided the substrate for syncope and Torsades de Pointes.
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Affiliation(s)
- Merce Gil
- Internal Medicine Department, Infectious Diseases Unit, Corporació Sanitària Parc Taulí-Hospital de Sabadell, Barcelona, Spain
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Kornick CA, Kilborn MJ, Santiago-Palma J, Schulman G, Thaler HT, Keefe DL, Katchman AN, Pezzullo JC, Ebert SN, Woosley RL, Payne R, Manfredi PL. QTc interval prolongation associated with intravenous methadone. Pain 2003; 105:499-506. [PMID: 14527710 DOI: 10.1016/s0304-3959(03)00205-7] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Numerous medications prolong the rate-corrected QT (QTc) interval and induce arrhythmias by blocking ionic current through cardiac potassium channels composed of subunits expressed by the human ether-a-go-go-related gene (HERG). Recent reports suggest that high doses of methadone cause torsades de pointes. To date, no controlled study has described an association between methadone and QTc prolongation. The only commercial formulation of parenteral methadone available in the United States contains the preservative chlorobutanol. The objectives of this study are to determine: (1) whether the administration of intravenous (i.v.) methadone causes QTc prolongation in humans; (2) whether methadone and/or chlorobutanol block cardiac HERG potassium currents (IHERG) in vitro. Over 20 months, we identified every inpatient with at least one electrocardiogram (ECG) performed on i.v. methadone. For each patient, we measured QTc intervals for every available ECG performed on and off i.v. methadone. Concurrent methadone doses were also recorded. Similar data were collected for a separate group of inpatients treated with i.v. morphine. In a separate set of experiments IHERG was evaluated in transfected human embryonic kidney cells exposed to increasing concentrations of methadone, chlorobutanol, and the two in combination. Mean difference (+/- standard error) per patient in QTc intervals on and off methadone was 41.7 (+/- 7.8)ms, p<0.0001. Mean difference in QTc intervals on and off morphine was 9.0 (+/- 6.1)ms, p=0.15. The approximately linear relationship between QTc measurements and log-dose of methadone was significant (p<0.0001). Methadone and chlorobutanol independently block IHERG in a concentration-dependent manner with IC50 values of 20 +/- 2 microM and 4.4 +/- 0.3 mM, respectively. Chlorobutanol potentiates methadone's ability to block IHERG. Methadone in combination with chlorobutanol is associated with QTc interval prolongation. Our data strongly suggest that methadone in combination with chlorobutanol is associated with QTc interval prolongation.
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Affiliation(s)
- Craig A Kornick
- Pain and Palliative Care Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA Department of Pharmacology, Georgetown University Medical Center, Washington, DC, USA Department of Pharmacy, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA Department of Cardiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA Department of Medicine, University of Arizona Health Sciences Center, Tucson, AZ, USA
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Frishman WH, Del Vecchio A, Sanal S, Ismail A. Cardiovascular manifestations of substance abuse: part 2: alcohol, amphetamines, heroin, cannabis, and caffeine. HEART DISEASE (HAGERSTOWN, MD.) 2003; 5:253-71. [PMID: 12877759 DOI: 10.1097/01.hdx.0000080713.09303.a6] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The abuse of alcohol is associated with chronic cardiomyopathy, hypertension, and arrhythmia. Abstinence or using alcohol in moderation can reverse these cardiovascular problems. Alcohol is also distinguished among the substances of abuse by having possible protective effects against coronary artery disease and stroke when used in moderate amounts. Amphetamines (eg, speed, ice, ecstasy) have many of the cardiovascular toxicities seen with cocaine, including acute and chronic cardiovascular diseases. Heroin and other opiates can cause arrhythmias and noncardiac pulmonary edema, and may reduce cardiac output. Cardiovascular problems are less common with cannabis (marijuana) than with opiates, but major cognitive disorders may be seen with its chronic use. It is still controversial whether caffeine can cause hypertension and coronary artery disease, and questions have been raised about its safety in patients with heart failure and arrhythmia.
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Affiliation(s)
- William H Frishman
- Department of Medicine, The New York Medical College/Westchester Medical Center, Valhalla, NY 10595, USA
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Abstract
Three patients who developed torsades de pointes while receiving high dosages of oral methadone (>600mg/day) are presented. In all of the cases, drug interactions involving methadone and CYP3A4 isoenzyme system were possible. Two cases involve some previous cardiac impairment. The potential for toxic doses of methadone to cause ventricular arrhythmia is raised by these cases. Until further evidence is available it may be prudent to be vigilant for arrhythmias when high dosages of methadone (>600mg/day) are used, especially in patients on other drugs that interact with the CYP3A4 isoenzyme system, or with conditions that predispose to torsades de pointes.
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Affiliation(s)
- Paul W Walker
- Department of Symptom Control and Palliative Care, 1515 Holcombe Blvd., Box 8, M.D. Anderson Cancer Center, The University of Texas, Houston, TX 77030, USA Family Medicine, University of Alberta, Edmonton, Alberta, Canada Department of Cardiology, Grey Nuns Community Hospital and Health Centre, Edmonton, Alberta, Canada
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