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Brown C, Ray A. Substance Use Disorders and Medication-Assisted Therapies: Current Practices and Implications for Nursing. Nurs Clin North Am 2023; 58:165-181. [PMID: 37105652 DOI: 10.1016/j.cnur.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
In the United States, the opioid epidemic and COVID-19-related substance use have exacerbated the overall incidence of substance use disorders (SUDs). Medication-assisted therapy (MAT), or cognitive and behavioral therapy that combines medications that reduce substance use or acute withdrawal symptoms, has dramatically improved outcomes for SUD patients, including preventing mortality. With recent US Congressional funding for MAT, patients presenting for acute care on MAT-related medications will continue to increase. Nurses should be aware of these medications' mechanism of action, typical side effects, and implications on treating acute pain to optimize their care.
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Affiliation(s)
- Courtney Brown
- Novant Health, Winston-Salem, NC 27106, USA; Department of Academic Nursing, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA.
| | - Anisa Ray
- Emergency Room, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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Kay A, Shmuts R, Beck M. Understanding and co-managing medication treatment options for opioid use disorder. Intern Emerg Med 2022; 17:2159-2165. [PMID: 35138549 DOI: 10.1007/s11739-022-02936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
The number of patients with opioid use disorder (OUD) has increased dramatically. Substance use disorders in general are thought to occur in one in five patients in primary care. However, despite this prevalence, there is a dearth of training in undergraduate and continuing medical education to manage OUDs, and internal medicine doctors need to have an understanding of the basic physiology and treatment options for this illness. Expanding knowledge of OUD treatments will allow internists to use their skills and strong patient-doctor relationships to ensure the trust of their patients with OUD, leading to better outcomes and increased chances of recovery. It will also allow clinicians to appropriately refer their patients for lifesaving specialized care and help them prevent dangerous medical complications often seen as a result of addiction. There are three FDA-approved medications to treat OUD disorder, known collectively as medication-assisted treatment (MAT). In this paper, the three medications-methadone, naltrexone, and buprenorphine-are presented, compared, contrasted, and clinically reviewed.
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Affiliation(s)
- Abigail Kay
- Department of Psychiatry and Human Behavior-Division of Substance Abuse, The Sidney Kimmel Medical College at Thomas Jefferson University, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rachel Shmuts
- Department of Psychiatry, Rowan University School of Osteopathic Medicine, Mount Laurel, NJ, USA.
| | - Melanie Beck
- Cooper Medical School of Rowan University at AtlantiCare Regional Medical Center, Atlantic City, NJ, USA
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Effects of opioid receptor agonist and antagonist medications on electrocardiogram changes and presentation of cardiac arrhythmia: review article. J Interv Card Electrophysiol 2021; 63:471-500. [PMID: 34674120 DOI: 10.1007/s10840-021-01072-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE Mortality associated with prescription opioids has significantly increased over the past few decades and is considered a global pandemic. Prescribed opioids can cause cardiac arrhythmias, leading to fatal outcomes and unexpected death, even in the absence of structural cardiac disease. Despite the extent of cardiac toxicity and death associated with these medications, there is limited data to suggest their influences on cardiac electrophysiology and arrhythmias, with the exception of methadone. The goal of our review is to describe the possible mechanisms and to review the different ECG changes and arrhythmias that have been reported. METHODS A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct to identify studies that demonstrated the use of prescription opioids leading to electrocardiogram (ECG) changes and cardiac arrhythmias. RESULTS Many of the commonly prescribed opioid medications can uniquely effect the ECG, and can lead to the development of various cardiac arrhythmias. One of the most significant side effects of these drugs is QTc interval prolongation, especially when administered to patients with a baseline risk for QTc prolongation. A prolonged QTc interval can cause lethal torsades de pointes and ventricular fibrillation. Obtaining an ECG at baseline, following a dosage increase, or after switching an opioid medication, is appropriate in patients taking certain prescribed opioids. Opioids are often used first line for the treatment of acute and chronic pain, procedural sedation, medication opioid use disorders, and maintenance therapy. CONCLUSIONS To reduce the risk of cardiac arrhythmias and to improve patient outcomes, consideration of accurate patient selection, concomitant medications, electrolyte monitoring, and vigilant ECG monitoring should be considered.
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Abstract
PURPOSE OF REVIEW Opioid use disorder (OUD) remains a national epidemic with an immense consequence to the United States' healthcare system. Current therapeutic options are limited by adverse effects and limited efficacy. RECENT FINDINGS Recent advances in therapeutic options for OUD have shown promise in the fight against this ongoing health crisis. Modifications to approved medication-assisted treatment (MAT) include office-based methadone maintenance, implantable and monthly injectable buprenorphine, and an extended-release injectable naltrexone. Therapies under investigation include various strategies such as heroin vaccines, gene-targeted therapy, and biased agonism at the G protein-coupled receptor (GPCR), but several pharmacologic, clinical, and practical barriers limit these treatments' market viability. This manuscript provides a comprehensive review of the current literature regarding recent innovations in OUD treatment.
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Shi M, Bouwmeester H, Rietjens IMCM, Strikwold M. Integrating in vitro data and physiologically based kinetic modeling-facilitated reverse dosimetry to predict human cardiotoxicity of methadone. Arch Toxicol 2020; 94:2809-2827. [PMID: 32367273 PMCID: PMC7395048 DOI: 10.1007/s00204-020-02766-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/22/2020] [Indexed: 12/23/2022]
Abstract
Development of novel testing strategies to detect adverse human health effects is of interest to replace in vivo-based drug and chemical safety testing. The aim of the present study was to investigate whether physiologically based kinetic (PBK) modeling-facilitated conversion of in vitro toxicity data is an adequate approach to predict in vivo cardiotoxicity in humans. To enable evaluation of predictions made, methadone was selected as the model compound, being a compound for which data on both kinetics and cardiotoxicity in humans are available. A PBK model for methadone in humans was developed and evaluated against available kinetic data presenting an adequate match. Use of the developed PBK model to convert concentration–response curves for the effect of methadone on human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) in the so-called multi electrode array (MEA) assay resulted in predictions for in vivo dose–response curves for methadone-induced cardiotoxicity that matched the available in vivo data. The results also revealed differences in protein plasma binding of methadone to be a potential factor underlying variation between individuals with respect to sensitivity towards the cardiotoxic effects of methadone. The present study provides a proof-of-principle of using PBK modeling-based reverse dosimetry of in vitro data for the prediction of cardiotoxicity in humans, providing a novel testing strategy in cardiac safety studies.
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Affiliation(s)
- Miaoying Shi
- Division of Toxicology, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Hans Bouwmeester
- Division of Toxicology, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands
| | - Ivonne M C M Rietjens
- Division of Toxicology, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands
| | - Marije Strikwold
- Van Hall Larenstein University of Applied Sciences, 8901 BV, Leeuwarden, The Netherlands
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Blanco-Gandía MC, Rodríguez-Arias M. Pharmacological treatments for opiate and alcohol addiction: A historical perspective of the last 50 years. Eur J Pharmacol 2018; 836:89-101. [DOI: 10.1016/j.ejphar.2018.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/13/2018] [Accepted: 08/03/2018] [Indexed: 12/17/2022]
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Abstract
OBJECTIVES Methadone is often used in pediatric patients to prevent or treat opioid withdrawal after prolonged sedation. Prolonged corrected QT interval is an important adverse effect of methadone because it can progress to torsades de pointes, a potentially fatal dysrhythmia. The prevalence of corrected QT interval prolongation and contributing risk factors are not well defined in hospitalized pediatric patients receiving methadone. The study purpose was to identify the frequency and risk factors of corrected QT interval prolongation in hospitalized pediatric patients receiving methadone. DESIGN Retrospective cohort study. SETTING Tertiary academic pediatric hospital, University of California Davis Children's Hospital, Sacramento, CA. PATIENTS Cohort of 89 pediatric patients (birth to 18 yr) who received at least one dose of methadone while hospitalized. INTERVENTIONS Retrospective data over 7.5 years were obtained from the electronic health record. MEASUREMENTS AND MAIN RESULTS From the cohort, 45 patients (50.6%) had documented corrected QT interval prolongation (≥ 450 ms) during the study period. No episodes of torsades de pointes were identified. In univariate analyses, higher maximum methadone doses were associated with a prolonged corrected QT interval (0.98 vs 0.59 mg/kg/d; odds ratio, 2.56; 1.15-5.70). Corrected QT interval prolongation occurred more frequently in patients with cardiac disease (63% vs 41%; p = 0.10). No factors were statistically significant in the multivariate analysis. CONCLUSIONS In hospitalized pediatric patients receiving methadone, corrected QT interval prolongation was common, but no episodes of torsades de pointes were documented. Risk factors that have been identified in adults were not associated with prolongation in our study population.
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Heath TS, Greenberg RG, Hupp SR, Turner DA, Hornik CP, Zimmerman KO. Effects of Methadone on Corrected Q-T Interval Prolongation in Critically Ill Children. J Pediatr Pharmacol Ther 2018; 23:119-124. [PMID: 29720913 DOI: 10.5863/1551-6776-23.2.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to determine the association between methadone use and corrected Q-T interval (QTc) prolongation in critically ill children. METHODS A retrospective cohort study of critically ill children receiving methadone at a tertiary care pediatric hospital was conducted. Patients younger than 19 years who had been admitted to the intensive care unit between January 1, 2009, and June 21, 2013, who had received methadone while inpatients, and who had had electrocardiograms (ECGs) performed within 30 days before and after methadone initiation were included. The primary outcome was the net change in QTc interval between baseline and postmethadone ECGs. Secondary outcomes included percent change in QTc interval and the proportion of patients whose QTc intervals changed from normal to prolonged following methadone initiation. We also evaluated potential predictors of QTc interval prolongation, including age, sex, admission diagnosis category, exposure to other QTc-prolonging medications, presence of congenital heart disease or known arrhythmias, and methadone daily dose and route of administration. RESULTS Sixty-four patients met the inclusion criteria. The median (25th, 75th percentiles) change in QTc interval following methadone initiation was -8 msec (-34, 13.5 msec; p = 0.19). Five patients (8%) had a baseline normal QTc interval that became prolonged after methadone initiation. We identified no statistically significant predictors of QTc prolongation after methadone initiation. CONCLUSIONS In this dedicated pediatric safety study, methadone initiation did not result in prolongation of the QTc interval. Although these findings suggest methadone initiation may not have a substantial effect of QTc prolongation in critically ill children, a controlled, prospective evaluation in this population remains warranted.
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Regarding Methadone and the QTc Interval: Paucity of Clinically Significant Factors in a Retrospective Cohort, Gavin Bart et al. J Addict Med 2018. [DOI: 10.1097/adm.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Author Response to Stoklosa and Haber. J Addict Med 2018. [DOI: 10.1097/adm.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Methadone maintenance therapy (MMT), a pharmacological treatment for opioid use disorder for the past 50 years, continues to remain controversial. Despite consistent and overwhelming evidence confirming the effectiveness and safety of MMT, misconceptions and myths persist regarding its legitimacy as a treatment for opioid addiction. This often results in the underutilization and limited availability of this treatment modality. Despite successful outcomes, the controversial nature of MMT, and the stigma experienced by the patients on methadone, has been a particularly difficult obstacle to overcome. We present the history of MMT, review the evidence for its efficacy in the treatment of opioid dependence, and explore the origins of the stigma and misconceptions related to MMT.
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Gao L, Dimitropoulou P, Robertson JR, McTaggart S, Bennie M, Bird SM. Risk-factors for methadone-specific deaths in Scotland's methadone-prescription clients between 2009 and 2013. Drug Alcohol Depend 2016; 167:214-23. [PMID: 27593969 PMCID: PMC5047032 DOI: 10.1016/j.drugalcdep.2016.08.627] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/01/2016] [Accepted: 08/22/2016] [Indexed: 01/31/2023]
Abstract
AIM To quantify gender, age-group and quantity of methadone prescribed as risk factors for drugs-related deaths (DRDs), and for methadone-specific DRDs, in Scotland's methadone-prescription clients. DESIGN Linkage to death-records for Scotland's methadone-clients with one or more Community Health Index (CHI)-identified methadone prescriptions during July 2009 to June 2013. SETTING Scotland's Prescribing Information System and National Records of Scotland. MEASUREMENTS Covariates defined at first CHI-identified methadone prescription, and person-years at-risk (pys) thereafter until the earlier of death-date or 31 December 2013. Methadone-specific DRDs were defined as: methadone implicated but neither heroin nor buprenorphine. Hazard ratios (HRs) were assessed using proportional hazards regression. FINDINGS Scotland's CHI-identified methadone-prescription cohort comprised 33,128 clients, 121,254 pys, 1,171 non-DRDs and 760 DRDs (6.3 per 1,000 pys), of which 362 were methadone-specific. Irrespective of gender, methadone-specific DRD-rate, per 1,000 pys, was higher in the 35+ age-group (4.2; 95% CI: 3.6-4.7) than for younger clients (1.9; 95% CI: 1.5-2.2). For methadone-specific DRDs, age-related HRs (e.g., 2.9 at 45+ years; 95% CI: 2.1-3.9) were steeper than for all DRDs (1.9; 95% CI: 1.5-2.4); there was no hazard-reduction for females; no gender by age-group interaction; and, unlike for all DRDs, the highest quintile for quantity of prescribed methadone at cohort-entry (>1960mg) was associated with increased HR (1.8; 95% CI: 1.3-2.5). CONCLUSION Higher methadone-specific DRD rates in older clients, irrespective of gender, call for better understanding of methadone's pharmaco-dynamics in older, opioid-dependent clients, many with progressive physical or mental ill-health.
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Affiliation(s)
- Lu Gao
- MRC Biostatistics Unit, Cambridge CB2 0SR, United Kingdom
| | | | - J Roy Robertson
- Usher Institute of Population Health Sciences and Informatics, Edinburgh University, EDINBURGH EH16 4UX, United Kingdom
| | - Stuart McTaggart
- Information Services Division, NHS National Services Scotland, Edinburgh EH12 9EB, United Kingdom
| | - Marion Bennie
- Information Services Division, NHS National Services Scotland, Edinburgh EH12 9EB, United Kingdom; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, United Kingdom
| | - Sheila M Bird
- MRC Biostatistics Unit, Cambridge CB2 0SR, United Kingdom; Department of Mathematics and Statistics, Strathclyde University, Glasgow G1 1XH, United Kingdom.
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Wedam EF, Haigney MC. The Impact of Opioids on Cardiac Electrophysiology. Curr Cardiol Rev 2016; 12:27-36. [PMID: 26818485 PMCID: PMC4807715 DOI: 10.2174/1573403x1201160126122405] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 11/22/2022] Open
Abstract
Synthetic opioid agents have been used in modern medicine for over a century and for opioid addiction treatment for over a half-century. Liberal use of opioids in the United States has been attended by an extraordinary increase in opioid-related mortality, with over 16,000 deaths in 2012. As there have been advances in opioid agents for pain and addiction, so have there been advances in our understanding of the cardiac effects of these agents. In the last 10 years, significant data regarding electrophysiologic effects of these agents have been collected. We aim in this review to discuss the effects on cardiac electrophysiology of the various opioid agents currently in use and the evidence that these effects are contributing to the rise in opioid-related mortality.
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Affiliation(s)
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, A3060, USUHS, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Hassamal S, Fernandez A, Moradi Rekabdarkolaee H, Pandurangi A. QTc Prolongation in Veterans With Heroin Dependence on Methadone Maintenance Treatment. INTERNATIONAL JOURNAL OF HIGH RISK BEHAVIORS & ADDICTION 2015; 4:e23819. [PMID: 26097838 PMCID: PMC4464576 DOI: 10.5812/ijhrba.4(2)2015.23819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/26/2014] [Accepted: 12/02/2014] [Indexed: 12/04/2022]
Abstract
Background: QTc prolongation and Torsade de Ppointes have been reported in patients on methadone maintenance. Objectives: In this study, QTc was compared before and after the veteran (n = 49) was on a stable dosage of methadone for 8.72 ± 4.50 years to treat heroin dependence. Risk factors were correlated with the QTc once the veteran was on a stable dose of methadone. Differences in the clinical risk factors in subgroups of veterans with below and above mean QTc change was compared. Patients and Methods: ECG data was obtained from a 12-lead electrocardiogram (pre-methadone and on methadone) on 49 veterans. Data and risk factors were retrospectively collected from the medical records. Results: The mean QTc at baseline (pre-methadone) was 426 ± 34 msec and after being on methadone for an average of 8.72 ± 4.50 years was significantly higher at 450 ± 35 msec. No significant relationships were found between QTc prolongation and risk factors except for calcium. The methadone dosage was significantly higher in veterans with a QTc change above the mean change of ≥ 24 msec (88.48 ± 27.20 mg v.s 68.96 ± 19.84 mg). None of the veterans experienced cardiac arrhythmias. Conclusions: The low complexity of medical co-morbidities may explain the lack of a significant correlation between any risk factor with the QTc except calcium and methadone dosage. The absence of TdP may be explained by the low prevalence of QTc values > 500 msec as well as the retrospective design of the study. During long-term methadone treatment, there was a slight increase in the QTc interval but we did not find evidence of increased cardiac toxicity as a reason for treatment termination.
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Affiliation(s)
- Sameer Hassamal
- Department of Psychiatry, Virginia Commonwealth University, Virginia, USA
- Corresponding author: Sameer Hassamal, Department of Psychiatry, Virginia Commonwealth University, Virginia, USA. Tel: +1-6263991005, E-mail:
| | - Antony Fernandez
- Department of Psychiatry, Virginia Commonwealth University, Virginia, USA
- McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
| | | | - Ananda Pandurangi
- Department of Psychiatry, Virginia Commonwealth University, Virginia, USA
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DeJongh B, Birkeland K, Brenner M. Managing comorbidities in patients with chronic heart failure: first, do no harm. Am J Cardiovasc Drugs 2015; 15:171-84. [PMID: 25837622 DOI: 10.1007/s40256-015-0115-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Heart failure (HF) affects approximately 5.1 million adults in the USA, with expectations of a rise to nearly 8 million adults by 2030. Patients with HF are at increased risk for morbidity/mortality, and comorbidities can further complicate care for these patients. Diabetes mellitus, chronic pain, arrhythmias, and depression are diagnoses that often coexist with HF. Medications commonly used to treat these comorbidities may induce or worsen HF symptoms, so determining appropriate drug therapy is important. Healthcare providers must understand the relationship between these medications and HF in order to improve prescribing practices to increase patient safety and reduce morbidity and mortality. This manuscript discusses the association between certain medications used to treat the aforementioned diagnoses and their relationship to HF. The purpose of this article is to provide guidance on which pharmacologic options require special consideration, increased monitoring, or complete avoidance in HF patients with diabetes mellitus, chronic pain, arrhythmias, and/or depression.
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Affiliation(s)
- Beth DeJongh
- Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI, 53097, USA
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Alinejad S, Kazemi T, Zamani N, Hoffman RS, Mehrpour O. A systematic review of the cardiotoxicity of methadone. EXCLI JOURNAL 2015; 14:577-600. [PMID: 26869865 PMCID: PMC4747000 DOI: 10.17179/excli2015-553] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 01/14/2015] [Indexed: 01/07/2023]
Abstract
UNLABELLED Methadone is one of the most popular synthetic opioids in the world with some favorable properties making it useful both in the treatment of moderate to severe pain and for opioid addiction. Increased use of methadone has resulted in an increased prevalence of its toxicity, one aspect of which is cardiotoxicity. In this paper, we review the effects of methadone on the heart as well as cardiac concerns in some special situations such as pregnancy and childhood. METHODS We searched for the terms methadone, toxicity, poisoning, cardiotoxicity, heart, dysrhythmia, arrhythmia, QT interval prolongation, torsade de pointes, and Electrocardiogram (ECG) in bibliographical databases including TUMS digital library, PubMed, Scopus, and Google Scholar. This review includes relevant articles published between 2000 and 2013. The main cardiac effects of methadone include prolongation of QT interval and torsade de pointes. Other effects include changes in QT dispersion, pathological U waves, Taku-Tsubo syndrome (stress cardiomyopathy), Brugada-like syndrome, and coronary artery diseases. The aim of this paper is to inform physicians and health care staff about these adverse effects. Effectiveness of methadone in the treatment of pain and addiction should be weighed against these adverse effects and physicians should consider the ways to lessen such undesirable effects. This article presents some recommendations to prevent heart toxicity in methadone users.
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Affiliation(s)
- Samira Alinejad
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences,Birjand, Iran
| | - Toba Kazemi
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences,Birjand, Iran
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Pereleman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Pasdaran Avenue, Birjand, 9713643138 Iran
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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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Raina S, Paydak H, Al-lahham T, Shihabuddin BS. Methadone induced Torsades de Pointes mimicking seizures in clinical presentation. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2014; 40:490-2. [DOI: 10.3109/00952990.2014.965311] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sameer Raina
- University of Arkansas for Medical Sciences
Little RockArkansas
| | - Hakan Paydak
- University of Arkansas for Medical Sciences
Little RockArkansas
- Central Arkansas Veterans Healthcare System
Little RockArkansas
| | | | - Bashir S. Shihabuddin
- University of Arkansas for Medical Sciences
Little RockArkansas
- Central Arkansas Veterans Healthcare System
Little RockArkansas
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Mijatović V, Samojlik I, Ajduković N, Đurendić-Brenesel M, Petković S. Methadone-related deaths - epidemiological, pathohistological, and toxicological traits in 10-year retrospective study in Vojvodina, Serbia. J Forensic Sci 2014; 59:1280-5. [PMID: 24502699 DOI: 10.1111/1556-4029.12425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 04/12/2013] [Accepted: 05/24/2013] [Indexed: 12/01/2022]
Abstract
The number of methadone-related deaths (MRDs) during a 10-year period (2002-2011) in the region of Vojvodina, Serbia, was increased. The cases were evaluated according to epidemiological parameters, pathohistological findings, and toxicological screening. The majority of victims were men, aged from 20 to 38. Pathohistologically, the signs of acute focal myocardial damage were present in the heart of victims with drug abuse history shorter than 2 years, while both signs of recent and chronic focal myocardial damage were developed among victims with longer drug abuse history (2-5 years). In postmortem blood samples of 54.84% of victims, methadone was detected in combination with diazepam, both in therapeutic range. Alcohol was absent in most cases. Other detected drugs were antipsychotics and antidepressants in therapeutic concentrations. These findings raise the attention to the concomitant use of methadone and benzodiazepines with the need for further studies to clarify the mechanism of death in such cases.
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Affiliation(s)
- Vesna Mijatović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
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Ben Bassat OK, Peles E, Schreiber S, Adelson M, Zeltser D, Viskin S, Adler A. Response of QT interval in methadone maintenance treated patients to the rapid changes in heart rate provoked by brisk standing: Comparison to healthy controls and patients with long QT syndrome. J Electrocardiol 2013; 46:519-23. [DOI: 10.1016/j.jelectrocard.2013.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Indexed: 10/26/2022]
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Pani PP, Trogu E, Maremmani I, Pacini M. QTc interval screening for cardiac risk in methadone treatment of opioid dependence. Cochrane Database Syst Rev 2013:CD008939. [PMID: 23787716 DOI: 10.1002/14651858.cd008939.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Methadone represents today the gold standard of efficacy for the pharmacological treatment of opioid dependence. Methadone, like many other medications, has been implicated in the prolongation of the rate-corrected QT (QTc) interval of the electrocardiogram (ECG), which is considered a marker for arrhythmias such as torsade de pointes (TdP). Indications on the association between methadone, even at therapeutic dosages, and TdP or sudden cardiac death have been reported. On these bases, consensus and recommendations involving QTc screening of patients receiving methadone treatment have been developed to identify patients with QTc above the thresholds considered at risk for cardiac arrhythmias, and they provide these individuals with alternative treatment (reduction of methadone dosage; provision of alternative opioid agonist treatment; treatment of associated risk factors). OBJECTIVES To evaluate the efficacy and acceptability of QTc screening for preventing cardiac-related morbidity and mortality in methadone-treated opioid dependents. SEARCH METHODS We searched MEDLINE, EMBASE, CINAHL (to April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Cochrane Drug and Alcohol Review Group Specialised Register (Issue 3, 2013), main electronic sources of ongoing trials, specific trial databases and reference lists of all relevant papers. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs) and non-randomised studies (cohort studies, controlled before and after studies, interrupted time series studies, case control studies) examining the efficacy of QTc screening for the prevention of methadone-related mortality and morbidity in opioid addicts. DATA COLLECTION AND ANALYSIS Two review authors independently screened and extracted data from studies. MAIN RESULTS The search strategy led to the identification of 872 records. Upon full-text assessment, no study was found to meet the quality criteria used for this review. AUTHORS' CONCLUSIONS It is not possible to draw any conclusions about the effectiveness of QTc screening strategies for preventing cardiac morbidity/mortality in methadone-treated opioid addicts. Research efforts should focus on strengthening the evidence about the effectiveness of widespread implementation of such strategies and clarifying the associated benefits and harms.
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Affiliation(s)
- Pier Paolo Pani
- Social-Health Division, Health District 8 (ASL 8) Cagliari, Cagliari, Italy.
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Spevak C, Hamsher C, Brown CQ, Wedam EF, Haigney MC. The clinical significance of QT interval prolongation in anesthesia and pain management: what you should and should not worry about. PAIN MEDICINE 2012; 13:1072-80. [PMID: 22680349 DOI: 10.1111/j.1526-4637.2012.01406.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The most feared drug-induced complication is fatal cardiac arrest. Torsades de pointes (TdP) is a polymorphic ventricular tachycardia occurring in the setting of a QT interval prolongation and is the most frequent type of drug-induced pro-arrhythmia. The most common mechanism of QT prolongation and TdP is blockade of the rapid component of the delayed rectifier repolarizing potassium conductance IKr. Anesthesiologists have extensive experience with QT prolonging drugs, but there are relatively few reports of TdP occurring in the perioperative setting. Nevertheless, regulatory concern regarding the drug droperidol resulted in a significant reduction in its use. Concern regarding two other agents that potently block IKr, i.e., sevoflurane and methadone, has grown, and practitioners are worried that these valuable agents may meet the same fate. In this review, the data regarding the TdP risk of droperidol, sevoflurane, and methadone are compared with particular emphasis on the different settings in which they are employed. While the three drugs are potent IKr inhibitors, little evidence exists to suggest that droperidol or sevoflurane are associated with significant proarrhythmia in the perioperative setting. Due to factors such as inhibition of the parasympathetic nervous system, prevention of hypoxia and hypercarbia, and attention to serum electrolytes, TdP is a very rare occurrence in the perioperative environment. Methadone, however, is typically given to outpatients, over long periods, and in combination with agents that inhibit its metabolism or are QT prolonging in their own right. Thus, pre- and post-drug electrocardiograms may be appropriate when prescribing methadone for outpatients, while the much lower risk for TdP (and the difficulties inherent in QT measurement in the perioperative period) render this approach unfruitful and worthy of reevaluation.
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Affiliation(s)
- Christopher Spevak
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Wenzel-Seifert K, Wittmann M, Haen E. QTc prolongation by psychotropic drugs and the risk of Torsade de Pointes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:687-93. [PMID: 22114630 DOI: 10.3238/arztebl.2011.0687] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 03/10/2011] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Many psychotropic drugs can delay cardiac repolarization and thereby prolong the rate-corrected QT interval (QTc). A prolonged QTc often arouses concern in clinical practice, as it can be followed, in rare cases, by the life-threatening polymorphic ventricular tachyarrhythmia called torsade de pointes (TdP). METHOD We searched PubMed for pertinent literature on the risk of QTc prolongation and/or TdP associated with commonly used psychotropic drugs. RESULTS Thioridazine and ziprasidone confer the highest risk of QTc prolongation and/or TdP. There is also a clinically significant risk associated with haloperidol given intravenously in high doses. TdP has been reported in a few cases in association with the use of newer antipsychotic drugs (mainly quetiapine and amisulpride), most of the tri- and tetracyclic antidepressants, and the selective monoamine reuptake inhibitors citalopram, fluoxetine, paroxetine, and venlafaxine. As a rule, however, QTc prolongation and/or TdP occur only in the presence of multiple additional risk factors, such as age over 65 years, pre-existing cardiovascular disease, bradycardia, female sex, hypokalemia, hypomagnesemia, a supratherapeutic or toxic serum concentration, or the simultaneous administration of other drugs that delay repolarization or interfere with drug metabolism. CONCLUSION Before prescribing a psychotropic drug, the physician should carefully assess its risks and benefits to avoid this type of adverse reaction, particularly when additional risk factors are present. The ECG and electrolytes should be regularly monitored in patients taking psychotropic drugs.
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Affiliation(s)
- Katharina Wenzel-Seifert
- Klinische Pharmakologie, Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie der Universität Regensburg, Universitätstr. 84, 93053 Regensburg, Germany.
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26
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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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Thanavaro KL, Thanavaro JL. Methadone-induced torsades de pointes: A twist of fate. Heart Lung 2011; 40:448-53. [DOI: 10.1016/j.hrtlng.2010.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 12/16/2010] [Accepted: 12/17/2010] [Indexed: 01/08/2023]
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Cheng JWM, Frishman WH, Aronow WS. Updates on cytochrome p450-mediated cardiovascular drug interactions. Dis Mon 2010; 56:163-79. [PMID: 20189501 DOI: 10.1016/j.disamonth.2009.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cytochrome P (CYP) 450 is a superfamily of hemoproteins that play an important role in the metabolism of steroid hormones, fatty acids, and many medications. Many agents used for management of cardiovascular diseases are substrates, inhibitors, or inducers of CYP450 enzymes. When two agents that are substrates, inhibitors, or inducers of CYP450 are administered together, drug interactions with significant clinical consequences may occur. This review discusses CYP450-mediated cardiovascular drug interactions as well as noncardiovascular drug interactions that produced significant cardiovascular side effects. The principles in predicting drug interactions are also discussed.
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Affiliation(s)
- Judy W M Cheng
- Arnold and Marie Schwartz College of Pharmacy and Sciences, Long Island University, Brooklyn, New York, Mt. Sinai Medical Center, New York, New York
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Hanon S, Seewald RM, Yang F, Schweitzer P, Rosman J. Ventricular arrhythmias in patients treated with methadone for opioid dependence. J Interv Card Electrophysiol 2010; 28:19-22. [PMID: 20177760 DOI: 10.1007/s10840-009-9465-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 12/11/2009] [Indexed: 01/19/2023]
Abstract
PURPOSE Over the last decade, there has been a significant rise in reported cases of methadone induced QT prolongation (QTP) and Torsades de Pointes (TdP) in patients treated for opioid dependence. Optimal management of these patients is challenging. METHODS We report a case series of 12 consecutive patients admitted to our institution with methadone-induced QTP and ventricular arrhythmias. RESULTS All patients survived the presenting arrhythmia. Successful transition to buprenorphine was accomplished in three patients. QT interval normalized and none of these patients had recurrent arrhythmias. Methadone dose was reduced in five patients with improvement of QT interval and resolution of arrhythmia. Four patients, including two with ICDs, refused or did not tolerate a reduction in their methadone dose. CONCLUSION Ventricular arrhythmias in patients on methadone are an uncommon but important problem. Buprenorphine, a partial micro-opiate-receptor agonist and a kappa-opiate-receptor antagonist does not cause QTP or TdP. Buprenorphine is a useful and effective alternative to methadone in a select group of patients, including those with documented ventricular arrhythmias on methadone. Pacemakers or defibrillators should be reserved for patients who have failed buprenorphine or a reduced methadone dose.
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Affiliation(s)
- Sam Hanon
- Division of Cardiology, Beth Israel Medical Center, University Hospital and Manhattan Campus for the Albert Einstein College of Medicine, New York, NY, 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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Abstract
Cytochrome P (CYP) 450 is a superfamily of hemoproteins that play an important role in the metabolism of steroid hormones, fatty acids, and many medications. Many agents used for management of cardiovascular diseases are substrates, inhibitors, or inducers of CYP450 enzymes.When two agents that are substrates, inhibitors, or inducers of CYP450 are administered together, drug interactions with significant clinical consequences may occur. This review discusses CYP450-mediated cardiovascular drug interactions as well as noncardiovascular drug interactions that produced significant cardiovascular side effects. The principles in predicting drug interactions are also discussed.
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Armstrong SC, Wynn GH, Sandson NB. Pharmacokinetic Drug Interactions of Synthetic Opiate Analgesics. PSYCHOSOMATICS 2009; 50:169-76. [DOI: 10.1176/appi.psy.50.2.169] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Fonseca F, Marti-Almor J, Pastor A, Cladellas M, Farré M, de la Torre R, Torrens M. Prevalence of long QTc interval in methadone maintenance patients. Drug Alcohol Depend 2009; 99:327-32. [PMID: 18774239 DOI: 10.1016/j.drugalcdep.2008.06.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 06/27/2008] [Accepted: 06/27/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a concern about cardiac rhythm disorders related to QTc interval prolongation induced by methadone. A cross-sectional study was designed to evaluate the prevalence of long QTc (LQTc) interval in patients in methadone maintenance treatment (MMT) and risk factors for LQTc. METHODS The study population included 109 subjects (74 males, median age 43 years). Socio-demographic and toxicological variables were recorded, as well as concomitant use of drugs related with QT prolongation, history of heart diseases, and corrected QT interval by heart rate (QTc) in the ECG. Plasma concentrations of (R)-methadone and (S)-methadone enantiomers were determined in 69 subjects. RESULTS Ten patients (9.2%) presented a QTc above 440 ms but a QTc above 500 ms was observed in only 2 (1.8%). Patients with QTc above 440 ms compared with the remaining subjects were older (median [25th-75th percentile range]: 49 [39-56] years vs. 37 [33-43]; Wilcoxon's W=217.5, p=0.002) and took a higher daily dose of methadone (median [25th-75th percentile range]: 120 [66-228] mg/day vs. 60 [40-110] mg/day; W=298.5, p=0.037). Methadone dose correlated with QTc interval (Pearson's r(2)=0.291, p=0.002). Patients with and without long QTc showed no differences in plasma concentrations of (R)-methadone and (S)-methadone enantiomers. CONCLUSIONS The prevalence of LQTc was 9.2%. An association between LQTc and methadone doses was observed but the relationship with plasma concentrations of methadone enantiomers is unclear.
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Affiliation(s)
- Francina Fonseca
- Drug Addiction Unit, IAPS-Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain
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Abstract
ABSTRACT Background Methadone has been associated with QT prolongation and Torsades de pointes. Ciprofloxacin may prolong QT interval and induce Torsades de pointes when other risk factors are present. Case description A case is described in which a patient receiving methadone treatment developed Torsades de pointes following the addition of ciprofloxacin. Conclusion Ciprofloxacin should be used with caution in patients receiving methadone.
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Affiliation(s)
- Murali K Nair
- Department of Internal Medicine, Mount Sinai School of Medicine, Elmhurst Hospital Center, New York, NY 11373, USA.
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Fanoe S, Jensen GB, Sjøgren P, Korsgaard MPG, Grunnet M. Oxycodone is associated with dose-dependent QTc prolongation in patients and low-affinity inhibiting of hERG activity in vitro. Br J Clin Pharmacol 2008; 67:172-9. [PMID: 19159406 DOI: 10.1111/j.1365-2125.2008.03327.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
WHAT IS ALREADY KNOWN During recent years some opioids have been associated with prolonged QT and torsade de pointes (TdP). In vitro testing has shown that most opioids can block the cardiac potassium channels. This indicates that QT prolongation and TdP could be a more general problem associated with the use of these drugs. WHAT THIS PAPER ADDS This study is the first to show that oxycodone dose is associated with QT prolongation and in vitro blockade of hERG channels expressed in HEK293. Neither morphine nor tramadol doses are associated with the QT interval length. AIMS During recent years some opioids have been associated with prolonged QT interval and torsade de pointes (TdP). In vitro patch clamp testing has shown that most opioids can block human ether-a-go-go related gene (hERG) channels that are known to underlie cardiac repolarizing I(Kr) current. This indicates that QT prolongation and TdP could be a more general problem associated with the use of these drugs. The aims of this study were to evaluate the association between different opioids and the QTc among patients and measure hERG activity under influence by opioids in vitro. METHODS One hundred chronic nonmalignant pain patients treated with methadone, oxycodone, morphine or tramadol were recruited in a cross-sectional study. The QTc was estimated from a 12-lead ECG. To examine hERG activity in the presence of oxycodone, electrophysiological testing was conducted using Xenopus laevis oocytes and HEK293 cells expressing hERG channels. RESULTS There were no differences in gender distribution or age between the treatment groups. The known association between methadone dose and QTc was confirmed (R(2) = 0.09; P = 0.02). Higher oxycodone dose was also associated with longer QTc (R(2) = 0.21; P = 0.02). A 100 mg higher oxycodone dose was associated with a 10 ms(1/2) (95% CI 2-19) longer QTc. Neither morphine nor tramadol dose was associated with the QTc. Electrophysiological testing revealed low-affinity inhibition of the potassium current through hERG channels expressed in HEK293 cells (IC(50) = 171 microM oxycodone). CONCLUSIONS Among patients treated with methadone or oxycodone, higher doses were associated with longer QTc. Oxycodone is capable of inhibiting hERG channels in vitro.
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Affiliation(s)
- Søren Fanoe
- Department of Cardiology, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, Denmark.
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Dubrey SW, Grocott-Mason R. Methadone-associated QT prolongation and torsades de pointes. Br J Hosp Med (Lond) 2007. [DOI: 10.12968/hmed.2007.68.4.221b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Simon W Dubrey
- Consultant Cardiologists, Department of Cardiology, Hillingdon Hospital, Uxbridge, Middlesex UB8 3NN
| | - Richard Grocott-Mason
- Consultant Cardiologists, Department of Cardiology, Hillingdon Hospital, Uxbridge, Middlesex UB8 3NN
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Affiliation(s)
- H Al-Sardar
- Consultant Physician and Honorary Senior Lecturer, Department of Medicine, Southend University Foundation Hospital, Westcliff on Sea SS0 0RY
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