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Shanahan CW, Reding O, Holmdahl I, Keosaian J, Xuan Z, McAneny D, Larochelle M, Liebschutz J. Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed. BMJ Open 2021; 11:e047928. [PMID: 34385249 PMCID: PMC8362709 DOI: 10.1136/bmjopen-2020-047928] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management. DESIGN Longitudinal survey of patients 7 days before and 7-14 days after surgery. SETTING Academic urban safety-net hospital. PARTICIPANTS 181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES Total morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids. RESULTS Surgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (-2.05 to -0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (-0.09% to -0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to -104.82) total MED increase in opioid consumption, and 19% (-0.35% to -0.02%) fewer unused opioids. High-risk drug use was associated with 9% (-0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices. CONCLUSIONS Participants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.
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Affiliation(s)
- Christopher W Shanahan
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Olivia Reding
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Inga Holmdahl
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia Keosaian
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ziming Xuan
- Community Health Sciences, Boston University, Boston, Massachusetts, USA
| | - David McAneny
- Department of General Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Marc Larochelle
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Prescribing Opioids: Universal Education on Opioid Use, Storage, and Disposal. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00427-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mohsen W, Chan P, Whelan M, Glass A, Mouton M, Young E, Tran Q, Arora S, Davison S, Lama T, Cobrador C, Levy M. Hepatitis C treatment for difficult to access populations: can telementoring (as distinct from telemedicine) help? Intern Med J 2019; 49:351-357. [PMID: 30091164 DOI: 10.1111/imj.14072] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although hepatitis C virus (HCV) infection is curable, treatment of difficult to access populations (DTAP) presents unique challenges. Project ECHO (PE) (Extension for Community Healthcare Outcomes) is a telementoring programme adopted to support clinicians treating DTAP. AIMS To determine if the PE model supports primary care clinicians treating HCV and to compare cohort of PE patients with those in a tertiary liver clinic (TLC). METHODS Weekly PE group video conferences were conducted. Clinical information, laboratory indices, psychosocial elements and treatment outcomes, including sustained virological response (SVR) data were recorded in the first 100 consecutive cases and retrospectively compared to 100 consecutive patients seen at a TLC from July 2016 to April 2017. RESULTS Some patient characteristics were similar between PE and TLC: gender (72% vs 75% male; P = 0.23), median age (45 vs 50; P = 0.344) and the proportion of treatment naïve patients (95.0% vs 90.9%). Treatment for HCV was commenced in 78% of the PE patients and 81% of the TLC patients; 67/68 of the TLC patients and 60/61 PE patients with virological follow up who completed treatment and attended follow up have confirmed SVR. PE patients are more likely to have ongoing substance use (44% vs 17% P < 0.001), be active intravenous drug users (32% vs 17%; P < 0.001) and polysubstance abusers (26% vs 7%; P < 0.001) and were more likely to be taking opioid substitution therapy (74% vs 20%; P < 0.001). Indigenous patients were three times more greatly represented in PE (15% vs 5%; P = 0.018). CONCLUSION PE is an effective model to support primary healthcare providers treating HCV in DTAP with similar rates of treatment uptake and SVR compared to patients in TLC.
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Affiliation(s)
- Waled Mohsen
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Patrick Chan
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Michelle Whelan
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ann Glass
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Marlize Mouton
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ernest Young
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Quyen Tran
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Sanjeev Arora
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Scott Davison
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Tenzin Lama
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Cherry Cobrador
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Miriam Levy
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Reddy A, de la Cruz M. Safe Opioid Use, Storage, and Disposal Strategies in Cancer Pain Management. Oncologist 2019; 24:1410-1415. [PMID: 31097618 DOI: 10.1634/theoncologist.2019-0242] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Opioids are required by a majority of patients with advanced cancer. Oncologists and palliative care clinicians are faced with the challenge of safely prescribing opioids in the current environment of an opioid crisis. Many patients with cancer use opioids unsafely, store them in unsecure locations, and do not dispose of unused opioids, leading to increased availability of these opioids for others to misuse. More than 50% of people who misuse opioids obtain the drugs from a friend or relative with or without their consent. Patient and provider education has been shown to improve safe opioid use, promote secure storage, and also increase disposal of unused opioids safely in drug take-back programs that are now widely available. This article highlights the importance of patient education and cautious opioid prescribing in patients with cancer. IMPLICATIONS FOR PRACTICE: The current opioid crisis makes it challenging to effectively manage cancer pain. Providers play a prominent role in minimizing opioid misuse. Cautious prescribing with limits enforced on the quantity of opioids prescribed, close follow-up, and consistent and frequent provision of opioid education are a must. Evidence points to the impact of patient education in promoting safety around opioid use. Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others. The importance of not sharing, always locking up, and disposing of unused and expired opioids must be highlighted as part of the opioid education that must be delivered every time that opioids are prescribed. Information about local drug take-back programs may also help increase disposal of unused opioids.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Schwartz L, Mercurio-Zappala M, Howland MA, Hoffman RS, Su MK. Unintentional methadone and buprenorphine exposures in children: Developing prevention messages. J Am Pharm Assoc (2003) 2017; 57:S83-S86. [PMID: 28292505 DOI: 10.1016/j.japh.2017.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To develop key messages for methadone and buprenorphine safety education material based on an analysis of calls to the NYC Poison Control Center (NYC PCC) and designed for distribution to caregivers of young children. METHODS Retrospective review of all calls for children 5 years of age and younger involving methadone or buprenorphine from January 1, 2000, to June 15, 2014. A data abstraction form was completed for each case to capture patient demographics, exposure and caller sites, caller relation to patient, qualitative information regarding the exposure scenario, the product information, if naloxone was given, and the medical outcome of the case. RESULTS A total of 123 cases were identified. The ages of the children ranged from 4 days to 5 years; 55% were boys. All exposures occurred in a home environment. The majority of the calls were made to the NYC PCC by the doctor (74%) or nurse (2%) at a health care facility. Approximately one-fourth of the calls came from the home and were made by the parent (22%) or grandparent (2%). More than one-half of the exposures involved methadone (64%). Naloxone was administered in 28% of cases. Approximately one-fourth of the children did not experience any effect after the reported exposure, one-half (51%) experienced some effect (minor, moderate, or major), and there was 1 death (1%). More than one-half of the children were admitted to the hospital, with 40% admitted to critical care and 13% to noncritical care. Approximately 23% were treated and released from the hospital, and 20% were lost to follow-up or never arrived to the hospital. The remaining 4% were managed on site without a visit to the hospital. CONCLUSION Exposures to methadone and buprenorphine are dangerous with some leading to serious health effects. Safe storage and disposal instructions are needed for homes where children may be present.
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Anderson M, Hawkins L, Eddleston M, Thompson JP, Vale JA, Thomas SHL. Severe and fatal pharmaceutical poisoning in young children in the UK. Arch Dis Child 2016; 101:653-6. [PMID: 27185085 DOI: 10.1136/archdischild-2015-309921] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 03/16/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Accidental poisoning in young children is common, but severe or fatal events are rare. This study was performed to identify the number of such events occurring in the UK and the medications that were most commonly responsible. DESIGN Analysis of national data sets containing information relating to severe and fatal poisoning in children in the UK. DATA SOURCES Office of National Statistics mortality data for fatal poisoning; Paediatric Intensive Care Audit Network admissions database and the National Poisons Information Service for severe non-fatal poisoning; Hospital Episode Statistics for admission data for implicated agents. RESULTS Between 2001 and 2013, there were 28 children aged 4 years and under with a death registered as due to accidental poisoning by a pharmaceutical product in England and Wales. Methadone was the responsible drug in 16 (57%) cases. In the UK, 201 children aged 4 years and under were admitted to paediatric intensive care with pharmaceutical poisoning between 2002 and 2012. The agent(s) responsible was identified in 115 cases, most commonly benzodiazepines (22/115, 19%) and methadone (20/115, 17%). CONCLUSIONS Methadone is the most common pharmaceutical causing fatal poisoning and a common cause of intensive care unit admissions in young children in the UK.
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Affiliation(s)
- Mark Anderson
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK Newcastle Unit, National Poisons Information Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Leonard Hawkins
- Newcastle Unit, National Poisons Information Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael Eddleston
- Edinburgh Unit, National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK Department of Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John P Thompson
- Cardiff Unit, National Poisons Information Service, University Hospital Llandough, Penarth, Vale of Glamorgan, UK
| | - J Allister Vale
- Birmingham Unit, National Poisons Information Service, City Hospital, Birmingham, UK
| | - Simon H L Thomas
- Newcastle Unit, National Poisons Information Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK Institute of Cellular Medicine, Medical Toxicology Centre, Newcastle University, Newcastle upon Tyne, UK
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Binswanger IA, Glanz JM. Pharmaceutical Opioids in the Home and Youth: Implications for Adult Medical Practice. Subst Abus 2015; 36:141-3. [PMID: 25671706 DOI: 10.1080/08897077.2014.991058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pharmaceutical opioid prescribing, opioid use disorders, and related poisonings have increased substantially in the last decade. In particular, pharmaceutical opioid deaths among youth have markedly increased. One area that has received relatively little attention is the role of home safety, given that parents are an important source of opioids for youth. Parents may intentionally share opioids with youth, due to low perceived risks or limited knowledge, and youth may divert opioids from parents' medicine cabinets. Safe medication storage has long been mandated by treatment programs that provide pharmacologically supported treatment of opioid use disorders, but it is not generally encouraged or required for pharmaceutical opioids prescribed for pain. Greater attention is needed on the development, evaluation, and implementation of 3 preventive strategies. These 3 strategies can be delivered in or supported by adult medical practices: (1) fully informing adults prescribed opioids about the risks of opioids to family members and others; (2) providing locked medication safe storage devices; and (3) educating parents on safe disposal options. However, a critical evidence base is still lacking for these opioid safety interventions.
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Affiliation(s)
- Ingrid A Binswanger
- a Division of General Internal Medicine and Division of Substance Dependence , University of Colorado School of Medicine , Aurora , Colorado , USA
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Reddy A, de la Cruz M, Rodriguez EM, Thames J, Wu J, Chisholm G, Liu D, Frisbee-Hume S, Yennurajalingam S, Hui D, Cantu H, Marin A, Gayle V, Shinn N, Xu A, Williams J, Bruera E. Patterns of storage, use, and disposal of opioids among cancer outpatients. Oncologist 2014; 19:780-5. [PMID: 24868100 DOI: 10.1634/theoncologist.2014-0071] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our objective was to determine the patterns of storage, utilization, and disposal of opioids among cancer outpatients. PATIENTS AND METHODS We surveyed 300 adult cancer outpatients receiving opioids in our supportive care center and collected information regarding opioid use, storage, and disposal, along with scores on the CAGE (cut down, annoyed, guilty, eye-opener) alcoholism screening questionnaire. Unsafe use was defined as sharing or losing opioids; unsafe storage was defined as storing opioids in plain sight. RESULTS The median age was 57 years. CAGE was positive in 58 of 300 patients (19%), and 26 (9%) had a history of illicit drug use. Fifty-six (19%) stored opioids in plain sight, 208 (69%) kept opioids hidden but unlocked, and only 28 (9%) locked their opioids. CAGE-positive patients (p = .007) and those with a history of illicit drug use (p = .0002) or smoking (p = .03) were more likely to lock their opioids. Seventy-eight (26%) reported unsafe use by sharing (9%) or losing (17%) their opioids. Patients who were never married or single (odds ratio: 2.92; 95% confidence interval: 1.48-5.77; p = .006), were CAGE positive (40% vs. 21%; p = .003), or had a history of illicit drug use (42% vs. 23%; p = .031) were more likely to use opioids unsafely. Overall, 223 of 300 patients (74%) were unaware of proper opioid disposal methods, and 138 (46%) had unused opioids at home. CONCLUSION A large proportion of cancer patients improperly and unsafely use, store, and dispose of opioids, highlighting the need for establishment of easily accessed patient education and drug take-back programs.
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Affiliation(s)
- Akhila Reddy
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eden Mae Rodriguez
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Thames
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jimin Wu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gary Chisholm
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Yennurajalingam
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hilda Cantu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alejandra Marin
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vicki Gayle
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nancy Shinn
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Angela Xu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Gibson JC, Vulliamy A. Accidental methadone poisoning in children: a call for Canadian research action. CHILD ABUSE & NEGLECT 2010; 34:553-554. [PMID: 20605632 DOI: 10.1016/j.chiabu.2010.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 01/20/2010] [Accepted: 02/02/2010] [Indexed: 05/29/2023]
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Abstract
INTRODUCTION We discuss accidental methadone intoxication in an 11-month-old female infant, review the literature, and stress the potential for child abuse among methadone-maintained caregivers. CASE An 11-month-old female infant presented with lethargy. Vital signs were normal, and pupils were constricted. Sepsis workup revealed no evidence of bacterial infection. High venous pCO2 suggested respiratory acidosis. Urine toxicology revealed high concentrations of methadone and its metabolites, and the diagnosis of methadone intoxication was confirmed when 0.1 mg/kg intravenous naloxone normalized the child's behavior. Social service agency inquiries found that the child's grandfather had been prescribed methadone for acquired morphine addiction. He carried 5-mg methadone tablets in his pocket and had recently babysat the infant. The patient was subsequently discharged home with pediatric and community services follow-up. DISCUSSION Methadone intoxication should be considered in children presenting with lethargy, miosis, and respiratory depression. Seventy-two percent of reported methadone poisoning patients are symptomatic, and unintentional poisoning is a real danger to children because small amounts can be fatal. There are also several case reports where the cause of intoxication was homicide by the parents. Initial management consists of establishing an airway, and naloxone may be indicated, before urine toxicology results are obtained, to help establish the diagnosis. However, if 2 doses do not reverse the child's symptoms, the diagnosis should be questioned. When repeated bolus doses of naloxone are indicated, a continuous infusion may be preferable.
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