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Ramaiah VK, Kharasch ED. Methadone and Enhanced Recovery After Surgery: Concepts and Protocols. Anesth Analg 2024; 139:670-674. [PMID: 38295148 PMCID: PMC11289168 DOI: 10.1213/ane.0000000000006790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Vijay K Ramaiah
- From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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2
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Smith K, Wang M, Abdukalikov R, McAullife A, Whitesell D, Richard J, Sauer W, Quaye A. Pain Management Considerations in Patients with Opioid Use Disorder Requiring Critical Care. J Clin Pharmacol 2021; 62:449-462. [PMID: 34775634 DOI: 10.1002/jcph.1999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/07/2021] [Indexed: 11/07/2022]
Abstract
The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit (ICU) clinician with guidance and treatment options, including non-opioid analgesia, for patients receiving medications for opioid use disorder (MOUD) and for patients actively misusing opioids. Verification and continuation of the patient's outpatient MOUD regimen, specifically buprenorphine and methadone formulations, assessment of pain and opioid withdrawal, and treatment of acute pain with non-opioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and to reduce the risk of unplanned discharge and other associated morbidity. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kathryn Smith
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ruslan Abdukalikov
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Amy McAullife
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Dena Whitesell
- Department of Psychiatry, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - William Sauer
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA.,Department of Critical Care, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.,Spectrum Healthcare Partners, 324 Gannett Dr, Suite 200, South Portland, ME, 04106, USA
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3
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Niimi N, Yuki K, Zaleski K. Long QT Syndrome and Perioperative Torsades de Pointes: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2020; 36:286-302. [PMID: 33495078 DOI: 10.1053/j.jvca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Naoko Niimi
- Department of Anesthesiology, Juntendo University, Tokyo, Japan.
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Katherine Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
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4
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Abstract
Studies have been conducted on adults prescribed with methadone to determine the necessary frequency of QTc monitoring but no consensus has been reached and no similar research has been conducted in the pediatric population. The objective of this retrospective study was to determine the occurrence rate of QTc interval prolongation associated with methadone use in a pediatric oncologic population. In total, 18% of patients developed QTc interval prolongation. These patients had longer baseline QTc intervals and were on more QTc interval-prolonging medications. Our data suggest that these variables may be able to risk stratify patients who require more frequent monitoring.
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5
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Walroth TA, Boyd AN, Hester AM, Schoenle MK, Hartman BC, Sood R. Risk Factors and Prevalence of QTc Prolongation in Adult Burn Patients Receiving Methadone. J Burn Care Res 2020; 41:416-420. [PMID: 31808804 DOI: 10.1093/jbcr/irz200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Methadone is an opioid commonly used for acute pain management in burn patients. One adverse effect of methadone is QTc interval prolongation, which may be associated with adverse cardiac outcomes. There is currently a paucity of data regarding risk of QTc prolongation in burn patients taking methadone and a lack of evidence-based recommendations for monitoring strategies in this population. The study objective was to determine the prevalence, risk factors, and cardiac outcomes related to methadone-associated QTc prolongation in adult burn patients. A total of 91 patients were included and were divided into groups according to maximum QTc. QTc prolongation was defined as greater than or equal to 470 ms (males) or 480 ms (females). There were no differences between groups regarding patient-specific risk factors, baseline QTc, or time to longest QTc. Patients in the prolonged QTc group had a higher rate of cardiac events (44% vs 9%; P < .001), higher median (IQR) change from baseline to longest QTc (61 ms [18,88] vs 23 ms [13,38]; P < .001), higher median (IQR) total daily dose of methadone (90 mg [53,98] vs 53 mg [30,75]; P = .004), and longer median (IQR) length of stay (53 [33,82] vs 35 [26,52] days; P = .008). QTc prolongation in burn patients was associated with increased methadone dose and resulted in a higher rate of cardiac events. This study was the first of its kind to look at risk factors and cardiac outcomes associated with methadone use in burn patients.
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Affiliation(s)
- Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana
| | - Allison N Boyd
- Department of Pharmacy, Rhode Island Hospital, Providence, Rhode Island
| | | | - Marilyn K Schoenle
- Department of Pharmacy and Therapeutics, University of Pittsburgh Medical Center Presbyterian, Shadyside, Pennsylvania
| | - Brett C Hartman
- Richard M. Fairbanks Burn Center, Eskenazi Health, Indianapolis, Indiana
| | - Rajiv Sood
- Richard M. Fairbanks Burn Center, Eskenazi Health, Indianapolis, Indiana
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6
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Sheibani M, Zamani N, Hassanian-Moghaddam H. Electrocardiographic Findings in Mortalities Due to Pure Methadone Toxicity. Cardiovasc Toxicol 2019; 19:62-71. [PMID: 30019098 DOI: 10.1007/s12012-018-9474-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We aimed to evaluate electrocardiographic (ECG) abnormalities in mortalities due to pure methadone toxicity in ICU patients since methadone-related mortality may be due to cardiac complications even in acute toxicities. In a retrospective single-center study, files of all patients who had died with confirmed diagnosis of pure methadone toxicity between 2011 and 2016 were evaluated. Autopsy was performed in all cases. A cardiologist measured all ECG quantitative and qualitative indices. Fifty-one deaths were recorded. Forty-two dead patients were males. Median [IQR] age of the patients was 44 [30, 60] years. Of them, 38 (69%) were methadone-dependent and were significantly older than methadone-naïve patients (p = 0.008 and p = 0.001, respectively). ECG abnormalities were detected in all cases. ST-T abnormalities were found in 33 (64.7%) patients. Except longer PR interval in dependent patients (p = 0.017) and specific ST elevation in naïve cases (p = 0.008), other ECG indices were similar in two groups. No correlation was found between ST-T abnormalities and coronary disease in autopsy. ECG abnormalities irrelevant to coronary artery diseases are common in methadone-related mortalities. Methadone toxicity may affect myocardium and play a role in death. Further prospective studies to evaluate other cardiac indices in methadone-poisoned patients are recommended.
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Affiliation(s)
- Mehdi Sheibani
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Nasim Zamani
- Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, 19839-63113, Tehran, Islamic Republic of Iran
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, 19839-63113, Tehran, Islamic Republic of Iran.
- Department of Clinical Toxicology, Loghman-Hakim Hospital, Kamali Street, South Karegar Avenue, 1333431151, Tehran, Islamic Republic of Iran.
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7
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Lovell AG, Protus BM, Saphire ML, Kale SS, Lehman A, Hartman A. Evaluation of QTc Interval Prolongation Among Patients With Cancer Using Enteral Methadone. Am J Hosp Palliat Care 2018; 36:177-184. [PMID: 30428683 DOI: 10.1177/1049909118811904] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
CONTEXT: The effect of methadone on corrected QT interval (QTc) in patients with cancer pain is not well-known. OBJECTIVES: To describe and characterize the effect of low-, moderate-, and high-dose enteral methadone on QTc interval in patients with cancer. METHODS: Retrospective cohort study including patients prescribed enteral methadone during the 27-month study period. Participants were divided into 3 methadone daily dose groups: <30 (low dose), 30 to 59 (moderate dose), ≥60 (high dose) mg. The primary outcome was the incidence of QTc prolongation (>450 ms for females and >430 ms for males). Secondary outcomes included the magnitude of change in QTc after starting methadone, the incidence of clinically significant QTc prolongation (>500 ms) and the prevalence of torsades de pointes and syncope. RESULTS: Two hundred three patients met study inclusion criteria: 91 (45%) low dose, 52 (26%) moderate dose, and 60 (29%) high dose. Incidence of QTc prolongation for low-, moderate-, and high-dose groups was 50 (55%), 37 (71%), and 43 (72%), respectively ( P = .039, low vs high dose). Incidence of clinically significant QTc prolongation was 10 (11%), 4 (8%), and 7 (12%) for low-, moderate-, and high-dose groups. For patients without QTc prolongation prior to initiating methadone, 62% of moderate-dose patients and 67% of high-dose patients had QTc prolongation, while taking methadone. CONCLUSION: This study found a notably high incidence of QTc prolongation in patients with cancer using enteral methadone. Future studies should aim to determine the risk of adverse cardiac effects in the cancer population and determine appropriate monitoring of methadone for pain management.
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Affiliation(s)
| | | | - Maureen L Saphire
- 2 The Arthur G. James Cancer Hospital, Richard Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Sachin S Kale
- 3 Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amy Lehman
- 4 Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Amber Hartman
- 2 The Arthur G. James Cancer Hospital, Richard Solove Research Institute, The Ohio State University, Columbus, OH, USA
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8
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Behzadi M, Joukar S, Beik A. Opioids and Cardiac Arrhythmia: A Literature Review. Med Princ Pract 2018; 27:401-414. [PMID: 30071529 PMCID: PMC6244110 DOI: 10.1159/000492616] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE One of the most important side effects of opioids is their influence on the electrical activity of the heart. This review focusses on the effects of opioids on QT interval prolongation and their arrhythmogenic liability. METHODS By using various keywords, papers published up to 2018 in different databases were searched and identified. The search terms were opioids names, corrected QT interval, human-ether-a-go-go gene, torsades de pointes (TdP), cardiac arrhythmias, opioid dependence and other relevant terms. It emphasized the effects of each opioid agent alone on electrocardiogram (ECG) and some interactions. RESULTS Available data indicate that some opioids such as methadone are high-risk even at low doses, and have potential for prolongation of the QT interval and development of TdP, a dangerous ventricular tachycardia. A number of opioids such as tramadol and oxycodone are intermediate risk drugs and may develop long QT interval and TdP in high doses. Some other opioids such as morphine and buprenorphine are low-risk drugs and do not produce QT interval prolongation and TdP at least in routine doses. Opium-consumers are at higher risk of supra-ventricular arrhythmias, sinus bradycardia, cardiac block and atrial fibrillation. CONCLUSION The cardiac arrhythmogenicity of various opioids is different. Methadone has a higher capability to induce long QT interval and dangerous arrhythmias in conventional doses than others. To reduce of arrhythmogenic risk, high doses of opioids must be used cautiously with periodic monitoring of ECG in high-risk consumers such as patients under opioid maintenance treatment.
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Affiliation(s)
- Mina Behzadi
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences and Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Siyavash Joukar
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences and Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Beik
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
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9
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Relationship between Corrected-QT Intervals and Other ECG Characteristics with Methadone Dose in Methadone Maintenance Treatment (MMT) Patients and Healthy Subjects: A Case- Control Study. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2017. [DOI: 10.5812/rijm.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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10
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Juba KM, Khadem TM, Hutchinson DJ, Brown JE. Methadone and Corrected QT Prolongation in Pain and Palliative Care Patients: A Case-Control Study. J Palliat Med 2017; 20:722-728. [PMID: 28186837 DOI: 10.1089/jpm.2016.0411] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Methadone (ME) is commonly used in pain and palliative care (PPC) patients with refractory pain or intolerable opioid adverse effects (AEs). A unique ME AE is its corrected QT (QTc) interval prolongation risk, but most evidence exists in methadone maintenance therapy patients. OBJECTIVE Our goal was to identify QTc interval prolongation risk factors in PPC patients receiving ME and other medications known to prolong the QTc interval and develop a risk stratification tool. DESIGN We performed a case-control study of adult inpatients receiving ME for pain management. Settings/Subjects: Adult inpatients receiving ME with a QTc >470 msec (males) and >480 msec (females) were matched 1:2 according to age, history of QTc prolongation, and gender with ME patients who did not have a prolonged QTc interval. QTc prolongation risk factors were collected for both groups. Covariates were analyzed using conditional logistic regression. Classification and regression tree analysis was used to identify the ME dose associated with QTc prolongation. RESULTS Predictors of QTc prolongation included congestive heart failure (CHF) (OR: 11.9; 95% CI: 3.7-38.2; p < 0.00), peptic ulcer disease (PUD) (odds ratio [OR]: 8.3; 95% confidence interval [95% CI]: 2.4-28.9; p < 0.00), hypokalemia (OR: 6.5; 95% CI: 1.5-28.2; p < 0.01), rheumatologic diseases (OR: 4.7; 95% CI: 1.6-13.9; p < 0.00), taking medications with a known torsades de pointes (TdP) risk (OR: 4.4; 95% CI: 1.8-10.7; p < 0.01), malignancy (OR: 3.3; 95% CI: 1.2-9.3; p < 0.03), hypocalcemia (OR: 2.1; 95% CI: 0.9-4.8; p < 0.07), and ME doses >45 mg per day (OR: 1.9; 95% CI: 0.8-4.8; p < 0.16). Mild liver disease was protective against QTc prolongation (OR: 0.05; 95% CI: 0.0-0.46; p < 0.01). CONCLUSIONS Predictors of QTc prolongation in our multivariate conditional logistic regression model included CHF, PUD, hypokalemia, rheumatologic disorders, use of medications with a known TdP risk, malignancy, hypocalcemia, and ME doses >45 mg per day.
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Affiliation(s)
- Katherine M Juba
- 1 Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College , Rochester, New York
| | - Tina M Khadem
- 2 Department of Pharmacy, University of Rochester Medical Center-Strong Memorial Hospital , Rochester, New York
| | - David J Hutchinson
- 1 Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College , Rochester, New York
| | - Jack E Brown
- 1 Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College , Rochester, New York
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11
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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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12
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Elefritz JL, Murphy CV, Papadimos TJ, Lyaker MR. Methadone analgesia in the critically ill. J Crit Care 2016; 34:84-8. [PMID: 27288616 DOI: 10.1016/j.jcrc.2016.03.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 02/19/2016] [Accepted: 03/27/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE Methadone is increasingly used as an analgesic or a bridge to weaning other analgesics and sedatives in critically ill patients. This review discusses the pharmacology of methadone, summarizes available evidence for its use in the intensive care unit setting, and makes suggestions for appropriate use and monitoring. MATERIALS/METHODS Articles evaluating the efficacy, safety, and pharmacology of methadone were identified from a PubMed search through June 2015. References from selected articles were reviewed for additional material. Experimental and observational English-language studies that focused on the efficacy, safety, and pharmacology of methadone in critically-ill adults and children were selected. RESULTS Methadone is a synthetic opioid analgesic with potential advantages over other commonly used opioids. Limited evidence from critically ill pediatric, adult, and burn populations suggests that methadone protocols may expedite weaning opiate infusions, decrease the length of mechanical ventilation, and reduce the incidence of negative outcomes such as opiate withdrawal, delirium, and over-sedation. CONCLUSIONS Data from current literature supports a role for methadone analgesia in weaning opiates and potentially reducing the duration of mechanical ventilation in critically ill patients. More studies are needed to confirm these benefits and determine criteria for patient selection.
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Affiliation(s)
- Jessica L Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael R Lyaker
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
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Pham TC, Fudin J, Raffa RB. Is levorphanol a better option than methadone? PAIN MEDICINE 2015; 16:1673-9. [PMID: 26307179 DOI: 10.1111/pme.12795] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Methadone has been a stalwart pharmacologic option for the management of opioid drug dependence for many years. It substitutes for opioid agonists and possesses certain pharmacokinetic properties that confer characteristics preferable to those of other opioids for this application. Methadone is likewise used as an option for the treatment of pain, particularly chronic pain. It has a spectrum of pharmacodynamic activity, including contributions from non-opioid components, that translates to its specific clinical attributes as an analgesic. Unfortunately, basic science studies and accumulated clinical experience with methadone have revealed some undesirable, and even worrisome, features, including issues of safety. The benefit/risk ratio of methadone might be acceptable if there was no better alternative, but neither its pharmacokinetic nor pharmacodynamic properties are unique to methadone. OBJECTIVE We review the basic and clinical pharmacology of methadone and suggest that levorphanol should receive attention as a possible alternative. CONCLUSION Unlike methadone, levorphanol is a more potent NMDA antagonist, possesses a higher affinity for DOR and KOR, has a shorter plasma half-life yet longer duration of action, has no CYP450 interactions or QTc prolongation risk, can be a viable option in the elderly, palliative care, and SCI patients, requires little to no need for co-administration of adjuvant analgesics, and has potentially a lower risk of drug-related Emergency Department visits compared to other opioids.
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Affiliation(s)
- Thien C Pham
- PGY2 Pain and Palliative Care Pharmacy Residency, Stratton VA Medical Center, Albany, New York, USA
| | - Jeffrey Fudin
- Western New England University College of Pharmacy, Springfield, Massachusetts, USA.,School of Pharmacy, University of Connecticut, Storrs, Connecticut, USA.,Clinical Pharmacy Specialist in Pain Management, Stratton VA Medical Center, Albany, New York, USA
| | - Robert B Raffa
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, Pennsylvania, USA
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14
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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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15
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Grodofsky S, Edson E, Huang S, Speck RM, Hatchimonji J, Lacy K, Farrar JT, Ashburn MA. The QTc effect of low-dose methadone for chronic pain: a prospective pilot study. PAIN MEDICINE 2015; 16:1112-21. [PMID: 25644980 DOI: 10.1111/pme.12658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Methadone is associated with QT prolongation and serious cardiac complications, but this has been primarily demonstrated in opioid dependent patients receiving moderate to high doses. This study investigates the effect of low-dose methadone on the QTc interval in a chronic pain population. DESIGN AND SUBJECTS We conducted a prospective cohort study in a chronic pain clinic including 82 patients receiving methadone and 102 patients receiving non-methadone opioid therapy. METHODS We analyzed automated QTc calculations from 12-lead electrocardiograms at baseline and during the subsequent 6 months. The primary outcome of interest was the incidence of QTc greater than 470 milliseconds or an increase from baseline of greater than 60 milliseconds. RESULTS The methadone group did not manifest an overall higher frequency of QTc > 470 milliseconds (6% for the methadone group vs 5% for controls, P = 0.722) or an increase in the QTc of > 60 milliseconds (4% for the methadone group vs 4% for controls, P = 0.94). In the first month after initiating methadone, patients demonstrated an increase in QTc compared to controls (5% for the methadone group vs 0% for the controls, P = 0.073) but the difference disappeared in the third and sixth months. CONCLUSION Data from our chronic pain clinic support a potential association of QTc prolongation during the initiation of methadone, but this effect is small and short lived. We believe larger scale studies to further characterize the safety profile of low-dose methadone are warranted.
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Affiliation(s)
- Samuel Grodofsky
- Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - Emmanuel Edson
- Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - Stephanie Huang
- Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - Rebecca M Speck
- Department of Anesthesiology and Critical Care, University of Pennsylvania.,Center for Pharmacoepidemiology Research and Training, University of Pennsylvania
| | - Justin Hatchimonji
- Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - Kim Lacy
- Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - John T Farrar
- Department of Anesthesiology and Critical Care, University of Pennsylvania.,Center for Pharmacoepidemiology Research and Training, University of Pennsylvania.,Department of Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
| | - Michael A Ashburn
- Department of Anesthesiology and Critical Care, University of Pennsylvania
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Heesch CB, Copfer AE, Davis SJ, Edwards BW. Evaluation of Methadone-Induced QTc Prolongation in a Veteran Population. Fed Pract 2015; 32:36-41. [PMID: 30766045 PMCID: PMC6363331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Understanding the effects of methadone on the QTc interval in a veteran patient population using the drug at lower doses for pain may help clinicians develop strategies and protocols for safe use.
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Affiliation(s)
- Chelsie B Heesch
- is a mental health clinical pharmacy specialist, is an intensive care and cardiology clinical pharmacist, is a program manager for education and clinical services, and is an emergency department clinical pharmacist, all at the Southern Arizona VA Health Care System in Tucson
| | - Amy E Copfer
- is a mental health clinical pharmacy specialist, is an intensive care and cardiology clinical pharmacist, is a program manager for education and clinical services, and is an emergency department clinical pharmacist, all at the Southern Arizona VA Health Care System in Tucson
| | - Stephanie J Davis
- is a mental health clinical pharmacy specialist, is an intensive care and cardiology clinical pharmacist, is a program manager for education and clinical services, and is an emergency department clinical pharmacist, all at the Southern Arizona VA Health Care System in Tucson
| | - Bryan W Edwards
- is a mental health clinical pharmacy specialist, is an intensive care and cardiology clinical pharmacist, is a program manager for education and clinical services, and is an emergency department clinical pharmacist, all at the Southern Arizona VA Health Care System in Tucson
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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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Goldschneider KR, Good J, Harrop E, Liossi C, Lynch-Jordan A, Martinez AE, Maxwell LG, Stanko-Lopp D. Pain care for patients with epidermolysis bullosa: best care practice guidelines. BMC Med 2014; 12:178. [PMID: 25603875 PMCID: PMC4190576 DOI: 10.1186/s12916-014-0178-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 09/09/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB. METHODS The process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB. RESULTS The first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted. CONCLUSIONS Evidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is often times horrific in its effects on quality of life, and whose care is resource-intensive and difficult. The guideline development process also highlighted areas for research in order to improve further the evidence base for future care.
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Affiliation(s)
- Kenneth R Goldschneider
- Pain Management Center, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | - Julie Good
- Lucille Packard Children's Hospital, Department of Anesthesia (by courtesy, Pediatrics), Stanford University, Stanford, California, USA.
| | - Emily Harrop
- Helen and Douglas Hospices, Oxford and John Radcliffe Hospital, Oxford, USA.
| | - Christina Liossi
- University of Southampton, Southampton, UK.
- Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | - Anne Lynch-Jordan
- Pain Management Center and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | - Anna E Martinez
- National Paediatric Epidermolysis Bullosa Centre, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Danette Stanko-Lopp
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Price LC, Wobeter B, Delate T, Kurz D, Shanahan R. Methadone for pain and the risk of adverse cardiac outcomes. J Pain Symptom Manage 2014; 48:333-42.e1. [PMID: 24480532 DOI: 10.1016/j.jpainsymman.2013.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/24/2013] [Accepted: 10/04/2013] [Indexed: 01/22/2023]
Abstract
CONTEXT There are few studies that describe cardiac adverse events in patients prescribed methadone for pain management. OBJECTIVES To describe incident cardiac adverse events and risk factors for cardiac adverse events in primary care patients prescribed methadone for pain. METHODS This was a retrospective, descriptive, cohort study in patients 18 years or older receiving methadone for pain management during 2010. Patients were followed for 12 months and were categorized as "chronic" or "non-chronic" methadone users. The primary outcomes were a cardiac event, at risk for an event, or neither. Patients were grouped on their outcome and were compared on risk factors and methadone monitoring. RESULTS A total of 1246 patients were included. Thirty (2.4%), 628 (50.4%), and 588 (47.2%) patients had a cardiac event, were at risk for an event, or had neither an event nor a risk factor, respectively. Overall, the rate of QTc prolongation was 49.4% and the rate of adherence to recommended cardiac monitoring was 39.0%. Similar percentages of chronic and non-chronic users had a cardiac event (P > 0.05). Among the patients who had a cardiac event and were at risk for an event, factors independently associated with having had an event included age (odds ratio = 1.06; 95% CI = 1.03-1.09) and a dose 100 mg/day or higher (odds ratio = 6.18; 95% CI = 1.08-35.45). CONCLUSION Few cardiac adverse events resulting from methadone use for pain were detected. However, a large proportion of patients were at risk for an adverse event, especially patients who were older and had received ≥ 100 mg/day of methadone.
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Affiliation(s)
- Lea C Price
- Kaiser Permanente-Colorado, Denver, Colorado, USA; University of Colorado Skaggs School of Pharmacy, Denver, Colorado, USA; Regis University Rueckert-Hartman College for Health Professions, School of Pharmacy, Denver, Colorado, USA.
| | - Brooke Wobeter
- Denver Health Hospital and Authority, Denver, Colorado, USA
| | - Thomas Delate
- Kaiser Permanente-Colorado, Denver, Colorado, USA; University of Colorado Skaggs School of Pharmacy, Denver, Colorado, USA
| | - Deanna Kurz
- Kaiser Permanente-Colorado, Denver, Colorado, USA
| | - Roberta Shanahan
- Kaiser Permanente-Colorado, Denver, Colorado, USA; University of Colorado Skaggs School of Pharmacy, Denver, Colorado, USA
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20
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Prognostic factors in acute methadone toxicity: a 5-year study. J Toxicol 2014; 2014:341826. [PMID: 25197273 PMCID: PMC4146352 DOI: 10.1155/2014/341826] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 07/23/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Delayed or recurrent profound respiratory depression, ventricular dysrhythmias, acute lung injury, and death are the major complications of MTD overdose. We aimed to clarify the prognostic factors in MTD toxicity. Materials and Methods. Retrospectively, medical files of all patients poisoned by MTD and older than 12 years of age who had presented to Loghman Hakim Poison Center between 2007 and 2012 were evaluated. The data was compared between survivors and nonsurvivors. Results. Twenty-eight out of 322 patients died (mortality rate = 8.7%). MTD-related death was higher in patients with acute on chronic toxicity who were on daily dose of MTD and had ingested higher doses (in comparison to those with acute toxicity due to first-time exposure; 13% versus 6%). Renal failure was the most common medical complication related to deaths due to MTD toxicity. Conclusions. Based on previous researches, the most common cause of MTD overdose-related deaths is respiratory impairment; however, in our study, acute renal failure with or without rhabdomyolysis was the main delayed cause of deaths in MTD-poisoned patients. Antidotal therapy, early recognition, and treatment of hemodynamic compromise and rhabdomyolysis can be life-saving in these patients.
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Staikou C, Stamelos M, Stavroulakis E. Impact of anaesthetic drugs and adjuvants on ECG markers of torsadogenicity. Br J Anaesth 2014; 112:217-230. [DOI: 10.1093/bja/aet412] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Fareed A, Patil D, Scheinberg K, Blackinton Gale R, Vayalapalli S, Casarella J, Drexler K. Comparison of QTc Interval Prolongation for Patients in Methadone Versus Buprenorphine Maintenance Treatment: A 5-Year Follow-Up. J Addict Dis 2013; 32:244-51. [DOI: 10.1080/10550887.2013.824333] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ayman Fareed
- a Atlanta VA Medical Center , Decatur , Georgia , USA
- b Department of Psychiatry and Behavioral Sciences, Emory University , Atlanta , Georgia , USA
| | - Dustin Patil
- c Department of Psychiatry, Boston University , Boston , Massachusetts , USA
| | - Kelly Scheinberg
- a Atlanta VA Medical Center , Decatur , Georgia , USA
- b Department of Psychiatry and Behavioral Sciences, Emory University , Atlanta , Georgia , USA
| | | | - Sreedevi Vayalapalli
- b Department of Psychiatry and Behavioral Sciences, Emory University , Atlanta , Georgia , USA
| | - Jennifer Casarella
- a Atlanta VA Medical Center , Decatur , Georgia , USA
- b Department of Psychiatry and Behavioral Sciences, Emory University , Atlanta , Georgia , USA
| | - Karen Drexler
- a Atlanta VA Medical Center , Decatur , Georgia , USA
- b Department of Psychiatry and Behavioral Sciences, Emory University , Atlanta , Georgia , USA
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Vadivelu N, Huang Y, Mirante B, Jacoby M, Braveman FR, Hines RL, Sinatra R. Patient considerations in the use of tapentadol for moderate to severe pain. DRUG HEALTHCARE AND PATIENT SAFETY 2013; 5:151-9. [PMID: 23861601 PMCID: PMC3704302 DOI: 10.2147/dhps.s28829] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Poorly controlled acute and chronic pain can increase morbidity, impair quality of life and prolong disability. Over 80 percent of post surgical patients report moderate to severe uncontrolled postoperative pain. Over-reliance on potent opioid agonists can lead to several opioid related side effects such as gastrointestinal intolerability, respiratory depression and cognitive impairment. A recently approved dual acting central analgesic tapentadol may offer improved tolerability over traditional opioid agonists while having multimodal opioid and nonopioid analgesic benefits. Tapentadol, classified by the US Food and Drug Administration as a class 2 opioid, is currently marketed in the United States as immediate release (IR) NUCYNTA® for moderate to severe acute pain in tablets of 50 mg, 75 mg, and 100 mg, and as extended release (ER) NUCYNTA ER® for the treatment of chronic moderate to severe pain in tablets of 50 mg, 100 mg, 150 mg, 200 mg, and 250 mg. Tapentadol is a low affinity mu opioid receptor agonist and a norepinephrine reuptake inhibitor. Tapentadol has no active metabolites and this property makes it useful in patients with hepatic and renal failure. Clinical trials with tapentadol IR showed that there was improved gastrointestinal tolerability and similar pain relief as compared to oxycodone IR. Tapentadol ER allows for twice daily dosing. Clinical trials showed that tapentadol ER could effectively relieve moderate to severe chronic pain and was associated with significantly fewer gastrointestinal adverse effects as compared to oxycodone controlled release. Tapentadol ER is indicated and has Food and Drug Administration approval for the treatment of chronic painful diabetic neuropathy. The most common side effects of tapentadol are nausea (30%), vomiting (18%), dizziness (24%), and somnolence (15%). Tapentadol, due to its potential synergistic effects on norepinephrine levels, is contraindicated in patients who have taken monoamine oxidase inhibitors within the last 14 days. Caution has to be exercised with the use of tapentadol IR and tapentadol ER in the presence of other central nervous system depressants such as neuroleptics, opioids, illicit drugs, muscle relaxants, sedatives, and anxiolytics.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University, New Haven, CT, USA
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Fareed A, Vayalapalli S, Scheinberg K, Gale R, Casarella J, Drexler K. QTc interval prolongation for patients in methadone maintenance treatment: a five years follow-up study. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2013; 39:235-40. [PMID: 23808912 DOI: 10.3109/00952990.2013.804525] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND QTc prolongation for patients in methadone maintenance treatment (MMT) has been reported. In this study we wanted to identify the predictor factors for QTc prolongation >500 ms and other medical risk factors for mortality in this population. METHODS A retrospective chart review study with 55 patients who had previously been included in our performance improvement project and who were eligible to be reviewed. A linear regression model with one-sided p value was used for data analysis. RESULTS Over 5 years, 41% to 56% of patients had QTc > 450 and <500 ms and 4% to 10% of patients had at least one reading of QTc > 500 ms. This QTc prolongation from baseline showed statistical significance (p < 0.0001). Being diagnosed with congestive heart failure (CHF), elevated HgA1c level and recent cocaine use were significantly associated with QTc prolongation >500 ms. The model as a whole showed statistical significance (F = 3.50, p = 0.02). Being diagnosed with CHF and elevated HgA1c level was significantly associated with mortality. The model as a whole also showed statistical significance (F = 4.63, p = 0.01). CONCLUSIONS This study confirms that methadone may be associated with QTc prolongation. It identified three risk factors for significant QTc prolongation for patients on MMT which are recent cocaine use, uncontrolled blood glucose and CHF. Two of these three risk facts (uncontrolled blood glucose and CHF) were associated with mortality in this cohort. Patients with these medical co-morbidities may benefit from EKG screening and aggressive treatment of the medical risk factors while taking MMT.
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Affiliation(s)
- Ayman Fareed
- Department of Psychiatry, Emory University, School of Medicine, Atlanta, GA, USA.
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Roy AK, McCarthy C, Kiernan G, McGorrian C, Keenan E, Mahon NG, Sweeney B. Increased incidence of QT interval prolongation in a population receiving lower doses of methadone maintenance therapy. Addiction 2012; 107:1132-9. [PMID: 22168435 DOI: 10.1111/j.1360-0443.2011.03767.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The aim of this study was to investigate the frequency of corrected QT interval (QTc) prolongation in a methadone maintenance therapy (MMT) population, and to examine potential associations between this QTc interval and methadone dose as well as concurrent use of opiates, cocaine and benzodiazepines. DESIGN Cross-sectional study of patients attending a specialist drug treatment clinic from July 2008 to January 2009. SETTING Single-centre inner-city specialist drug treatment clinic, Ireland. PARTICIPANTS A total of 180 patients on stable MMT attending for daily methadone doses, over a 6-month period, where a total of 376 patients were attending during the study period. MEASUREMENTS All patients agreeing to participate in the study underwent 12-lead electrocardiograms and QTc analysis, as well as analysis of urine toxicology screen results for opiates, benzodiazepines and cocaine. ECGs were carried out prior to methadone dose being received, regardless of time of day (trough ECG). FINDINGS The average age was 32.6 ± 7.1 years, with mean [standard deviation (SD)] methadone dose 80.4 ± 27.5 mg. The mean (SD) QTc was 420.9 ± 21.1 ms, range 368-495 ms. Patients who had a positive toxicology screen for opiates were receiving significantly lower doses of methadone (77.8 ± 23.5 mg versus 85.0 ± 21.4 mg, P = 0.04). No significant association was noted between QTc interval prolongation and presence of cocaine metabolites in the urine (P = 0.13) or methadone dose (P = 0.33). 8.8% of patients had evidence of prolonged QTc interval (8.3% male QTc ≥ 450 ms and 0.5% female QTc ≥ 470 ms), with 11.1% (n = 20) having QTc intervals > 450 ms. CONCLUSIONS Drug-induced corrected QT interval prolongation is evident (ranging from 8.8-11.1%, depending on definition applied) in patients receiving relatively low daily doses of methadone therapy, with no evidence of a dose-response relationship. The presence of cocaine metabolites in urine does not appear to be associated with increased corrected QT interval. Increased awareness of cardiac safety guidelines, including relevant clinical and family history, baseline and trough dose ECG monitoring, should be incorporated into methadone maintenance therapy protocols.
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Affiliation(s)
- Andrew K Roy
- Mater Misericordiae University Hospital, Dublin, Ireland.
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Raffa RB, Burmeister JJ, Yuvasheva E, Pergolizzi JV. QTc interval prolongation byd-propoxyphene: what about other analgesics? Expert Opin Pharmacother 2012; 13:1397-409. [DOI: 10.1517/14656566.2012.682150] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Esfahani MA, Vosughi AA, Fatehi MH, Shahsanaee A, Teimuri A. Evaluation of QTc interval in Iranian causalities (Janbazan) of Iran-Iraq war receiving maintenance methadone treatment. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2012; 17:264-8. [PMID: 23267379 PMCID: PMC3527045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 10/20/2011] [Accepted: 11/25/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Methadone is a synthetic opioid, used in treatment of chronic pains. The current study was carried out to evaluate the QTc interval in Iranian causalities (Janbazan) of Iran-Iraq war receiving maintenance methadone treatment. MATERIALS AND METHODS In 2010, one hundred war causalities in Isfahan who chronically take daily dose of 20 mg or more of methadone (more than 2 weeks), and did not have the history of cerebrovascular or coronary artery diseases, cardiac pacemaker, congenital prolonged QTC, or taking drugs affecting QTc, or having electrolyte abnormalities, were selected for the study. An electrocardiogram was taken from each patient using cardiofax instrument, and QTC was calculated manually. The data was analyzed using SPSS software with descriptive statistical methods and Pearson's correlation coefficient. FINDINGS All patients were male and had the mean age of 45.6 ± 6.1 years. The patients received 20-240 mg methadone daily for 1 to 108 months. The QTc was prolonged in 25% of the patients (QTc 5 450 ms), with the mean of 472.72 ± 18.5 ms (range 450-508 ms) and the mean daily dose of methadone 85.2 ± 59.0 mg. No significant relationship was observed between QTC interval on the one hand, and methadone dose (R = 0.025, P = 0.8), duration of treatment (R =-0.048, P = 0.68), age (R = 0.037, P = 0.71), and weight (R = 0.1, P = 0.21) of the patients, on the other hand. None of the patients had faint, syncope, arrhythmia, or sudden death. CONCLUSION Oral methadone causes prolongation of QTC interval. However, the dosage of methadone and duration of treatment were not statistically related to QTC interval.
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Affiliation(s)
- Morteza Abdar Esfahani
- Associate Professor, Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Akbar Vosughi
- Specialist in Internal Medicine, Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohamad Hossein Fatehi
- Resident, Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Armindokht Shahsanaee
- Community Medicine Specialist, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azam Teimuri
- Assistant Professor, Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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CHANG KUANCHENG, HUANG CHIEHLIANG, LIANG HSINYUEH, CHANG SHIHSHENG, WANG YUCHEN, LIANG WENMIIN, LANE HSIENYUAN, CHEN CHUHUANG, STEPHEN HUANG SHOEIK. Gender-Specific Differences in Susceptibility to Low-Dose Methadone-Associated QTc Prolongation in Patients with Heroin Dependence. J Cardiovasc Electrophysiol 2011; 23:527-33. [DOI: 10.1111/j.1540-8167.2011.02231.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Goldberg JS. Low Molecular Weight Opioid Peptide Esters Could be Developed as a New Class of Analgesics. PERSPECTIVES IN MEDICINAL CHEMISTRY 2011; 5:19-26. [PMID: 21863129 PMCID: PMC3153123 DOI: 10.4137/pmc.s6803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Low molecular weight opioid peptide esters (OPE) could become a class of analgesics with different side effect profiles than current opiates. OPE may have sufficient plasma stability to cross the blood brain barrier (BBB), undergo ester hydrolysis and produce analgesia. OPE of dipeptides, tyr-pro and tyr-gly conjugated to ethanol have a structure similar to the anesthestic agent, etomidate. Based upon the analgesic activity of dipeptide opioids, Lipinski's criteria, and permeability of select GABA esters to cross the BBB, opioid peptides (OP) conjugated to ethanol, cholesterol or 3-glucose are lead recommendations. Preliminary animal data suggests that tyr-pro-ethyl ester crosses the BBB and unexpectedly produces hyperalgesia. Currently, there are no approved OP analgesics available for clinical use. Clinical trials of good manufacturing practice OP administered to patients suffering from chronic pain with indwelling intrathecal pumps could resolve the issue that OP may be superior to opiates and may redirect research.
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Affiliation(s)
- Joel S Goldberg
- Durham Veterans Affairs Medical Center and Duke University School of Medicine, Durham, NC, USA
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