Safety of rapid inpatient methadone initiation protocol: A retrospective cohort study

BACKGROUND

Current methadone titration guidelines recommend low initial doses (15-40 mg) and slow increases (10-20 mg every 3 to 7 days) to prevent dose accumulation and oversedation until reaching a target therapeutic dose between 60 and 120 mg. These guidelines were created primarily for outpatient settings in the pre-fentanyl era. Methadone initiations are becoming more common in hospitals, but no titration guidelines exist specific to this treatment setting, which has capacity for increased monitoring. Our objective was to assess the safety of rapid inpatient methadone initiation with regard to mortality, overdose, and serious adverse outcomes both in-hospital and postdischarge.

METHODS

This is a retrospective, observational, cohort study conducted at an urban, academic medical center in the United States. We queried our electronic medical record for hospitalized adults with moderate to severe opioid use disorder admitted between July 1, 2018, and November 30, 2021. Included patients were rapidly initiated on methadone with 30 mg as the initial dose and 10 mg increases daily until reaching 60 mg. The study extracted thirty-day post-discharge opioid overdose and mortality data from the CRISP database.

RESULTS

Twenty-five hospitalized patients received rapid methadone initiation during the study period. The study had no major adverse events including in-hospital or thirty-day post-discharge overdoses or deaths. The study did have two instances of sedation, but neither led to methadone dose holds. There were no instances of QTc prolongation. The study had one patient-directed discharge.

CONCLUSIONS

This study demonstrated that a small subset of hospitalized patients tolerated rapid methadone initiation. More rapid titrations can be utilized in a monitored inpatient setting to retain patients in the hospital and allow providers to account for increased tolerance in the fentanyl era. Guidelines should be updated to reflect the capabilities of inpatient settings to safely initiate and rapidly titrate methadone. Further work should determine optimal methadone initiation protocols in the fentanyl era.

Infective endocarditis in people who inject drugs: A scoping review of clinical guidelines

BACKGROUND

The incidence of infective endocarditis (IE) among people who inject drugs (PWID) is rising worldwide. Multiple clinical guidelines differ on the management of this condition, and few guidelines comment on treatment for primary substance use disorder (SUD). A comprehensive comparison of these guidelines is lacking.

OBJECTIVES

To perform a critical review identifying key differences in clinical guideline recommendations for treating IE among PWID, focusing on the inclusion of recommendations for SUD treatment and the presence of stigmatizing language.

ELIGIBILITY CRITERIA

Recently published, English-language, society-developed clinical guidelines for the treatment of IE among PWID.

SOURCES OF EVIDENCE

PubMed, Google Scholar, and CINAHL Plus databases.

CHARTING METHODS

In line with Arksey and O'Malley's framework, a scoping review was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Two reviewers independently performed database searches for clinical guidelines published between 2007 and 2020 that commented on the management of IE among PWID.

RESULTS

Ten clinical guidelines were included in the final analysis. Treatment recommendations varied with some societies proposing nonstandard care due to concern for return to drug use. Three guidelines include reference to addiction treatment. Only one guideline specifies the use of opioid agonist therapy for treating opioid use disorder and identifies the benefits of an addiction specialist consultation. Acute withdrawal management is not mentioned in any guideline. All guidelines utilized stigmatizing language to describe PWID.

CONCLUSIONS

Most guidelines do not address SUD treatment, despite its effectiveness in reducing adverse health outcomes. Future guidelines should address SUD treatment using patient-first language.

Synthesis and biological evaluation of1',2'-seconucleo-5'- phosphonates

A series of 1',2'-seconucleophosphonate analogues were prepared containing adenine, cytosine, thymine, and uracil as the nucleobase. The synthetic methodology is efficient and uses chloromethyl ethers derived from the chirons diethyl (3S)-(benzyloxy)-(2R)-hydroxybutane-phosphonate (1) and diethyl (3S),4-bis(benzyloxy)-(2R)-hydroxybutanephosphonate (2). Selected deblocked derivatives, i.e., two monoesters (13 and 14), four phosphonic acids (15-18), and one cyclic phosphonate (23), were screened for in vitro activity against certain RNA, adeno, and HIV viruses. All of them were found to be devoid of activity.