Methadone prescribing Management Baseline ECG (patients not at risk for QTc prolongation) Consider obtaining a baseline ECG prior to initiating methadone in patients without risk factors for QTc interval prolongation. C Consider using an ECG obtained within the past 12 months and showing a QTc < 450 ms, if already available, as the baseline study. C Urine drug testing Q Is methadone being prescribed for opioid addiction? Yes Obtain urine drug testing prior to initiating methadone for the treatment of opioid addiction, and at regular intervals thereafter, regardless of the perceived risk for drug abuse. B No Urine drug testing Q Is methadone being prescribed for chronic pain? Yes Obtain urine drug testing prior to initiating methadone for the treatment of chronic pain, and at regular intervals thereafter, regardless of the perceived risk for drug abuse. B No Buprenorphine therapy Consider using buprenorphine as a treatment option in patients who are being treated for opioid addiction and have risk factors for or known QTc interval prolongation. C General principles Q Does baseline ECG show a QTc interval > 500 ms? Yes Avoid prescribing methadone in patients with a baseline QTc interval > 500 ms. D No General principles Q Does baseline ECG show a QTc interval > 450 ms? Yes Consider alternate opioids in patients with a baseline QTc interval 450 ms but < 500 ms; if methadone is chosen, evaluate for and correct reversible causes of QTc interval prolongation before initiation. C Correct reversible causes of QTc interval prolongation before initiating methadone in patient with QTc interval between 450-500 ms. B No General counseling Educate patients in whom methadone therapy is being considered regarding the indications for treatment, goals of therapy, availability of alternative therapies, potential adverse effects associated with methadone, and specific plans for monitoring therapy, adjusting doses, reducing the risk of adverse effects and managing them. B Methadone therapy Initiate methadone at low doses, individualized based on the indication for treatment and prior opioid exposure status. Titrate doses slowly and monitor patients for sedation. B View patients who have not taken opioids for 1-2 weeks as being opioid-na ve for the purpose of methadone reinitiation. B Pregnant patients Q Is the patient pregnant? Yes Monitor neonates born to mothers receiving methadone for neonatal abstinence syndrome, and treat when present. B No Follow-up clinical assessment Schedule a follow-up face-to-face or telephone assessment within 3-5 days after initiating methadone, and within 3-5 days after each dose increase. B Monitor patients receiving methadone for common opioid adverse effects, and manage adverse effects as part of routine therapy. B Follow-up electrocardiogram Obtain follow-up ECGs to assess for methadone-induced QTc interval prolongation, guided by baseline ECG findings, methadone dose changes, and other risk factors for QT prolongation. B Switch to an alternative opioid, or immediately reduce the methadone dose, in adult patients who are receiving methadone and in whom a follow-up ECG shows a QTc interval 500 ms. Obtain a repeat ECG after the methadone dose has been decreased. B