Guideline sources The following summarized guidelines for the evaluation and management of methadone prescribing are prepared by our editorial team based on guidelines from the American Pain Society (APS/CPDD/HRS 2014). 1 Pathway Calculator Methadone prescribing Prescription Opioid Misuse Inde Management Guidelines 1. Diagnostic investigations Behavioral risk evaluation: perform an individualized medical and behavioral risk evaluation in patients in whom methadone therapy is being considered, in order to assess the risks and benefits of therapy, given methadone's specific pharmacologic properties and adverse effect profile. B Baseline ECG (patients at risk for QTc prolongation): https://web.pathway.md/diseases/rec7Cg8Ar0HnV8O9T 1/3 6/30/23, 1:02 AM Methadone prescribing Pathway Obtain a baseline ECG prior to initiating methadone in patients with risk factors for QTc interval prolongation, any prior ECG demonstrating a QTc > 450 ms, or a history suggestive of prior ventricular arrhythmia. B Use an ECG obtained within the past 3 months and showing a QTc < 450 ms, if already available, as the baseline study. B 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: 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 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 2. Medical management General principles: avoid prescribing methadone in patients with a baseline QTc interval > 500 ms. D Show 2 more 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 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 3. Specific circumstances Pregnant patients: monitor neonates born to mothers receiving methadone for neonatal abstinence syndrome, and treat when present. B 4. Patient education https://web.pathway.md/diseases/rec7Cg8Ar0HnV8O9T 2/3 6/30/23, 1:02 AM Methadone prescribing Pathway 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 5. Follow-up and surveillance 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 References 1. Chou R, Cruciani RA, Fiellin DA et al. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014 Apr;15 4 321 37. Open 2. Vania Modesto-Lowe, Donna Brooks, Nancy Petry. Methadone deaths: risk factors in pain and addicted populations. J Gen Intern Med. 2010 Apr;25 4 305 9. Open 3. Mark Faul, Michele Bohm, Caleb Alexander. Methadone Prescribing and Overdose and the Association with Medicaid Preferred Drug List Policies United States, 2007 2014. MMWR Morb Mortal Wkly Rep. 2017 Mar 31;66 12 320 323. Open 4. Janet S Knisely, Martha J Wunsch, Karen L Cropsey et al. Prescription Opioid Misuse Index: a brief questionnaire to assess misuse. J Subst Abuse Treat. 2008 Dec;35 4 380 6. Open https://web.pathway.md/diseases/rec7Cg8Ar0HnV8O9T 3/3