Methadone Induction for Inpatients: Working with OTPs, but Stabilizing Quickly

Many hospital-based physicians are not comfortable with methadone, although they are very comfortable with morphine and a lot of other opioids used for pain. When these physicians find their patients who are admitted to the hospital for an injury, acute illness or other problem also have untreated opioid use disorder (OUD), they may panic. “Methadone? I don’t know anything about methadone!” They know about it for pain, perhaps, but not for OUD.

There are some important points to remember.

  • If untreated, the patient’s OUD will quickly turn into withdrawal, compounding whatever other problems the patient has with symptoms that could include severe vomiting and diarrhea, not to mention great discomfort.
  • Giving the patient opioids will relieve those symptoms, but physicians should not be tempted to use medications like hydromorphone instead of methadone, which, like buprenorphine, is approved to treat OUD. In fact, only methadone and buprenorphine, among all of the opioids, are approved to treat OUD.
  • Hospitals do not have to be licensed OTPs to treat patients with methadone for OUD.

These bullet points are key to the training done by Melissa Weimer, D.O., medical director of the Addiction Medicine Consult Service at Yale University School of Medicine. “There’s still a lot of misunderstanding about buprenorphine and methadone,” she told AT Forum. “Every time I talk about this topic, this comes up: the first dose regulations apply to OTPs, not to hospitals.” This means a hospital can titrate a patient up to a stable dose of methadone a lot faster than an OTP can, she said.

Using analgesic opioids such as long-acting morphine or long-acting oxycodone to prevent withdrawal is not illegal in the hospital, but this is not an effective method, said Dr. Weimer. “For a patient who has OUD and is in withdrawal, my experience and 50 years of data tells us the methadone is very effective, because it is potent and addresses high tolerance, but also is long-acting.” There is no point in using other opioids when methadone and buprenorphine are “safer alternatives,” she said, although she admitted that these practices do take place in Canada and other countries, including on an outpatient basis, which would be illegal in the United States.

It’s not unreasonable to be cautious about methadone. Like other long-acting opioids, it takes time to have an effect, and doses can’t be increased until the first dose has had time to be metabolized. This is why, however, once-a-day dosing with methadone is effective, releasing the drug to relieve craving associated with OUD on a constant basis, avoiding the hills and valleys of euphoria and more craving.

Dr. Weimer recommends that hospital have agreements with OTPs so that patients, once admitted, can be transferred.

Physicians are also concerned about cardiac risks of methadone, although studies have shown that these are much less for patients treated with the medication for OUD than for pain (see attached studies.).

Dr. Weimer also recommends PCSS, now operated by the American Academy of Addiction Psychiatry, for information about methadone.

At Yale, Dr. Weimer’s group and colleagues generally stabilize inpatients with OUD within 72 hours, not only addressing the OUD, but providing multi-modal care. “We are also providing a lot of psychosocial support,” said Dr. Weimer. “Even someone on 90 milligrams of methadone could have craving, but that doesn’t necessarily mean you have to up their dose.” And the hospital can determine whether the patient needs additional treatment such as clonidine and other opioids. “We can rest assured that those doses are safe doses being given in a monitored setting.”

Having a pre-arranged setup with an OTP means the OTP receives the discharged patients at the current dose – not having to go back to the beginning – knowing that the patient is stabilized. OTPs are confident in this system; they see that the hard work has already been done for them.

Early treatment is a challenging time, Dr. Weimer conceded. Patients want to feel better immediately, but the methadone dose isn’t a steady state – it wears off. Being able to uptitrate when necessary, with the right amount, is essential. In outpatient treatment, those early days are especially concerning, because patients aren’t getting enough medication due to regulations, and they may resort to the highly dangerous use of street opioids laced with deadly illicit fentanyl.

See attached articles on cardiac issues, and the 2020 documentation from Connecticut’s health department on hospital induction with methadone and working with OTPs.

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