IN BRIEF

Methadone Weaning: The Role of the Pharmacist

October 23, 2015
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Pharmacist-led methadone tapers are improving outcomes and reducing practice variation in pediatric intensive care units.

In neonatal and pediatric intensive care units, opioid use is necessary for controlling pain and as an adjunct to sedation during mechanical ventilation. However, after as few as five days of use, approximately 50 percent of patients will experience withdrawal once the medication is stopped. After 10 days of opioid use, 100 percent of patients will experience withdrawal.

Several characteristics make methadone ideal for weaning pediatric patients off opioids, including its 80-85 percent oral absorption and long history of use. Patients can even finish their methadone tapers at home, decreasing overall length of hospital stays in some cases.

“It’s an important distinction to make that these babies and children have developed tolerance and are experiencing withdrawal, not addiction,” says Joseph Tobias, MD,chief of the Department of Anesthesiology & Pain Medicine at Nationwide Children’s Hospital. “Research has shown that these patients are not more likely to abuse drugs and become addicts in the future.”

While methadone has been used to reduce withdrawal symptoms in pediatric patients since the 1990s, a recent study published in Pediatric Critical Care Medicine by a team of researchers at the University of Minnesota Masonic Children’s Hospital evaluates the role of the pharmacist in managing methadone tapers.

“We saw long-term gains in the pharmacist-managed tapers for methadone weaning, including decrease in withdrawal symptoms, shorter tapers and decrease in physician involvement,” says Sameer Gupta, MD, pediatric critical care physician at University of Minnesota Masonic Children’s Hospital and senior author of the study.

According to Dr. Gupta, the hospital instituted pharmacist managed tapers more than five years ago, but after an increased emphasis on compliance in the last three to four years, the benefits became more profound.

“We found that methadone and lorazepam weans can be protocolized and handled more effectively by our Pharm.D colleagues, allowing physicians to spend more time on other aspects of patient care,” says Dr. Gupta, who is also assistant professor in the Division of Pulmonary and Critical Care Medicine in the Department of Pediatrics at the University of Minnesota.

In an editorial for the same journal, Dr. Tobias agrees that significant improvements in patient care can occur with the use of protocols such as those used by Dr. Gupta’s team. At Nationwide Children’s, pharmacists have been managing methadone tapers for more than a decade. “We identify patients who qualify for tapers and create a taper plan. We also decide the conversion dose, how to come off the infusion and start the oral meds,” explains Cheryl Sargel, Pharm.D, clinical pharmacy specialist in the pediatric intensive care unit (PICU). “Though the goal is standardization as much as possible, it’s important to make sure we’re taking a personalized approach from the beginning dose calculation to the completion of the taper.”

“Physical dependency and withdrawal remain a common problem following prolonged admission to the PICU,” Dr. Tobias says. “These problems have been reported with every sedative and analgesic agent used in the ICU setting. Using pharmacist-led protocols leads to a decrease in practice variation, which has been shown to improve outcomes.”

 

References:

  1. Steineck KJ, Skoglund AK, Carlson MK, Gupta, S. Evaluation of a pharmacist-managed methadone taper. Pediatric Critical Care Medicine. 2014 Mar;15(3):206-210.
  2. Tobias, JD. Methadone: Who tapers, when, where and how? Pediatric Critical Care Medicine. 2014 Mar;15(3):268-270.