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Updates, Alerts, Corrections


July 14, 2016

"New study highlights risks of combining benzodiazepines and opioids"

"Don't Use Oral Liquid Docusate Stool Softener in Any Patient, CDC Warns"


May 2015

Methadone changes and additions

  • delete parenteral values as they are highly variable
  • change PO equianalgesic dose to highly variable, and starting dose to 2.5-5 mg
  • Safest starting dose for adults is 5 mg, for opioid tolerant as well as opioid-naive. For opioid-naive patients over 70 yrs and/or with chronic illness, lower the starting dose to 2.5 mg.
  • Be sure to provide adequate breakthrough meds during titration.
  • Titrate slowly, do not increase daily dose by more than 25-50%, or more frequently than every 7 days. 

Webster LR. Methadone Side Effects: Constipation, Respiratory Depression, Sedation, Sleep-Disordered Breathing, and the Endocrine System. In: Cruciani RA, Knotkova, eds. Handbook of Methadone Prescribing and Buprenorphine Therapy. New York, NY: Springer; 2013:59-72. 
Webster LR. Eight Principles for Safer Opioid Prescribing. / Pain Med. 2013;14:959-61.

Methadone Statistics from the CDC - PDF

  • 5,000 people die every year of overdose related to methadone 
  • Methadone contributed to nearly 1 in 3 prescription opioid deaths in 2009 
  • Only 2% of opioid analgesic prescriptions were for methadone 

CDC. Prescription Painkiller Overdoses. Use and Abuse of Methadone as a Painkiller. CDC Vital Signs. July 2012.
Webster LR.  Responsible Prescribing of Methadone for Pain Management: Safety First. Providers’ Clinical Support System for Opioid Therapies (PCSS-O). Salt Lake City, UT: April 14, 2015.

Methadone ≠ Drug of First Choice (Excerpt from: The Evidence Against Methadone as a “Preferred” Analgesic) - PDF

  • Methadone should not be considered as a drug of first choice for chronic pain 
  • It should only be prescribed by providers experienced in its use 
  • Methadone belongs in the armamentarium of pain medications, but specific medical education is necessary to prescribe it safely 

The Evidence Against Methadone as a “Preferred” Analgesic: A Position Statement from the American Academy of Pain Medicine. 2014. 
Webster LR.  Responsible Prescribing of Methadone for Pain Management: Safety First. Providers’ Clinical Support System for Opioid Therapies (PCSS-O). Salt Lake City, UT: April 14, 2015.

Guidelines for QTc Interval Screening in Methadone Treatment - PDF

Krantz,MJ. QTc Interval Screening in Methadone Treatment Center for Substance Abuse Treatment (CSAT) Guideline. Ann Intern Med. 2009;150:387-395. 

February 2015 

Change in ABSTRAL package insert: In November 2014, the manufacturer added conversion instructions when switching patients from ACTIQ to ABSTRAL, in section 2.2 - PDF


2015 BPM printed edition and BPM Online
Pharmacology Pearl

Incorrect:  The dose and analgesic effect of most mu agonist opioids have no known ceiling. Exception: meperidine and methadone, due to active metabolites. Side effects, however, may be limiting. 7-Wrede-Seaman, p. 183
Explanation: Delete methadone. Methadone does not have active metabolites.
Reference: 1-Lexicomp Online, Lexi-Drugs. Hudson, OH: Lexi-Comp, Inc., 2015.

2015 edition, web address for GlobalRPH (online opioid dosage calculator)

The web address was misspelled – it should be the following:

2008 edition BPM, Pearl 9
2011 edition BPM, Pearl 10

Incorrect: “Hydromorphone (Dilaudid): a better drug choice for patients with renal insufficiency, due to it’s short
half-life (2-3 hrs) and no active metabolites. 3-McCaffery, p. 226”
Explanation: H3G is an active metabolite of hydromorphone. It has no analgesic properties and upon accumulation (as can occur with renal insufficiency), can cause neuroexcitatory symptoms: tremor, agitation, myoclonus, allodynia, seizures, cognitive dysfunction. Rotation to a structurally dissimilar opioid (ie: methadone or fentanyl) usually results in a resolution of these neuro symptoms over a period of hours to days.
References: Journal of Palliative Medicine. 2011 Sept; 14(9): 1029-1033.
Life Science. 2001 Jun 15; 69(4): 409-420.
Clinical and Experimental Pharmacology & Physiology. 2000 July; 27(7): 524.