Maria C. Foy, PharmD, remembers the patient who first piqued her research interest in methadone policy—a pregnant, recovering heroine addict on methadone therapy who presented to Abington Memorial Hospital in Abington, Pa.

“The incident made us aware that there was a real lack of understanding and knowledge on the use of methadone and the differences in the use of methadone in recovery versus pain management,” said Dr. Foy, a clinical pain specialist at Abington Memorial. “We wanted to provide our clinicians with some decision support when a patient on methadone presents to the hospital.”

In an abstract entitled “Methadone Policy Development and Computerized Decision Support Promoting Safe Inpatient Methadone Use,” presented during PainWeek, Dr. Foy chronicled how Abington Memorial refined its protocol for managing patients on methadone. According to Dr. Foy, the hospital formed an interdisciplinary committee that included psychiatrists, pharmacists, nurses and pain specialists to develop “an institution-specific policy for methadone use” designed to ensure proper and safe administration of the drug. Dr. Foy said the hospital’s clinicians are not authorized to prescribe methadone for the treatment of opioid withdrawal because the hospital is not a licensed detoxification facility.

The new policy outlines ordering procedures and dispensing processes based on the indication for methadone, and places restrictions on its use for analgesia. The policy also establishes pain, palliative care and oncology practitioners as the only health professionals allowed to prescribe methadone for pain—except in cases where patients are already on methadone—and sets dosing recommendations based on input from psychiatrists on the committee. The team also created a customized ordering screen in its pharmacy management system. The system includes a drop-down list of approved indications for methadone to prevent inappropriate prescribing, and requires verification of dosing and the date of the last dispense before the order can be processed.

Under the new policy, monitoring for accurate methadone dosing is reviewed on initial order by the pharmacy staff, and pain management pharmacists assess all methadone prescriptions for “appropriate use” based on the approved indications and restrictions outlined in the protocol. Dr. Foy wrote that the “development of an institutional methadone policy and order set with decision support has promoted safe and effective use of methadone at our institution.”

“We put this policy in place because we don’t want anybody in our institution to order methadone who is not trained in the kinetics of the drug,” said Dr. Foy, adding that the policy has also given the staff an enhanced education on opioids in general and methadone specifically. “Methadone can be a dangerous drug in the hands of providers not familiar with its use.”

Lynn Webster, MD, a pain specialist and the immediate past president of the American Academy of Pain Medicine (AAPM), believes that the Abington Memorial approach is something that other health systems should emulate. Dr. Webster, who was not involved in the research, noted that recent findings indicate that methadone is associated with a disproportionate number of patient deaths. He cited the AAPM white paper, “The Evidence Against Methadone as a ‘Preferred’ Analgesic”, which found that most states include methadone on their preferred lists for opioids.

“The single most effective way to reduce opioid-related unintentional overdose deaths is an educational program and cautious guidelines,” he said. “As more people are enrolled in Medicaid with accountable care organizations, more people will be at risk of being prescribed methadone by providers who fail to appreciate the risk associated with methadone. I am pleased to see a [health] system trying to prevent unintentional harm from methadone.”

—Brian Dunleavy

Original article: Dunleavy B. Lessons learned from Abington Memorial Hospital’s new institutional methadone policy. Pain Medicine News. January 2015;13(1).