Concerns About Consensus Guidelines for QTc Interval Screening in Methadone Treatment

Letters4 August 2009Concerns About Consensus Guidelines for QTc Interval Screening in Methadone TreatmentFREESteven P. Cohen, MD and Jianren Mao, MD, PhDSteven P. Cohen, MDFrom Johns Hopkins School of Medicine, Baltimore, MD 21205, and Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.Search for more papers by this author and Jianren Mao, MD, PhDFrom Johns Hopkins School of Medicine, Baltimore, MD 21205, and Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-3-200908040-00014 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:We read with great consternation the clinical guidelines by Krantz and colleagues (1) advocating rate-corrected QT interval (QTc) screening for methadone treatment. In our opinion, not only are the recommendations short-sighted and irresponsible, but they are also detrimental to society at large.We foresee multidimensional problems with these guidelines. First, Krantz and colleagues do not appreciate that, for most opioid users (both former substance abusers and pain patients), methadone represents a last-resort treatment. Therefore, even if a prolonged QT interval is found, the likelihood that an equally effective alternative treatment could be implemented is remote (2).Second, compared with the other potentially catastrophic risks associated with methadone, the chance of a fatal arrhythmia is minimal. The side effects and potential complications of opioid use in general far outweigh the marginally increased risk entailed by methadone use (3, 4). Not only methadone, but also oxycodone, has been associated with the surrogate outcome measure of a prolonged QT interval, suggesting that the full-fledged earthquake (that is, “recommendations” that in essence become restrictive practice mandates because of the litigious nature of our society) may be just over the horizon (5). Should we then perform serial ECG on every patient who initiates opioid therapy, including on emergency department visits and ambulatory surgical procedures? Or, because the sensitivity of 1 ECG screening is quite low, maybe we need to increase the surveillance interval to every month?Finally, the guidelines do not address a possible relationship between changes observed on ECG and dose, dosing interval, and treatment duration. Does this imply that a patient taking methadone, 5 mg twice daily, should be treated identically to a patient taking 100 mg three times daily? If so, this would be antithetical to everything we'e learned about drug-related toxicity.We do agree that the surge in methadone use has resulted in a corresponding increase in drug-related deaths. But we have no way of knowing how many of these are due to arrhythmias, misuse, or lack of physician education. We do not live in a society in which time and resources are unlimited, people are altruistic, and cost is irrelevant. Besides cardiologists, the only people likely to benefit from the published recommendations are ECG manufacturers and trial lawyers.Steven P. Cohen, MDJohns Hopkins School of MedicineBaltimore, MD 21205Jianren Mao, MD, PhDMassachusetts General Hospital, Harvard Medical SchoolBoston, MA 02114References1. Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MC. QTc interval screening in methadone treatment. Ann Intern Med. 2009;150:387-95. [PMID: 19153406] LinkGoogle Scholar2. Weschules DJ, Bain KT. A systematic review of opioid conversion ratios used with methadone for the treatment of pain. Pain Med. 2008;9:595-612. [PMID: 18565004] CrossrefMedlineGoogle Scholar3. Chugh SS, Socoteanu C, Reinier K, Waltz J, Jui J, Gunson K. A community-based evaluation of sudden death associated with therapeutic levels of methadone. Am J Med. 2008;121:66-71. [PMID: 18187075] CrossrefMedlineGoogle Scholar4. Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, Robertson AD, Mehler PS. Torsade de pointes associated with very-high-dose methadone. Ann Intern Med. 2002;137:501-4. [PMID: 12230351] LinkGoogle Scholar5. Fanoe S, Jensen GB, Sjøgren P, Korsgaard MP, Grunnet M. Oxycodone is associated with dose-dependent QTc prolongation in patients and low-affinity inhibiting of hERG activity in vitro. Br J Clin Pharmacol. 2009;67:172-9. [PMID: 19159406] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Johns Hopkins School of Medicine, Baltimore, MD 21205, and Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.Disclosures: Dr. Mao received grants from Takeda for a clinical study on neuropathic pain. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoTorsade de Pointes Associated with Very-High-Dose Methadone Mori J. Krantz , Laurent Lewkowiez , Helen Hays , Mary Ann Woodroffe , Alastair D. Robertson , and Philip S. Mehler QTc Interval Screening in Methadone Treatment Mori J. Krantz , Judith Martin , Barry Stimmel , Davendra Mehta , and Mark C.P. Haigney Concerns About Consensus Guidelines for QTc Interval Screening in Methadone Treatment George Girgis Concerns About Consensus Guidelines for QTc Interval Screening in Methadone Treatment Gavin Bart Concerns About Consensus Guidelines for QTc Interval Screening in Methadone Treatment Mori J. Krantz , Judith Martin , Barry Stimmel , and Mark C.P. Haigney Concerns About Consensus Guidelines for QTc Interval Screening in Methadone Treatment Andrew Byrne Metrics Cited ByThe ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused UpdateMethadone Therapy in Underserved Urban Community: QTc Prolongation and Life-Threatening Ventricular ArrhythmiasEffect of amphetamine on corrected-QT interval change during methadone maintenance treatment in Taiwan: A prospective cohort studyQTc interval screening for cardiac risk in methadone treatment of opioid dependenceUse of Methadone in Opioid Maintenance TreatmentMethadone maintenance, QTc and torsade de pointes: Who needs an electrocardiogram and what is the prevalence of QTc prolongation? 4 August 2009Volume 151, Issue 3Page: 216-217KeywordsAdverse reactionsArrhythmiaConflicts of interestDrugsNeuropathic painOpioidsOxycodoneToxicityTreatment guidelines ePublished: 4 August 2009 Issue Published: 4 August 2009 CopyrightCopyright © 2009 by American College of Physicians. 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