Life-threatening arrhythmias are a rare but serious complication of methadone. If QTc prolongation limits the ability to reach a therapeutic methadone dose during reinitiation, transitioning to buprenorphine should be considered. Given the emergent nature of the transition in these cases, cross-titration with buprenorphine can be helpful. However, patient response remains variable and precipitated withdrawal can occur. Therefore, a thorough discussion with patients regarding risks and benefits, as well as an action plan for precipitated withdrawal, is necessary before initiation.
Fourie et al. (2025) studied this question.