Steven M. Marcus

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

UNLABELLED Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence. PERSPECTIVE This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.

Methadone and Buprenorphine Toxicity in Children

Recent years have seen very large increases in the prescribing of methadone and buprenorphine formulations for treatment of opioid addiction as well as the increasing utilization of methadone for the treatment of chronic pain. Coincident with the rise in the prescribing of these drugs has been a substantial increase in pediatric opioid toxicities and adverse events. This review will address the current state of methadone- and buprenorphine-related adverse events in children in the United States. We will also discuss treatment of opioid toxicity in pediatric populations and make recommendations aimed at reducing these occurrences.

The impact of a poison control center on the length of hospital stay for patients with poisoning

While previous research suggests that poison control centers (PCCs) significantly reduce the number of emergency room visits and resultant health care costs for poisonings, little is known regarding the potential impact of the PCC on the length of hospital stay. The aim of this study was to examine whether assistance from a PCC is associated with a shorter length of hospital stay for patients admitted with poisonings. The cases reported to our PCC were matched over a period of 1 yr with the hospital admissions E-coded as poisonings in the Uniform Billing (UB) data maintained by the state health department. The length of hospital stay was then compared between the cases for which a PCC provided assistance (matches) and the cases for which a PCC was not contacted. During the study period, there were 32,245 hospitalizations for poisoning in the UB data and 52,498 poisonings reported to the PCC. The matching process yielded 1719 nonfatal cases. The length of hospital stay for patients who received assistance from a PCC ranged from 0 to 126 d (median = 2.0) and was significantly different compared to a range of 0 to 220 days (median = 5.0) for cases that were never called in to a PCC. The results of this study suggest that patients admitted to hospitals with poisonings who receive PCC assistance have measurable reductions in average hospital stay. Such a decrease may translate into substantial savings in health care costs and resources.

Phenylpropanolamine and Associated Myocardial Injury

We report the cases of two patients without significant past medical history in whom developed myocardial injury attributed to the use of anorectic agents containing phenylpropanolamine. The pharmacologic properties of phenylpropanolamine and the current management of common adverse reactions to phenylpropanolamine are briefly reviewed.

Evaluation of adverse drug reactions reported to a poison control center between 2000 and 2007

PURPOSE The likelihood of hospitalization caused by adverse drug reactions (ADRs) from commonly implicated therapeutic groups is discussed. METHODS A retrospective analysis of the computerized records of exposure cases involving pharmaceutical substances reported to the New Jersey Poison Information and Education System (NJPIES) was conducted from 2000 through 2007. The cases in the National Poisoning Data System that were categorized as an ADR were included in the study set. Only reports involving a single drug were selected for inclusion in the analyses. Characteristics of the ADRs, such as the sex and age of the patient, the therapeutic group involved, and the medical outcome of the exposure, were examined. Reports of ADRs with the most frequently implicated therapeutic groups were analyzed based on whether the patients were managed onsite, referred to a health care facility, or managed at a health care facility. The Adverse Drug Reaction Hospitalization (ADRH) index was calculated for all therapeutic groups, but the focus of the analyses was on the groups that were implicated in 5% or more of all ADRs. RESULTS A total of 454,520 cases of human poisoning exposure were reported to NJPIES from 2000 through 2007. Of these cases, 162,105 were exposures implicating a single drug, of which 5,461 (3.4%) were classified as an ADR. Of the 5,461 cases, 385 patients were admitted into a health care facility. Antidepressants had the highest ADRH index (20.4%) among the therapeutic groups implicated, and antimicrobials had the lowest (2.2%). CONCLUSION The analyses revealed a substantial variation in the likelihood of hospitalization associated with ADRs within different therapeutic groups. Among the groups that were most frequently implicated in ADRs, antidepressants showed the highest probability for an ADR-related hospitalization, followed by dietary supplements, herbals, and homeopathics and then by sedatives, hypnotics, and antipsychotics.

Case of elevated blood lead in a south Asian family that has used sindoor for food coloring

After a routine blood testing, a local pediatrician discovered that a 13-month-old boy had an elevated blood lead level (BLL) of 57 µg/dL. Since the baby was mostly breast-fed, the pediatrician did a blood test on the mother, and the result showed a BLL of 85 µg/dL. As the mother denied any history of pica behavior, the pediatrician suspected a source of lead to which the entire family might have been exposed and tested the fathers BLL. The results showed a BLL of 95 µg/dL, and the pediatrician informed the poison center. The subsequent epidemiological investigation revealed that the parents had used a product called Sindoor for food coloring. Laboratory analyses showed that the product contains more than 57.8% of acid-extractable lead by weight. Given the extremely high content of Pb in this product, Sindoor poses a serious risk of lead poisoning if it is used for food coloring.

Accidental death from take home methadone maintenance doses: A report of a case and suggestions for prevention

Methadone, a synthetic opioid receptor agonist, is used for the treatment of opioid withdrawal and dependence. It occupies the opioid receptor and prevents withdrawal while permitting opioid addicts to change their behavior and discontinue their opioid use. The drug must be administered daily. Federal law allows for select individuals to take home and keep methadone for their therapy at home. There are currently approximately 260,000 individuals eligible for methadone to take home a 30-day supply of such methadone. Federal regulations specify the labeling of the medication containers and the use of child resistant containers. No regulations specifically require methodology for safe storage of containers (US Public Health, 2009). To the methadone naïve individual, particularly a small child, even the content of 1 container, even if only partially full, could prove fatal if ingested. Over 30,000 exposures to methadone were reported to poison control centers between January 2000 and December 2008 (American Association of Poison Control Centers, 2009). There were 684 deaths reported. Of the individuals exposed, 2,186 were under 6 years of age and 20 of these died. Only 1 child reached an ER alive, all the rest were dead on arrival. We report a case of a childhood death from an unintentional exposure to take home methadone.

Adverse reactions to over-the-counter cough and cold products among children: the cases managed out of hospitals

Background and objective:  Prompted by continuing concerns about the safety of over‐the‐counter (OTC) cough and cold medications, we examined the frequency and severity of pediatric adverse drug reactions (ADRs) to OTC cough and cold products reported to a major poison control center. The goal was to focus on cases that are usually managed out of hospitals and may not be recognized by the traditional adverse events surveillance and reporting programs.

Assessment of Barriers to Utilization of Poison Centers by Hispanic/Latino Populations

Previous research suggests that Spanish-speaking parents and residents of areas with large Hispanic and Latino populations are likely to underutilize the assistance that is available through poison control centers (PCCs). In order to examine any real and perceived barriers to utilization of the New Jersey Poison Information and Education System (NJPIES), the only poison control center in the state, an intercept survey was conducted with self-identified Hispanics/Latinos at Women, Infant, and Children (WIC) centers and in nearby grocery stores, bus stops, and public laundromats. Only 38% of the study sample (n = 206) had heard of NJPIES. Common ways to have heard of NJPIES included school or church bulletins, family members, and friends. Twenty-three percent knew the NJPIESs toll-free phone number; 23% knew it was available 24 h per day; and 22% knew that Spanish-speaking personnel were available for assistance. Potential barriers to utilization included not knowing the phone number of the poison center, not speaking English, and not knowing if the poison center could offer any help. Respondent-recommended strategies for increasing awareness of NJPIES among Hispanics/Latinos included advertising on TV, and distributing information through school and church bulletins.

Poison control center surge capacity during an unusual increase in call volume--results from a natural experiment

INTRODUCTION Poison Control Centers (PCCs) play an integral role in the preparation for and management of poison emergencies. Large-scale public health disasters, caused by both natural and human factors, may result in a drastic increase in the number of inquiries received and handled by PCCs in short periods of time. In order to plan and prepare for such public health emergencies, it is important for PCCs to assess their ability to handle the surge in call volume and to examine how the unusually large number of calls could affect the level of services. On 26 January 2006, the New York City Poison Center experienced a sudden loss of telephone service. The disruption in telephone service led to the need to reroute calls from that geographical catchment area to the New Jersey Poison Information and Education System (NJPIES) for several hours. METHODS Data from the NJPIES was abstracted from the telephone switchs internal reporting system and the NJPIESs electronic record system and processed with a standard spreadsheet application. RESULTS Compared to the same time and day in the previous week, the total number of calls received by the NJPIES during the four hours after the disruption increased by 148%. A substantial rise in the number of calls was observed in almost every 15-minute increment during this four-hour (h) time period (with some of these increments increasing as much as 525%). Meanwhile, the percentage of calls answered by the NJPIES decreased, and the percentage of calls abandoned during a 15-minute increment reached as high as 62%. Furthermore, the average time for handling calls was longer than usual in most of these 15-minute increments. CONCLUSIONS Limitations of the telephone technology, which impacted the ability of the NJPIES to respond to the surge of calls, were observed. While the NJPIES was able to handle the unusual increase of incoming calls using available poison specialists and staff, the experience gained from this natural experiment demonstrates the need for PCCs to have a pre-planned surge capacity protocol that can be implemented rapidly during a public health emergency. A number of challenges that PCCs must meet in order to have adequate surge capacity during such events were identified.