Opioid use disorder — structured clinical viva

Frame it as a risk conversation, not a detox booking. Retention in methadone or buprenorphine treatment is associated with substantial reductions in all-cause and overdose mortality, and the time immediately after leaving treatment carries particularly increased mortality risk.^[2] NICE asks that people be told about the loss of opioid tolerance after detoxification and the ensuing increased risk of overdose and death.^[8]

The missed doses. The methadone label tells patients treated for opioid addiction who miss a dose to take the next dose the following day as scheduled and not to take extra doses.^[4]

If she stops altogether. Use lower initial doses for patients whose tolerance is expected to be low at treatment entry; any patient who has not taken opioids for more than 5 days may no longer be tolerant.^[4]

The QTc of 470 ms. The Krantz panel recommends informing patients of arrhythmia risk and asking about structural heart disease, arrhythmia and syncope. If QTc is above 450 but below 500 ms, discuss risks and benefits and monitor more often; above 500 ms, consider discontinuing or reducing methadone, removing contributing factors, or an alternative therapy.^[1]

Is buprenorphine safer? The buprenorphine/naloxone label reports QT prolongation of 15 msec or less in thorough QT studies. Patients dependent on methadone may be more susceptible to precipitated and prolonged withdrawal during induction than those on short-acting opioids, and the label recommends buprenorphine monotherapy for them on Days 1 and 2.^[6] With flexible dosing, methadone retains more people in treatment than buprenorphine.^[5]

Will naltrexone cure her? Patients transitioning from methadone may be vulnerable to precipitated withdrawal for as long as 2 weeks before extended-release naltrexone.^[7] In X:BOT, fewer participants initiated extended-release naltrexone than buprenorphine-naloxone (72% versus 94%); among those successfully inducted, 24-week relapse was similar.^[3]