Concerns About Consensus Guidelines for QTc Interval Screening in Methadone Treatment
Authors: Andrew Byrne
Journal: Annals of Internal Medicine (2009)

Letters4 August 2009Concerns About Consensus Guidelines for QTc Interval Screening in Methadone TreatmentFREEAndrew Byrne, MBBSAndrew Byrne, MBBSFrom The Byrne Surgery, Redfern, New South Wales, Australia.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-3-200908040-00013 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:The medical profession has been developing guidelines to improve opioid maintenance treatments for 40 years. The guidelines proposed by Krantz and colleagues (1) could set us back decades because they address only 1 extremely rare side effect with an unproven strategy of serial electrocardiography (ECG) on all patients regardless of risk.Worse than that, Krantz and colleagues give no alternative clinical strategy to maintain treatment outcomes. Indeed, their current advice may even do the opposite if put into practice. Vague notions of avoiding methadone treatment or using lower doses would be as helpful as saying that patients with diabetes need to avoid insulin and, when unavoidable, should take only small doses. The only licensed alternative to methadone, buprenorphine, is simply not effective in a significant proportion of patients (2).Justo and colleagues (3) reviewed the literature up to 2006 and found 40 cases of torsade de pointes in association with methadone treatment. None of the cases was fatal, and 85% were associated with a clear precipitant in addition to high-dose methadone treatment. Most patients with torsade de pointes have comedication or electrolyte disturbance contributing to their arrhythmia; therefore, ECG at a remote time could never prevent such cases.Before recommending effective clinical guidelines, Krantz and colleagues should have gone back to the field and determined an incidence rate for tachycardia. They also need to propose a viable, safe alternative strategy to compare with guideline-based treatment in addiction clinics, which currently reduce the high mortality in the addiction population by approximately 75%.Torsade de pointes rarely, if ever, occurs in young opioid-dependent patients starting methadone treatment. These guidelines should be taken along with a mountain of other clinical advice, and our patients should be treated individually, according to their needs. In the absence of other indications, patients prescribed methadone at more than 150 mg/d should probably be recommended routine ECG.Andrew Byrne, MBBSThe Byrne SurgeryRedfern, New South Wales, AustraliaReferences1. 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. Kakko J, Grönbladh L, Svanborg KD, von Wachenfeldt J, Rück C, Rawlings B, et al. A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: a randomized controlled trial. Am J Psychiatry. 2007;164:797-803. [PMID: 17475739] CrossrefMedlineGoogle Scholar3. Justo D, Gal-Oz A, Paran Y, Goldin Y, Zeltser D. Methadone-associated torsades de pointes (polymorphic ventricular tachycardia) in opioid-dependent patients. Addiction. 2006;101:1333-8. [PMID: 16911733] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Andrew Byrne, MBBSAffiliations: From The Byrne Surgery, Redfern, New South Wales, Australia.Disclosures: Dr. Byrne owns a clinic that charges fees for dispensing buprenorphine and methadone in addiction treatment. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoQTc 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 Steven P. Cohen and Jianren Mao 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 Metrics Cited byMethadone Therapy in Underserved Urban Community: QTc Prolongation and Life-Threatening Ventricular ArrhythmiasQTc interval screening for cardiac risk in methadone treatment of opioid dependenceUse of Methadone in Opioid Maintenance TreatmentManagement of opioid substitution therapy during medical interventionRevue des cas d’allongements du QTC et de torsades de pointe chez des patients traités par méthadoneCardiovascular-associated disease in an addicted population: an observation studyLes effets indésirables des médicaments de substitution dans le traitement de la dépendance aux opioïdes 4 August 2009Volume 151, Issue 3Page: 216KeywordsArrhythmiaConflicts of interestElectrocardiographyInsulinMortalityOpioid addictionOpioidsPatientsTachycardiaTreatment guidelines ePublished: 4 August 2009 Issue Published: 4 August 2009 Copyright & PermissionsCopyright © 2009 by American College of Physicians. 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