Clinical Practice and Cases in Emergency Medicine

Introduction

The prevalence of high-potency synthetic opioids (HPSOs), such as fentanyl and its analogs, present significant treatment challenges to current strategies for Emergency Department (ED) medication for opioid use disorder (MOUD).  While most EDs traditionally use buprenorphine for MOUD, its effectiveness can be limited in patients exposed to HPSOs due to risk of precipitated withdrawal or inadequate control of withdrawal symptoms.  Methadone, a full agonist, is an alternative MOUD agent that addresses the severe withdrawal symptoms and cravings associated with HPSO dependence and will not cause precipitated withdrawal. Traditional methadone protocols often fail to provide adequate doses, but new federal guidelines allow higher initial doses and rapid titration to therapeutic levels.

Case Report

We report on a case of rapid methadone titration in the ED for a patient with a history of high HPSO utilization.  The patient received an initial dose of 50 mg methadone, followed by titration of hourly 10 mg doses to a cumulative 70 mg at discharge.  Vital signs, mental status, and Clinical Opiate Withdrawal Scale (COWS) scores were monitored to guide dosing.  

Conclusion

The protocol allowed for safe, individualized care, achieving therapeutic dosing levels that alleviated withdrawal symptoms and enabled the patient to transition to outpatient follow-up treatment.  This approach addresses the need for rapid, effective methadone initiation in an era where HPSOs pose challenges to traditional opioid use disorder treatment.