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An Acute Pain Service experience initiating methadone for opioid use disorder in hospitalized patients with acute pain

Rebecca C. Dale, DO, Carol L. Metcalf, MN, ARNP, Dale J. Langford, Christina E. Bockman, PharmD, Debra B. Gordon, DNP, RN, FAAN, Daniel L. Krashin, MD, Katherin A. Peperzak, MD, Andrea K. Breuner, PA-C, Michelle C. Accardi-Ravid, PhD, Ivan K. Lesnik, MD


Objective: Inform readers of the use of a clinical pathway that includes initiation of methadone in hospitalized patients with acute pain who have untreated opioid use disorder (OUD).

Design: A retrospective chart review with frequency distributions and descriptive statistics calculated to describe demographic and clinical characteristics of the sample.

Setting: Urban academic hospital.

Patients: One hundred twenty consecutive patients with untreated OUD cared for by the Acute Pain Service (APS).

Interventions: APS leadership spearheaded development of a clinical pathway to standardize pain management and optimize outcomes. The authors outline pathway development and describe 120 patients managed using this pathway, initiated on methadone for OUD.

Results: The sample included patients, average age 40 years, predominantly non-Hispanic white (74.2 percent), male (61.7 percent), unemployed (88.2 percent), and on Medicaid (84.2 percent). 96.7 percent had a history of heroin use, and 52.1 percent had engaged in previous medication-assisted treatment (MAT). Methadone or other opioids were held for signs of intoxication/sedation in 10.9 percent or for prolonged corrected QT interval in 1.7 percent. The majority received at least one other analgesic agent. For those prescribed opioids upon discharge, the average maximum morphine equivalent dose was 68.2 mg/day for approximately 3 days. 68.3 percent agreed to schedule post-discharge MAT, and of these, 68 percent attended their intake appointment. A small percentage (4.7 percent) left the hospital against medical advice.

Conclusion: This pathway provides an example of an effective and safe response to address the opioid epidemic and provide quality care to patients with OUD and pain.


acute pain, heroin, methadone, opioid use disorder, clinical pathway, medication-assisted treatment

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