The purpose of this study is to explore the use of parenteral methadone in opioid-tolerant patients who are status-post transplantation. As an alternative to traditional opioids, methadone may reduce exposure to medications that increase risk of recidivism in patients with opioid use disorder. Methadone maintenance therapy for treatment of chronic opiate addiction may be viewed as a contraindication for transplant candidacy. Broadened clinical use and experience with methadone may decrease discrimination for transplant listing.

Method: Parenteral methadone dosing guidelines were developed and successfully implemented at a large, tertiary, academic hospital. Our program has transitioned 77 adult patients with high opioid requirements from July 2015 – Nov 2017. We implemented parenteral methadone for acute pain stabilization followed by conversion to oral methadone for chronic pain management. Three of the 77 were patients who underwent liver transplantation (and one also received a kidney). Outcome measures included medication utilization, functional outcome, and safety endpoints.

Results: All three transplant patients reported significant improvement in pain control once parenteral methadone was initiated. Two patients were successfully transitioned over to oral methadone within 72 hours, and one patient received parenteral methadone for a period of two months. Each patient is currently maintained on oral methadone for pain control. All three patients report better pain control as compared to prior treatment regimens that included high doses of traditional opioids. The use of parenteral methadone has allowed our service to better manage uncontrolled pain in this critically ill patient population.

Conclusion: We have successfully implemented a treatment algorithm to transition patients from high dose opioids onto an oral methadone regimen with optimal pain control using parenteral methadone. Although the unique pharmacokinetic profile of methadone present significant challenges to prescribers, with proper supervision and experience, this medication can be a powerful tool in achieving good functional pain outcomes following transplantation.

CITATION INFORMATION: Aljassem A., Hall L., Cohn S., Bedi D., Alsibae M., Putchakayala K., Tasleem S., Samarapungavan D., Carpenter C., Koffron A. Closing Pandora's Box: An Evidence Based Approach to Opioid-Tolerant Patients Following Transplantation. The Case for IV Methadone Am J Transplant. 2017;17 (suppl 3).

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