Early Results of Implementing Rapid Methadone Titration for Hospitalized Patients: A Case Series

With the increase in illicit fentanyl use in the USA, hospitals face challenges managing opioid withdrawal and opioid use disorder (OUD). To improve opioid withdrawal and OUD treatment among hospitalized patients with daily fentanyl use, we developed a rapid methadone titration (RMT) protocol. We describe development, implementation, and outcomes during the first 12 weeks.

We analyzed electronic health record data of hospitalizations seen by the Addiction Consult Team (ACT) for methadone initiation between 9/11/23 and 12/3/23. Adults aged 18-64 reporting daily fentanyl use, desiring methadone, and without end-stage organ damage or critical illness were RMT eligible. We characterized patients who received RMT, abstracting demographic and clinical characteristics, adverse events graded by the Common Terminology Criteria for Adverse Events (CTCAE), and methadone and additional full agonist opioid (FAO) dosing. Our primary outcome was adverse events. Secondary outcomes included median time to 100 mg of methadone, FAO dosing, and self-directed discharge.

ACT assessed 55 hospitalizations representing 47 patients for RMT eligibility. Among these, 19 (34.5%) hospitalizations representing 17 patients were eligible for and received RMT. Four (21.2%) hospitalizations that received RMT had sedation events, and all were mild or moderate grade by CTCAE. Hospitalizations achieved a median methadone dose of 100 mg by day 6, with FAO doses peaking on day 5. One (5.3%) hospitalization had a self-directed discharge.

With careful patient selection and ACT evaluation, a RMT protocol for hospitalized patients with fentanyl use disorder experienced few adverse events other than mild-moderate sedation, even among those receiving FAO and those with concurrent substance use disorders.