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Follow-Up on QT Interval Screening During Methadone Treatment

Questions have arisen about interpretation of the data cited in the January 2009 publication of this guideline.

Since publication of our summary on QT interval screening for patients who are receiving methadone therapy (JW Gen Med Jan 27 2009), a new version of the original article and an editorial have been published, and a controversy has emerged. Of note, the article was published online originally, removed, reposted, and then published in modified form both in print and online. Some of this controversy is detailed in rapid response letters on the Annals of Internal Medicine website.

In the latest version, the editors of the Annals note that the paper was written by some, but not all, members of the expert panel and that two authors specifically declined acknowledgement for the publication. The editors also stated that (despite being published under the heading "Clinical Guideline"), the recommendations were not approved by the U.S. Center for Substance Abuse Treatment as a federal guideline and that the agency was sending draft recommendations for field review. Finally, several authors received funds from makers of a methadone alternative.

The editorialist points out that the guideline was based on sparse evidence (i.e., the incidence of clinically relevant dysrhythmia is unknown, and no evidence of benefit exists for electrocardiographic screening) and that the risks associated with methadone for patients with opioid dependence are given in detail, whereas no mention is made of methadone treatment benefits or of harms associated with not using methadone. Because a change in clinical practice (i.e., requisite QT_c measurement) could limit access to methadone, current evidence does not point toward a clear course of action. This practice guideline was premature, and further research will be needed to determine how potential risk for torsades from methadone should be incorporated into practice decisions.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine May 7, 2009

Citation(s):

Krantz MJ et al. QTc interval screening in methadone treatment. Ann Intern Med 2009 Mar 17; 150:387.

• Original article (Subscription may be required)
• Medline abstract (Free)

Gourevitch MN. First do no harm. . . Reduction? Ann Intern Med 2009 Mar 17; 150:417.

• Original article (Subscription may be required)
• Medline abstract (Free)

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• methadone guidelines
  Brad Miller MD, 5 Jun 2009 2:15 PM EST
  I appreciate you cautionary editorial view. As a Hospice physician and a consultant in chronic pain mgt, I have found... [more]