On day 2, we among people with OUD, and many drug overdoses have ele- partially consolidated her previous total dose of short-acting opi- ments of suicidality.4 oids to SROM 200 mg/d orally, and we switched the as-needed There are 3 main opioid agonist treatment (OAT) options for medication for opioid withdrawal to morphine 40 mg orally every the treatment of OUD in Canada: buprenorphine, methadon. [...] We subsequently admitted her to the hospital for with a half-life of 24–42 hours.5 It has a ceiling effect on respiratory treatment of her concurrent psychiatric and substance use disor- depression, which reduces its risk of causing an overdose, and is ders, including up-titration of methadone and SROM. [...] Methadone is a full agonist opioid with a long and variable half-life (ranging from 8 to 59 h).7 Guidelines recommend Discussion waiting several days between methadone dose increases; this The case of this patient highlights some of the challenges that means it may take weeks before patients reach doses therapeutic for patients with opioid use disorder (OUD) face when presenting to opioid withdraw. [...] t olerance to methadone can be rapidly lost and that cross- For withdrawal from regular use of illicit fentanyl, we typically tolerance between methadone and other opioids is incomplete.7 start with as-needed doses of between 4 and 6 mg hydromorphone This creates a potential for iatrogenic overdose if methadone is orally every 3 hours, 20–30 mg of morphine orally every 3–4 hours, restarted at a hi. [...] licenses/by-nc-nd/4.0/ Medicine Scholars Program (R25DAO33211; National Institute on Drug Abuse), as well as a Contributors: Robert Kleinman contributed Disclaimer: This manuscript discusses the off- travel award from the American Psychiatric As- to the conception and design of the work and label prescribing of medications within the sociation (both outside of the submitted work).
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