(734) Methadone Versus Oxycodone/Morphine for Treatment of Iatrogenic Withdrawal in Pediatric Patients

Introduction: Patients admitted to the pediatric intensive care unit (PICU) often require prolonged opioid infusions, which can lead to withdrawal upon discontinuation. Methadone is an increasingly popular opioid used to prevent withdrawal in patients tapering off opioid infusions due to its long half-life, which minimizes breakthrough withdrawal symptoms. This freestanding pediatric hospital switched to primarily using methadone for prevention of iatrogenic withdrawal in May 2022. The goal of this study is to determine if the implementation of methadone as a first line agent for enteral sedation tapers in the PICU reduces withdrawal compared to any opioid comparator.

Methods: This retrospective chart review included patients who were admitted to the PICU from July to December 2021 and July to December 2022 for the comparator and methadone groups, respectively. Patients were included if they were under 18 years old and required continuous sedation infusions for at least 7 days. Patients were excluded if they died during admission or if they were re-intubated after taper initiation. This study evaluated modified withdrawal assessment tool (MWAT), duration of enteral taper, time to drip discontinuation, number of patients discharged on opioids, naloxone use, and cumulative exposure to opioid infusions.

Results: A total of 22 patients were included in the methadone group and 27 in the comparator group. Baseline characteristics were similar between both groups, except the comparator group required higher doses of opioid infusions (0.71 vs 0.89 MME/kg/day, p = 0.046). Patients who received methadone had significantly reduced sedation taper durations (8.3 vs 11.3 days, p=0.033) and fewer patients who required enteral sedation dose increases due to withdrawal (0 vs 6, p=0.010). Patients in the methadone group trended towards quicker time to drip discontinuation after enteral initiation (27.1 vs 36.2 hours, p=0.503), fewer patients discharged on opioids (3 vs 9, p=0.111), fewer patients requiring naloxone (1 vs 4, p=0.237), and decreased average number of MWATs greater than 4 (0.41 vs 1.15, p=0.094).

Conclusions: Compared to oxycodone and morphine, methadone significantly reduced enteral sedation taper duration and eliminated the number of patients who required enteral sedation dose increases due to withdrawal.