Discharging Patients on Methadone with Naloxone
Yes, you should absolutely discharge patients on methadone with a prescription for naloxone (Narcan) as a critical harm reduction and overdose prevention measure.
Core Recommendation
Naloxone should be prescribed to all patients on methadone maintenance therapy at discharge 1. This is a strong recommendation based on the principle that naloxone availability reduces the risk of overdose death, which is the leading cause of morbidity and mortality among opioid users 1.
Key Implementation Steps
Naloxone Prescribing Requirements
- Prescribe a naloxone rescue kit to all patients on methadone at discharge 1
- Provide overdose prevention education to both patients and their caregivers on recognizing signs of overdose and proper naloxone administration 1
- Educate family members on the medications, their risks, signs of overdose, and ensure the poison control number is readily visible 1
- Naloxone prescribing to someone at risk of overdose is legal in every state 1
Methadone Continuation at Discharge
Continue the patient's usual methadone maintenance dose without interruption 1. The evidence is clear that:
- Methadone maintenance doses should be verified with the patient's methadone maintenance clinic or prescribing physician 1
- Notify the addiction treatment program regarding the patient's discharge and confirm the time and amount of last maintenance opioid dose 1
- Inform the maintenance program of any medications given during hospitalization that may show up on routine urine drug screening 1
Post-Discharge Methadone Dosing Options
If immediate linkage to an outpatient methadone clinic cannot be arranged, federal regulations allow for up to 3 days of post-discharge methadone dispensing from the emergency department to facilitate treatment continuity 2. This "ED Bridge" approach:
- Uses the "3-day rule" to dispense methadone post-discharge 2
- Allows hospitals to serve as a point of entry into methadone treatment 2
- In one study, 40.4% of patients completed all bridge dosing and an additional 17.3% received at least one bridge dose 2
Critical Safety Considerations
Methadone-Specific Risks
Methadone has unique characteristics that increase overdose risk and require special attention 1:
- Variable half-life and unpredictable pharmacokinetics 1
- Risk of QT prolongation requiring electrocardiographic monitoring 1
- Should only be prescribed by clinicians familiar with its unique risk profile 1
Monitoring After Discharge
Patients must be observed until the risk of recurrent opioid toxicity is low 3:
- Monitor for at least 2 hours after any naloxone administration 3
- Watch for decreased respiratory rate, altered consciousness, and hypotension 3
- Naloxone's duration of action (45-70 minutes) is shorter than methadone's effects, creating risk for recurrent toxicity 3
Safe Storage Education
Controlled substances must be stored safely away from individuals at risk of misuse or overdose 1:
- Educate on safe storage devices such as lock boxes 1
- Provide information on safe disposal options if needed 1
Common Pitfalls to Avoid
- Do not discontinue methadone maintenance therapy during hospitalization or at discharge—this increases risk of relapse and overdose 1, 4
- Do not assume patients will automatically connect with outpatient methadone clinics—create a warm handoff process 2
- Do not discharge without naloxone even if the patient appears stable—this is a missed harm reduction opportunity 1
- Do not use mixed agonist-antagonist opioids in patients on methadone maintenance as they may precipitate acute withdrawal 1
Additional Preventive Health Measures
At discharge, strongly consider offering 1: