ALE Spotlight: Provider decision-making around Methadone treatment for Opioid Use Disorder patients with a prolonged QTc

By Michelle Ngeouyang, PA/MPH'22

As a dual degree PA/MPH student, I have an interest in preventing diseases and believe that it is important for us to do so for our community especially as we see many continue to deal with chronic health conditions. I also believe that a public health background will give me another perspective, in additional to the traditional clinical perspective, as I care for patients in the future. The Applied Learning Experience (ALE) was a chance for me to apply the skills and knowledge we learned in the classroom to a real-life problem before starting the PA program. After some initial ups and downs of searching for a project, I was excited to begin my ALE at Tufts Medical Center. Under the guidance of Dr. Alysse Wurcel, we developed a quality improvement project and planned on looking into how providers decide whether to continue Methadone or not for patients with opioid use disorder (OUD) and a prolonged QTc on their electrocardiogram (EKG). A prolonged QTc is when the measurement from the start of the Q wave to the T wave is longer than usual on an EKG.1

According to the 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes in the United States2, an estimated 2,144,000 persons aged 12 and older, reported an opioid use disorder in the previous year.2 As the opioid epidemic continues, more individuals are prescribed medications to treat OUD, including methadone. Methadone is a synthetic opioid agonist that acts on the same receptors in the brain as other opiates (ex. heroin) and opioids (ex. fentanyl). If the drug is discontinued, withdrawal symptoms including muscle tremors, nausea, diarrhea, vomiting, and abdominal cramps can occur.3 Methadone can prolong the QTc, putting patients at risk for fatal cardiac events. When a patient has a prolonged QTc and is on methadone, clinicians need to weigh the risks and benefits of discontinuing methadone. My ALE project aimed to determine what factors clinicians currently consider in making clinical decisions for OUD patients with a prolonged QTc with the overall goal of improve the care that is delivered to this population.

My project started off with a comprehensive literature review to gain a better understanding of the issue. With the help of Julia Zubiago, a Tufts BA/MPH’19 graduate and research assistant who works with Dr. Wurcel, I was able to find literature on the topic and gather background knowledge. Next steps involved conducting key informant interviews. With Dr. Wurcel’s guidance, I developed an interview guide and reached out to a variety of healthcare providers by email. Healthcare providers who were reached included cardiac electrophysiologists (EPs), an addiction psychiatrist, residents, pharmacists, attending physicians, and more. All in all, I was able to successfully conduct, transcribe, and analyze 8 interviews. By the end of my project, I was able to identify common themes that came up from my interviews and wrote a report for Dr. Wurcel detailing my findings. Moving forward, Dr. Wurcel plans to continue this project and I am passing my work off to Dr. Anne Dowton, a Tufts School of Medicine graduate and Tufts Medical Center internal medicine resident who is interested in addiction medicine. The next steps are performing more interviews and developing surveys for quantitative data collection.  

Overall, I was so grateful to have the opportunity to complete my ALE with Dr. Wurcel and I had a great experience. Being able to practice and apply skills that were taught in the classroom, especially conducting qualitative interviews, was great. I was nervous at first, but this project really allowed me to grow and practice my skills, including communicating and interacting with different health care professionals. Listening to providers talk about their experiences and perspectives was very interesting and solidified that this is a complex issue that requires more understanding, such as understanding which specialists providers should turn to when a clinical situation where a patient has a prolonged QTc and is on methadone arises. 

What stood out most to me was interacting with different healthcare providers, learning more about methadone, what a prolonged QTc is, and the potentially fatal outcomes from having a prolonged QTc. Additionally, how important methadone is as a medication for patients with OUD. We often overlook and underestimate the importance of medications that treats OUD. Regardless, as the opioid epidemic continues, we will continue to see more people prescribed methadone and they could have a prolonged QTc. The decision to discontinue methadone can have serious consequences for patients and thus is not an easy one to make. Further research will help healthcare providers improve the care that is delivered to patients. Again, I can’t express how grateful and glad I am to have completed this project with Dr. Wurcel. As I start my didactic year, I am sure the lessons I’ve learned will help me in the future as a physician assistant as I partake in the care for patients with OUD. 

References

1. Bart G, Wyman Z, Wang Q, Hodges JS, Karim R, Bart BA. Methadone and the QTc Interval: Paucity of Clinically Significant Factors in a Retrospective Cohort. J Addict Med. 2017;11(6):489-493. doi:10.1097/ADM.0000000000000353
2. Centers for Disease Control and Prevention: National Center for Injury Prevention and Control. 2018 Annual surveillance report of drug-related risks and outcomes: United States. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf. Accessed September 7, 2019. 
3. National Drug Intelligence Center. Methadone fast facts. National Drug Intelligence Center. https://permanent.access.gpo.gov/gpo11051/6096p.pdf. Accessed September 7, 2019.