 The QT interval is a time period on an EKG between one wave, the Q wave, and another wave, the T wave. And that interval is important for us, because if it is prolonged, it can rarely lead to a life-threatening arrhythmia known as torsad state points. So providers are often fearful of starting methadone in an individual without having an EKG. But if someone, after asking them screening questions, is low risk, really, you shouldn't be withholding methadone as a life-saving treatment for opioid use disorder. I had a patient who I was taking care of in the hospital who came in through the emergency room with an EKG that showed an abnormally long QT interval. And so the team was a little concerned about continuing her methadone. They got cardiology involved. And cardiology initially recommended stopping her methadone completely. So we advocated for her continuing her methadone, given her overdose risk, and that she was personally verbalizing that she knew if she didn't have methadone, she would overdose and die from opioids. So we talked with cardiology. And after that discussion, they came to the realization that they weren't even considering her overdose risk when doing the risk benefit analysis of stopping the methadone. And so they ultimately ended up recommending just decreasing the dose. Methadone is the oldest FDA-approved treatment for opioid use disorder. In 2015, over 350,000 people in the United States were on methadone daily for opioid use disorder. In rare cases, methadone treatment has been associated with QTC prolongation, which typically occurs without clinical consequences. QTC prolongation is an abnormally long time in electrocardiogram, or EKG, between the start of a Q wave and the end of a T wave. Since 2006, methadone prescriptions have had a black box warning, which is found in the insert. The black box warning warns about QTC prolongation and torsade de poin, a rare heart arrhythmia that can be life-threatening. QTC intervals above 500 milliseconds increase the risk of torsade de poin. An estimated 2% of patients in methadone treatment experience prolonged QTC. Most torsade de poin cases occur in patients receiving methadone for pain, not methadone maintenance for opioid use disorder. QTC prolongation is thought to be dose dependent, which means that the higher the dose of methadone, the higher the risk of QTC prolongation. There are other risk factors associated with prolonged QTC intervals that include the use of medications like antidepressants, antibiotics, or antifungals, and having a congenital prolonged QTC interval, low potassium levels, or a low heart rate. There is controversy about how best to screen for QTC prolongation without creating barriers to methadone treatment. Physicians are unsure about the effectiveness of QTC screening strategies that prevent adverse effects among methadone patients. Methadone is a life-saving medication, and the risk of reducing a patient's methadone dose or discontinuing methadone is often relapse, overdose, or death. This reality must be balanced against a real but rare complication of methadone, torsade de poin, which many providers incorrectly perceive as a common complication. Anxiety regarding prolonged QTC intervals and torsade de poin leads many providers to rush to decrease the dose or discontinue methadone, which can be a pitfall in the management of patients on methadone. Pensensis among expert panels, which include cardiologists, is that methadone treatment programs should assess cardiac risk factors at intake, which include patient or family history of sudden cardiac death, abnormal heart rhythm, heart attack or failure, or prolonged QTC, unexplained fainting, heart palpitations or seizures, current use of medications that can prolong QTC, current use of cocaine or amphetamines, and an electrolyte assessment that includes potassium and magnesium levels. If realistic, opioid treatment providers may consider universal EKG screening, although there is insufficient evidence to support this practice. If a positive risk factor is identified, further assessment should be conducted to help determine the appropriateness of starting methadone. This assessment should include an EKG for patients with one or more risk factors at admission. The EKG should be repeated within 30 days and conducted annually thereafter. If a patient has a QTC interval between 450 and 500 milliseconds, providers should discuss the risks and benefits of methadone maintenance, as well as any other risk factors that can be modified to reduce risk, for example, a medication change. If a patient has a QTC interval above 500 milliseconds, serious consideration should be given to stopping methadone and switching the patient to buprenorphine. For patients on methadone with positive risk factors, ongoing assessments should include a risk benefit discussion with the patient if a QTC interval above 500 milliseconds is discovered during treatment and an annual EKG if the patient is on greater than 120 milligram daily with positive risk factors. One, conduct an annual EKG. Two, strongly consider lowering the methadone dose. Three, consider stopping other medications that impact QTC, eliminating other risk factors. And four, if possible, consider transitioning the patient to buprenorphine. In summary, prolonged QTC in patients taking methadone for treatment of opioid use disorders is rare. Opioid treatment programs should develop a cardiac risk management plan that includes screening patients at initial assessment for risk factors and continuous monitoring of patients on methadone who have risk factors.