Opioid use disorder — structured clinical viva

This is a stability and shared-decision viva, not a pure detox request. Two missed methadone doses raise loss-of-tolerance and overdose concerns if she returns to street opioids or if an automatic full-dose unsupervised restart is given without review. Crisis-driven taper requests need empathic exploration of the relationship stress, suicide/overdose risk, and pain flare risk — not automatic agreement to stop OAT in one week.[2][4]

QTc 470 ms is borderline prolonged depending on sex-specific cut-offs and labs; review electrolytes, interacting drugs, symptoms (syncope, palpitations), and discuss risk–benefit of continuing methadone versus dose reduction or transfer. Krantz et al. frame systematic QTc screening in methadone treatment — not every borderline value mandates immediate cessation without a plan.[1]

Buprenorphine may be preferred for respiratory safety ceiling and take-home logistics in some patients, but transfer from high-dose methadone requires specialist protocols (methadone reduction and adequate withdrawal before buprenorphine) to avoid precipitated withdrawal. It is “safer” in some dimensions, not universally risk-free.[4][5]

Naltrexone (oral or XR) can prevent relapse in selected patients after completed detox, but it is not a magical implant cure; X:BOT shows induction difficulty versus buprenorphine–naloxone. Implants are jurisdiction-specific and not a substitute for engagement, psychosocial care, and overdose prevention during any transition.[3]

Dual pain needs multimodal care concurrent with OAT, not abandonment of analgesia or abrupt opioid cessation without a plan.[4]