Magazine article Drug Topics

Confusion between Methylphenidate and Methadone

Magazine article Drug Topics

Confusion between Methylphenidate and Methadone

Article excerpt

Problem: The Food & Drug Administration has received six medication error reports involving cases of inadvertent administration of methadone with various methylphenidate products. Four of the error reports involved cases of inadvertent administration of methadone (10-mg oral tablets) rather than the intended Metadate ER (methylphenidate HC1 extendedrelease, 10-mg oral tablets). In addition, two reports involved the inadvertent administration of methadone instead of the intended, unidentified methylphenidate product.

The first generic methadone product was approved in the early 1980s. Methadone is indicated for the relief of severe pain, detoxification treatment of narcotic addiction, and temporary maintenance treatment of narcotic addiction. A methadone product, when used as an analgesic, may be dispensed in any licensed pharmacy. Methadone products, when used for the treatment of narcotic addiction in detoxification or maintenance programs, are to be dispensed only by approved hospital pharmacies, approved community pharmacies, and by FDA- and stateapproved maintenance programs.

The agency has approved three Metadate products--all of which are manufactured by Celltech (formerly Medeva)-indicated for the treatment of attention deficit disorders. Metadate ER 20 mg was approved on June 1, 1988, and Metadate ER 10 mg was approved on Oct. 20,1999. Metadate CD (20 mg) was approved on April 3,2001.

Of the six medication errors reported to the FDA, four involved prescriptions for Metadate ER that were misinterpreted and dispensed as methadone (see table). At the time these errors occurred, Metadate ER had been approved for at least one year. All four errors, three of which were discovered prior to patient administration, occurred in outpatient settings in children ranging from five to 12 years of age. In only two of the cases, written prescriptions were identified as being part of the error process.

Two additional cases, also reported to the agency, did not specifically identify the type of methylphenidate product involved in the error (see table). One report involved the death of an eight-year-old male patient following a possible medication error at the dispensing pharmacy. In this case, the child was being treated for attention deficit disorder with methylphenidate (strength and brand name not identified in the report) and was found dead at home. Methadone substitution was listed as the suspected cause of death. In the second case, a patient had prescriptions for methylphenidate 5 mg and 10 mg, and methadone 5 mg and 10 mg were dispensed in error. …

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