Change in Methadone Concentration Results in an Overdose in a Post-Partum Patient

Methadone is a potent synthetic opioid analgesic that has been used for decades, in conjunction with supportive psychological and social services, to manage and treat addiction to other opioids.1 Numerous incidents involving methadone have been reported,2 and methadone continues to be implicated in preventable deaths.3 This bulletin describes an incident involving a 10-fold overdose of methadone associated with a changeover of a hospital’s supply from methadone 1 mg/mL to a newly available 10 mg/mL product. The findings and recommendations from this case are shared in the hope that similar events in the setting of methadone maintenance treatment can be prevented.