Implantable Cardioverter Defibrillator Placement to Permit Ongoing Methadone Treatment Despite QT Prolongation and Torsades de Pointes: A Case Report

Methadone is a highly effective medication for opioid use disorder (OUD) but has a risk of QT prolongation and life-threatening arrhythmias. This case report presents a patient with OUD on methadone treatment who experienced syncopal episodes due to recurrent episodes of polymorphic ventricular tachycardia (PMVT). Due to the effectiveness of methadone and prior lack of response to alternative treatments, including buprenorphine, rather than methadone dose-reduction, the patient ultimately received an extravascular implantable cardioverter defibrillator (ICD) for prevention of out-of-hospital arrest. This case highlights an important clinical dilemma in balancing the risks of procedures and arrhythmias with improved OUD-related outcomes with methadone. In this report, we review the literature and advocate for consideration of ICD placement in select, high-risk patients with methadone-related QT prolongation or arrhythmias.