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We read with interest the article by Goldschlager et al¹ entitled "Etiologic Considerations in the Patient With Syncope and an Apparently Normal Heart." This topic has recently become relevant to addiction medicine, in particular the field of opioid agonist therapy for heroin abuse. Despite the fact that persons addicted to opioids are relatively young and generally lack structural heart disease, they may be susceptible to arrhythmic syncope.

Goldschlager and colleagues provide an extensive review of drugs that may cause QT prolongation and torsade de pointes, but do not mention the synthetic opioid levacetylmethadol or its parent compound, methadone. Both of these long-acting opioids have been associated with QT prolongation and torsade de pointes.^2-3 Levacetylmethadol currently carries a black box warning to this effect and its use requires electrocardiographic screening prior to initiation and during titration.⁴

The purported mechanism of arrhythmia with these opioids may relate to blockade of the cardiac . . . [Full Text of this Article]

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