Rapid methadone metabolism in patients with opioid use disorder could complicate methadone treatment. Toxicology screenings to monitor methadone levels may show negative for methadone, even with regular adherence to a regimen. A patient receiving treatment for opioid use disorder tested negative for methadone in 11 out of 22 toxicology screenings (50.0%). We hypothesized that the patient was a rapid methadone metabolizer. After tapering doses to a maintenance level and using supervised urine collection, the patient was negative for methadone in seven out of seven tests (100.0%), but positive for cocaine in five out of seven tests (71.4%) near the end of the maintenance period. Chronic cocaine use and genetic factors, particularly CYP2B6 polymorphisms, have been found to cause rapid methadone metabolism. Clinicians should be vigilant for unusual metabolic reactions and modify dose and monitoring schedules accordingly. More investigation into the physiological and genetic aspects of methadone metabolism is needed.

Rapid methadone metabolism in patients with opioid use disorder could complicate methadone treatment. Toxicology screenings to monitor methadone levels may show negative for methadone, despite adherence regular regimen. A patient receiving treatment for opioid use disorder tested negative for methadone in 11 out of 22 toxicology screenings (50.0%). We hypothesized that the patient was a rapid methadone metabolizer. After tapering doses to a maintenance level and using supervised urine collection, the patient was negative for methadone in 7 out of 7 tests (100.0%) but positive for cocaine in 5 out of 7 tests (71.4%). Chronic cocaine use and genetic factors, particularly CYP2B6 polymorphisms, have been found to cause rapid methadone metabolism. Clinicians should be vigilant for unusual metabolic reactions and modify dose and monitoring schedules accordingly. More investigation into the physiological and genetic aspects of methadone metabolism is needed.

Background: Pyromania is an impulse-control disorder characterized by repeated, deliberate fire-setting accompanied by increasing tension and followed by a sense of immediate gratification afterwards, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Although rare, pyromania carries significant medicolegal consequences and occurs in the lifetime of approximately 3%–6% of psychiatric inpatients. This study evaluates socio-demographic characteristics, substance use patterns, and psychiatric comorbidities among individuals diagnosed with pyromania at a community hospital in the Bronx, New York. Methods: This retrospective observational study included patients aged 9 years or older admitted to the psychiatric center between December 2013 and 2023. Twelve individuals met the inclusion criteria and were diagnosed with pyromania based on clinical assessment documented in the electronic medical record. Extracted data included demographic characteristics, socioeconomic variables, substance use history, and co-occurring psychiatric diagnoses. Results: Included patients ranged in age from 9 to 59 years (mean 28.58 ± 16.21), and 75% were male. Most were US-born (83.33%), with 66.67% identifying as African American and 33.33% as Hispanic. All adults were single and unemployed. Psychotic disorders, primarily schizophrenia, were present in 58.33% of the sample, and 58.33% also had substance use disorders. Among youth, oppositional defiant disorder (ODD) and conduct disorder were common, while no adult met criteria for antisocial personality disorder. Conclusions: Pyromania frequently co-occurred with psychiatric comorbidities, especially psychotic disorders and substance use. Although the overall prevalence is low, this disorder carries notable clinical and legal implications, underscoring the importance of targeted assessment and intervention in urban mental health settings. To the best of our knowledge, this is the first observational study to describe the socio-demographic and clinical characteristics of individuals diagnosed with pyromania in New York, USA.