methadone therapy for cancer pain?

  1. I am caregiver for my brother who is in hospice care for base of the tongue and throat cancer.He did not tolerate morphine sulfate well(totally zonked out).He is on 200mcg fentenyl patch x 2 days,2tsp percocet 5/325 x 4-6hrs.(has been more like x 3 hrs. lately),2 ml neurontin x 8 hrs.,1 mg ativan x 8 hrs., phenergan x 6 hrs., pepsid 2 x day, maalox as needed.He uses fast acting morphine for breakthrough pain, last few days, 3-4 x a day.His pain is increasing daily. His hospice nurse has mentioned methadone treatment, she said she has seen good results from people who can't tolerate morphine.His only objection is the stay in the hospice center to monitor the initial dosing.I would appreciate advise from anyone with experience with this treatment.
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  2. 18 Comments

  3. by   river1951
    Methadone can work very well for cancer pain.
    Best of luck to you and your brother.
    River
  4. by   ginger58
    As a palliative nurse I have to question the use of some of these drugs. That's a lot of Fentanyl to not be working along with Percocet, neurontin (why?), Ativan, Phenergan and IR Morphine! Roxanol can be give Q 1-2 hours. I think I would personally drop the Percocet and up the Morphine oral dose. Are you sure it was the MS that zonked him out? Most of those other drugs are also very sedating. Curious why the neurontin? He's using a lot of different drugs and not getting relief. Maybe you could clarify the need for the Phenergan vs Ativan for nausea? I know methadone is cheap and effective for pain but it has a very long half life and it can accumulate trying to reach pain control. I think I'd adjust the rapid release Morphine.
  5. by   doodlemom
    We have a great deal of success with methadone. We use it frequently and have many skilled nurses and physicians that know how to dose it correctly - which is the key to using it. It is a good idea to use the inpatient facility in switching from such a high dose of fentanyl. They can keep a close watch on him while titrating the meds. Good luck.
  6. by   ceelynncee
    The neurontin was given for severe pain in jaw,ear,temple,face(he would place his spread open hand over this area to discribe the pain)the neurontin has helped.He was originally given percocet,fentenyl(started 25mcg x3 days with increases to 200)when he was switched to morpine sulphate he spent an entire week in a cloud,he could'nt think straight,could'nt write(he has a trach,can'tspeak)slept most of the time.After switching back to percocet adding neurontin,much clearer headed,more awake time.But, the pain has grown worse.He has had much nausea and anxiety,the phenergan and ativan have been given from the start,they work well for him.His main goal is to be as pain free as possible and also be able to think and be awake often enough to enjoy the time he has remaining.His nurse said methadone would eliminate the fentenyl,and the percocet yet still allow him to use the fast acting morphine as needed.He also has a PEG tube,(PEG and trach were in prep. for treatment)so all meds. are given by PEG.Does this affect the action of the drugs?Thanks to everyone who replied,his pain is the hardest thing about this for me to deal with.
  7. by   ginger58
    Thanks for your answers Ceelynnee to my questions. I'm glad the neurontin has helped. I'm sorry the pain is so hard to control as it is hard to sit by and watch. The PEG should be fine for those drugs. Maybe he needs more Ativan, like 1 mg every 4 hours as needed. Just don't let them stop the Fentanyl abruptly. I hope the meth works for him and the breakthrough pain med can be more frequent. Please let us know how things are going.
  8. by   ceelynncee
    Thank you for the encouraging replies.He has had a really rough time the last 2 days.I had to break the top off the fast acting morphine bottle to get the last few doses(called hospice for more this morning(Sun. 8am)my bad)I'll have to watch his meds. more closely.I'm learning.We talked about the methadone late last night(after 4 doses of morphine)he is going to go for it,he made a list of things to take to the hospice center.He amazes me sometimes.His nurse mentioned that they had started certain patients on methadone at home,but they perfered to do it inpatient,she said it can get kind of scarey.What is scarey about it?
  9. by   ginger58
    I think what's scary is just waiting to see what works since it has a long half life. Hospice just wants to be sure he doesn't get zonked but patients are started on it at home especially when there is no inpatient hospice. Don't worry about calling-that's what they're there for. Is the liquid morphine Roxanol and what dose are you giving?
  10. by   ceelynncee
    The fast acting morphine is Roxanol,0.25-0.50ml x4 hrs as needed.We haven't used 0.50 initial dose yet,we start 0.25,he doesn't like the way it effects him.He says"It wakes me up,then puts me to sleep."He is going to the hospice center today to start conversion to methadone.He is very nervous about the stay,we have all tried to reassure him,this is something I wish I could do for him!Please send out all those good hospice nurse vibes and prayers in his direction!Thank You!
  11. by   ginger58
    Quote from ceelynncee
    The fast acting morphine is Roxanol,0.25-0.50ml x4 hrs as needed.We haven't used 0.50 initial dose yet,we start 0.25,he doesn't like the way it effects him.He says"It wakes me up,then puts me to sleep."He is going to the hospice center today to start conversion to methadone.He is very nervous about the stay,we have all tried to reassure him,this is something I wish I could do for him!Please send out all those good hospice nurse vibes and prayers in his direction!Thank You!
    That is an extremely small dose of Roxanol. Have they considered going the Oxycontin route--also oral. He may have to put up with some drowsiness to get the pain under control. He probably doesn't have good quality sleep while in pain so if he can get some good sleep he may be more awake as a consequence. I am sending him lots of good thoughts and you also. Caregiving is a very hard task. I admire you. To put Roxanol in perspective--some patients receive 0.5-1 ml every 1-2 hours.
  12. by   bigjay
    This may be a bit late since your brother is likely recieving his treatment now and hopefully is doing well.

    I work on an oncology inpatient floor and our palliative docs use methadone very successfully. We typically will use methadone in cases where the pain is either not responding well to typical treatments (morphine, dilaudid, oxycontin, fentanyl) or the patient is having too many side effects due to being on high dose opioids. Methadone is typically very clean in terms of side effects and provides excellent pain control.

    The down side of methadone is the long half-life. It can accumulate in the system if not properly monitored. It can also cause significant respiratory depression and the rate and severity of this is much more than other commonly used opioids.

    Our usual protocol is to initially start a patient on only a prn dose of methadone q 4h (dose varying as per their prior pain medication routine). If the patient has pain between the four hour doses we will use dilaudid or morphine q 1h prn. We then track the usage over 2-4 days and start a routine dosage at that point. During the trial period we monitor the patients resps q 3h. If they drop to 8 or lower and the patient is unresponsive we will give sc narcan. If the patient is responsive we typically just wait it out and hold the methadone for 12 hrs or so, using the other BT medication until the methadone clears, then start again at a lower dosage.

    It's a tricky drug to use but with proper application and monitoring it works extremely well. The trick is to have knowledgable staff and physicians so you don't run into problems. In my five years or so with working with methadone we've only had to narcanize one patient and he came out fine.
  13. by   doodlemom
    Quote from bigjay
    This may be a bit late since your brother is likely recieving his treatment now and hopefully is doing well.

    I work on an oncology inpatient floor and our palliative docs use methadone very successfully. We typically will use methadone in cases where the pain is either not responding well to typical treatments (morphine, dilaudid, oxycontin, fentanyl) or the patient is having too many side effects due to being on high dose opioids. Methadone is typically very clean in terms of side effects and provides excellent pain control.

    The down side of methadone is the long half-life. It can accumulate in the system if not properly monitored. It can also cause significant respiratory depression and the rate and severity of this is much more than other commonly used opioids.

    Our usual protocol is to initially start a patient on only a prn dose of methadone q 4h (dose varying as per their prior pain medication routine). If the patient has pain between the four hour doses we will use dilaudid or morphine q 1h prn. We then track the usage over 2-4 days and start a routine dosage at that point. During the trial period we monitor the patients resps q 3h. If they drop to 8 or lower and the patient is unresponsive we will give sc narcan. If the patient is responsive we typically just wait it out and hold the methadone for 12 hrs or so, using the other BT medication until the methadone clears, then start again at a lower dosage.

    It's a tricky drug to use but with proper application and monitoring it works extremely well. The trick is to have knowledgable staff and physicians so you don't run into problems. In my five years or so with working with methadone we've only had to narcanize one patient and he came out fine.

    We never use methadone prn because of it's long half life. We use it only as a long acting drug and use another drug for BTP.
  14. by   a21chdchic
    6-26-2007
    I work with Methadone on a daily basis and find it to be very effective and useful as a long acting med. It may only be titrated up once Q 5-7 days due to the long half life. This must be managed very carefully with the assistance of a Methadone Pharmacist to convert the doseage of all the narcotics being used. I would get rid of the Duragesic, and percocet, and use the morphine for breakthrough pain. Neurontin is great for the nerve pain on the face. But you need to add up all the doseages and mg of the narcotics, because they need to be converted to the equivalent of Morphine, then the proper morphine dosage is converted to the proper methadone dosage. We don't use inpatient to initiate Methadone therapy, but am careful with cardiac patients. We rarely go with the RPH recommendations, starting at a lower dose. We are conservative in dosing, and titrate as appropriate.

    Ana

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