methadone therapy for cancer pain? - page 2

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... Read More

  1. by   Allow Mystery
    Thank all of you for this discussion; I have a patient with chronic pain and was told from the beginning that the patient had an allergy to all opiods. When questioned, the CG could not remember as to what the allergies were to the specific opiods, but advised that morphine caused the patient to be "too drowsy"; the patient has been on Lortab and is taking 22.5mg-30mg/day in divided doses; needless to say, the chronic pain persists. I was able to convince patient and CG to try Roxanol for
    BTP with only good effects for a period of 2-3 weeks. I was then able to convince patient and CG to try 15mg of SR morphine q 12; the trial lasted less than a week, although pain better managed, CG reports patient began hallucinating/forgtful, so now patient is back on Lortab with uncontrolled chronic pain. From reading this thread, and from other research, I think Methadone may be worth a try, but I don't have
    much experience with Methadone. I've had one patient who came into Hospice on Methadone and he did quite well on it. As I rememember, he was on 40mg q8 and also had a breakthrough dose of Methadone, 10%
    of his total daily dose; I don't recall him taking a lot of breakthrough Methadone, thus we didn't titrate his scheduled dose. We did add Roxanol towards the end to manage acute symptoms with much success.

    Please provide me with your recommendations. Thank you.
  2. by   SuesquatchRN
    I have nothing knowledgable to add, but I wanted to say, ceelynn, that I hope your brother finds freedom from his pain soon. I'm sorry.
  3. by   a21chdchic
    Methadone at 40 mg Q 8 hours is an extremely high dose for pain control, that would be an appropriate dosage for opiod withdrawal but not for pain. The higher limits for pain control is 20mg/day. When you do the conversion from lortab to morphine, and then to methadone, you will find the dosage will be minute compared to 40 mg. You should really have a Methadone Pharmacist make an appropriate recommendation. And the RPH's are even liberal in their recommendation. Methadone can be a very dangerous drug if not appropriately monitored. Personally, I would not start this particular patient out on more than 2 mg Q 12 hours, providing he doesn't have a history of ventricular dysrhythmias, and being careful in the presence of renal insufficiency. I do not like to use methadone for breakthrough pain, I was taught to use great caution when using this drug, so am very careful. I prefer to use either morphine or oxyfast for breakthrough pain. A lot of times people who hallucinate and have untoward reactions to opioids, will do ok on lower doses or wwith a different opioid. But seeing how he is going to be gunshy after using SR morphine, I would probably try Oxyfast 20 mg/ml, 0.10 - 0.25ml to start with and can work a little higher if he tolerates it ok. When I have a patient who is gunshy with opiods, I will have the liquid in hand and show them how little 0.1 - 0.25ml really is, and tell them I will sit with them for about a half hour after administration to monitor how he tolerates the med, and if he has a problem, I will immediately call the MD for an order change. A lot of times, patient are comforted in knowing you will be there with them., and will try it. I haven't had one that refused. Also keep in mind, you cannot increase the dosage for 5 days following the start of Methadone or a change in the dosage due to it's long halflife.
  4. by   Allow Mystery
    Quote from a21chdchic
    Methadone at 40 mg Q 8 hours is an extremely high dose for pain control, that would be an appropriate dosage for opiod withdrawal but not for pain. The higher limits for pain control is 20mg/day. When you do the conversion from lortab to morphine, and then to methadone, you will find the dosage will be minute compared to 40 mg. You should really have a Methadone Pharmacist make an appropriate recommendation. And the RPH's are even liberal in their recommendation. Methadone can be a very dangerous drug if not appropriately monitored. Personally, I would not start this particular patient out on more than 2 mg Q 12 hours, providing he doesn't have a history of ventricular dysrhythmias, and being careful in the presence of renal insufficiency. I do not like to use methadone for breakthrough pain, I was taught to use great caution when using this drug, so am very careful. I prefer to use either morphine or oxyfast for breakthrough pain. A lot of times people who hallucinate and have untoward reactions to opioids, will do ok on lower doses or wwith a different opioid. But seeing how he is going to be gunshy after using SR morphine, I would probably try Oxyfast 20 mg/ml, 0.10 - 0.25ml to start with and can work a little higher if he tolerates it ok. When I have a patient who is gunshy with opiods, I will have the liquid in hand and show them how little 0.1 - 0.25ml really is, and tell them I will sit with them for about a half hour after administration to monitor how he tolerates the med, and if he has a problem, I will immediately call the MD for an order change. A lot of times, patient are comforted in knowing you will be there with them., and will try it. I haven't had one that refused. Also keep in mind, you cannot increase the dosage for 5 days following the start of Methadone or a change in the dosage due to it's long halflife.
    Thank you! Your recommendation at 2 mg q12 is close to the recommended starting dose of 2.5 mg q8 as suggested per my research at http://www.aafp.org/afp/20050401/1353.html;
    I'm in agreement with your trials of Oxydose and/or Roxanol.

    I understand your concern with the patient on 40mg q8, I inherited this patient on this dose, and it served him quite well. Thanks again.
  5. by   doodlemom
    I have had a patient with up to 70 mg q 8 hrs for pain control and it worked quite well. It took quite some time to titrate up to this dose.
  6. by   a21chdchic
    Patient's who are on doses of Morphine (SR) like 700-1200mg, when converted to Methadone will have higher doses and tolerate it well. But when starting out, you generally start very low.

    Ana

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