methadone therapy for cancer pain?

Specialties Hospice

Published

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.

Specializes in Hospice, Med Surg, Long Term.

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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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.

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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.

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Specializes in Hospice, Med Surg, Long Term.

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.

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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.

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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.

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Specializes in Hospice, Med Surg, Long Term.

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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