Methadone

RNsRWe, ASN, RN · Dec 12, 2008

Without being there, it's very hard for me to say. Ok, impossible. Sometimes, patients have a chronic pain issue (perhaps that's why the meth?) and it takes ALOT of pain meds to ease a new pain. Sometimes, they don't seem to be in that much pain, but do seem to 'like' the meds. We have frequent fliers who are drug seekers and no one sees any pain except the prescribing doc in the ED....and sometimes we have pain management patients who are on so many meds I don't know how they can think straight. And they do.

I don't have much for you except to let you vent

Every patient is different (duh moment) but you'll learn in time who is dying of pain and who isn't. Just how it is.

Virgo_RN, BSN, RN · Dec 12, 2008

It sounds like he has a high tolerance for pain medications due to chronic pain. It can be very difficult to control acute pain in folks like this, and his doctor should have warned him about this. I would suggest some patient education here, informing him that because he has a high tolerance to pain medications, that the acute postop pain will be hard to control, and that a reasonable pain goal for this situation may be higher than what he normally is able to achieve for his chronic pain. But the good news is that the further out he gets from the surgery, the less severe the acute pain will be.

I'm wondering why he is not on a PCA?

ETA: Methadone does not produce a "high", which is why it is used as a substitution for other opiates like heroin or morphine, both of which do produce euphoria. Also, at the dose of methadone that he's getting, it should block any euphoric effects from the morphine and the Percocet.

District46 · Dec 12, 2008

He won't be drug seeking trust me. Drug addicts have much easier ways to get hold of thier hits than to go into hospital and put up with judgemental staff just for a small (to them) hit! I can hear from your post that you are not judging this patient and want to help so from experience I will tell you that the methadone your patient is on actually stops his body from producing any painkilling endorphins at all, he has not capacity at all to tolerate pain - none. However hard it is for you, it is harder for him. One thing that strikes me is that all the painkillers are opiates, and yet painkillers work on different pathways. As the methadone is already blocking all the receptors in that part of the pain he may be better with an anti-inflammatory type painkiller, such as voltarol. I have seen addicts get a lot of relief from two paracetamol, who are on huge doses of opiates, that you wouldn't think paracetamol would touch the sides! Try not to lose patience with him, you are doing a good job, and just having an understanding, non-judgemental nurse will help him immensly.

core0 · Dec 12, 2008

i have been taking care of a post op pt this past week that had a total knee. he is on 40 mg of methadone every 8 hours in addition to 10 mg of morphine ivp q 4 two percocet q 3, toradol ivp 30 mg q 6 and restoril 15mg for sleep. this pt was moaning screaming and carrying on :crying2:and stated his pain has been a 10 to 9.5 for the last two nights. the patient would ask for something for pain every 1/2 to 1 hour. i tried comfort measures such as repositioning, back rub, ice, and just trying to speak with the patient calmly and issue reassurance. what i am wondering is how does it come to this? has his body built up such a tolerance to pain meds that he does not find relief. what i am also wondering is what is next for this person? if the above does not help relieve some of the pain then what? or is this a person with an addiction that actually feels no pain and likes the high?
i know as nurses we should remain non judgemental but taking care of someone like this is a challenge. i felt at my wits end. :banghead:thanks for reading and letting me vent.

the problem is the methadone. methadone is an excellent medicine for chronic pain which is presumably what your patient was on it for. however, when you have an acute exacerbation of pain it causes problems.

methadone binds to both the opiod and nmda receptors. the nmda receptors are thought to be the key to avoiding the rush that you get for opiates as well as preventing tolerance with the methadone. methadone has a very long half life and is very fat soluble so you build up levels quickly. since methadone binds to the opiod receptors more agressively than other opiods it keeps the opiods from working. when you have an acute pain event you cannot engage or recruit other opiod receptors with morphine and the percocet because the receptors are already fully engaged. this means the patient gets no added relief from the morphine or the percocet.

if it was my patient i would take them off the methadone and put them on a long acting narcotic such as oxycodone with either morphine or dilaudid for breakthrough pain. this is also a patient that migh benefit from a pca. in your situation a request for a pain consult is probably the best bet.

also the tylenol dose for that percocet order is very high. above the recommended dose. a question about that might be in order.

david carpenter, pa-c

MedicalMaven · Dec 12, 2008

I know that the level of opioids in this PT's system seems unbelievably high, but there are a number of factors that must be considered when dealing with pain - REAL - Pain and opioid analgesics.

1). Each and every PT will metabolize meds in a completely unique manner.

Some PT's lack the necessary enzyme to metabolize certain opioids (synthetic or natural; single or compound). These poor PT's swallow meds in desperate hope for relief, while the meds pass through the body and are excreted nearly untouched, and are 'punched in the gut' again when faced with irritated, disbelieving docs/rns/staff who leave them in absolute agony w/the line: "well, if THAT dosage of meds doesn't relieve your pain, then there is nothing else we can do/give you". Codeine, morphine and some of their synthetic off-shoots are the most common opioids that are metabolized by a particular enzyme that many PT's lack. This runs in families and a solid family history can give you the heads up. PT's (or family members) might describe it as being 'allergic' to the med (but not reporting anaphylaxis, rash, hives, etc. -- instead claiming severe headache, increased pain - severe eye/sinus pain/pressure, nausea, vomiting, etc.) and most often will mention additional close family members (family of origin, multiple generations) with the same/similar problem. Other PT's may claim the med has "no effect" or gives "minimal pain relief" without detailing the other symptoms (above), however, when questioned at length, are typically found to have family members who also have problems with the med. These PT's are not drug-seekers ... they cannot help or control the biological 'lot' they were dealt any more than they can correct their faulty DNA/enzymes.

2. We often overlook the fact that REAL Painis a physical response, a Multi-System Event complete with metabolic/hormonal-adrenal/enzymatic changes.

Putting this in its most simplistic form, the reason that Recreational Drug Users experience a High ingesting the same meds that give Pain Relief withOUT any High to patients who are Genuine Chronic Pain Sufferers is because REAL Pain causes a cascade of changes within the body. These chemical changes comprising the "Pain Response" directly interact with the chemical composition of the analgesic (opioid) ingested to bring it to an End.

IF the body (the individual PT) has properly metabolized the meds (opioids), THEN the resultant metabolites of the meds seek out and bind with the chemicals comprising the pain response, just like a lock and key. Properly joined, the onslaught is Neutralized ~~on both sides of the equation (pain & analgesic). However, any imbalance creates havoc. A defective metabolic pathway or a total inability to metabolize a particular analgesic leaves the chemical pain response to continue unabated & unchecked, while the PT suffers in agony.

In the absence of pain (there are no chemical changes, no release of hormones/adrenals, etc.), if an analgesic is then introduced it is metabolized by the body without any "counterpart" - nothing to 'neutralize' it. Therefore, the full measure of the meds is free to affect the body, essentially overwhelming it, creating the 'Recreational High'.

3). (As noted by the previous poster) PT's can, and do, develop a physical tolerance to meds (and not just pain meds/opioids). There is a direct tolerance (same med) and a cross-tolerance (tolerance to one med causing tolerance to one or more different meds). This happens often in PT's with Chronic Pain, multi-system diseases/disorders,and/or a history of treatments involving various analgesics, including opioids (agonist, agonist/antagonist; pure, synthetic, semi-synthetic) and non-opioid analgesic alternatives such as NSAIDS, corticosteroids (topical, oral, injection - muscular, epidural), antidepressants (SSRI's, tricyclic, SSNRI's), anticonvulsants/antiseizure, etc. These meds, in combination or alone, can affect a PT's tolerance to pain meds for days, weeks, months or even years. The new and recently praised opioid alternative, Suboxone, has both a welcome and immediate affect on the body by making the PT "immune" to the effects of opioids (no pain relief, no euphoria, no possibility of a "high"). It works by blocking and interfering with the 'lock and key' mechanism of the pain response and metabolized opioid. However, it has an unfortunate long-term consequence in a particular population of PT's, causing them to essentially be 'immune' to analgesics for months to years. This cross-tolerance has yet to be studied, but these PT's require the use of Fentanyl as propoxyphene, codeine, hydrocodone, oxycodone and morphine have little to no analgesic effect, while slowing the PT's respiration to dangerous, even deadly, levels.

Physical Tolerance is frustrating and tricky for both the PT and the caregivers. A PT Hx that is more in depth than usual may provide some clues or even reveal the answer.

REAL/True Pain has no ceiling; it knows no bounds. Just when you think you've seen, felt or heard the worst of it ... it somehow climbs even higher, grows even larger, and lasts even longer. On the positive side, that is the beauty of opioid analgesics ==> they (potentially) have no ceiling effect (for analgesia) and seem to be a practically God-given weapon for waging war against pain. Used properly, for their intended purpose, they are quite simply the best option we have today. The closer to the chemical makeup found in nature, the better the results coupled with the least likely opportunities for problems (ie: side effects). The synthetic analogues become more and more problematic the further you go from the natural original (think Vioxx), with unexpected/unknown effects on organs, systems, etc. over time, not to mention the number of know/expected side effects discovered almost immediately in clinical trials.

For myself, I certainly did not expect or intend to compose a treatise on pain management in response to your question ... as anyone can probably tell, it is a passion for me - to ensure that no one suffers unnecessarily.

With your patient, delve a bit more into their chart/Hx and you just might find the answer. The likelihood that you've got a druggie party monster on your hands is pretty slim.

Take Good Care.... :specs:

iwanna · Dec 12, 2008

It is my understanding that while taking methadone, other opiates will not create a "high". When addicts try other opiates while on methadone treatment they will not get high. However, I believe that other opiates will help with the pain. This is what was explained to me from a counselor at methadone treatment clinic. (My daughter is on methadone for opiate addiction) Also, I was told that pain med, "tramadol" will decrease the effects of methadone.

FireStarterRN, BSN, RN · Dec 12, 2008

It's very difficult to sort out the factors contributing to this scenario in this type of patient, which often include psychological as well as physical.

I would have called and asked for a morphine PCA for this patient.

Not every patient on methadone, btw, is a drug addict. It's used for chronic pain patients.

FireStarterRN, BSN, RN · Dec 12, 2008

It is my understanding that while taking methadone, other opiates will not create a "high". When addicts try other opiates while on methadone treatment they will not get high.

I've never understood this reasoning and I tend to think it's a product of our puritanical roots. Addicts are put on methadone to keep them from going through physical withdrawel but without the 'high'. They end up addicted to methadone anyways.

Now, I'm not advocating drug use or anything, but why are lawmakers so down of people enjoying themselves? :confused:

nurselsteele · Dec 12, 2008

i have been taking care of a post op pt this past week that had a total knee. he is on 40 mg of methadone every 8 hours in addition to 10 mg of morphine ivp q 4 two percocet q 3, toradol ivp 30 mg q 6 and restoril 15mg for sleep. this pt was moaning screaming and carrying on :crying2:and stated his pain has been a 10 to 9.5 for the last two nights. the patient would ask for something for pain every 1/2 to 1 hour. i tried comfort measures such as repositioning, back rub, ice, and just trying to speak with the patient calmly and issue reassurance. what i am wondering is how does it come to this? has his body built up such a tolerance to pain meds that he does not find relief. what i am also wondering is what is next for this person? if the above does not help relieve some of the pain then what? or is this a person with an addiction that actually feels no pain and likes the high?
i know as nurses we should remain non judgemental but taking care of someone like this is a challenge. i felt at my wits end. :banghead:thanks for reading and letting me vent.

i guess my confusion is: methadone is used to deter addicts from using opiates, narcotics & heroin/crack, etc... i am unsure why we are using it along with the other medications?:thankya:

if i understand methadone & its intended uses: when methadone is used, it is believed to prevent morphine or narcotics like heroin from getting to interact on receptors for painkillers that are basically natural and termed as endorphins.

so if i understand methadone right, they are using it with the drugs that it blocks, so its really doing its job when you say that he is screaming in pain.... :confused: ...... because the methadone is blocking that morphine from working on the pain receptors? correct? :nono:

i guess my question would be to the doctor that has ordered these drugs, my father 65 yrs old had a total knee last year, was home in 2 days & started rehab in 2 weeks, he was taking oxycodone for 1 week, then his orthopod put him on anti inflamatories & a mild muscle relaxer........... nothing more.:wink2:

i guess i am confused regarding the use /over use of methadone, i agree it can be used for terminal pain such as bone cancer etc............ but mixing methaone w/ anything is a dangerous cocktail. :sleep: :down:

i hope anyone with more experience will let me know... because i am confused by the mixing of these medications. :no:

core0 · Dec 12, 2008

i guess my confusion is: methadone is used to deter addicts from using opiates, narcotics & heroin/crack, etc... i am unsure why we are using it along with the other medications?:thankya:
if i understand methadone & its intended uses: when methadone is used, it is believed to prevent morphine or narcotics like heroin from getting to interact on receptors for painkillers that are basically natural and termed as endorphins.
so if i understand methadone right, they are using it with the drugs that it blocks, so its really doing its job when you say that he is screaming in pain.......... because the methadone is blocking that morphine from working on the pain receptors? correct?
i guess my question would be to the doctor that has ordered these drugs, my father 65 yrs old had a total knee last year, was home in 2 days & started rehab in 2 weeks, he was taking oxycodone for 1 week, then his orthopod put him on anti inflamatories & a mild muscle relaxer........... nothing more.:wink2:
i guess i am confused regarding the use /over use of methadone, i agree it can be used for terminal pain such as bone cancer etc............ but mixing methaone w/ anything is a dangerous cocktail.
i hope anyone with more experience will let me know... because i am confused by the mixing of these medications.

methadone here is being used for chronic pain. it is a long acting opiate receptor antagonist similar to oxycontin or fentanyl patches. the way that you can usually distinguish this is by the bid or tid dosing. methadone can only be given in daily doses if the practitioner has a special dea license for the treatment of opiod addiction. methadone is an accepted way of dealing with chronic pain. automatically associating it with addiction does your patient a disservice. i would also suggest you look up the mechanism of action of crack.

patients on long term narcotics develop tolerance. pts on methadone also develop tolerance. you are going to have to use more narcotics to get their pain under control. i'm not the worlds expert on pain meds, but essentially the way that our pain team explained it, with methadone you have to use much more opiate to get any effect because the methadone is bound tightly to the opiod receptor. i used to make the exact same mistake noted above with our patients until i talked to our palliative care np about this.

pain is what the patient says it is. every patient will have a different threshold and needs for pain. trying to apply another patients needs for pain will only frustrate everyone. my guess is the patient was already on the methadone for chronic pain before the surgery. if the physician is not used to chronic pain patients then this is the root of your problem. once again a pain consult is probably your best bet (if available).

david carpenter, pa-c

nurselsteele · Dec 12, 2008

i am not debating that methadone can be used for chronic pain, & i have indeed researched methadone & its receptors, my question was : should it be used with other narcotics & opiates, is it healthy for the patient who is using it long term, i understand the addiction of all medications in increased with longer term, but what would be the benefit of using methadone along with other medicaitons, why not increase the methadone doseage and leave out the rest of the pain medications, i realize some peoples pain is what it says its is, but we have all run across those that "elevate" their pain to elevate their pain medications.

i work in a prison, i have people fake collapses due to pain, when every mri & ct & xray shows no injury or anything, to get pain medication, i guess i am the one that is sceptical of all people & their pain........... my downfall in life, i am more suspicious of people since i have worked in the prison for so long..........

but i also see the downfall to methadone & polysubstance abuse inmates.................................. lives are shattered with people that have a polysubstance abuse problem.

i have an inmate who was on fentynl patches for 11 yrs prior to incarceration, he has been w/ us for 1 1/2 yrs, we have him stable on neurontin 900mg tid.......... and he admitted that he hasnt been so comfortable............ in his life........... +++++ :yeah: :yeah:for us seeing beyond the obvious "chronic pain medications", i am sure when he gets out of jail he will resort to the patches again, because those where what he knew!!!

i guess different medications for different situations!!