Methadone

Magsulfate, BSN, RN · Dec 12, 2008

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

This is a very good explanation. The best course of action would be to d/c the methadone while he is in acute pain. This patient doesn't sound like he's drug seaking. Most drug seekers will get thier high.. and then pass out, , not beg for more 30 minutes later. Once the drug seeker gets enough,, he'll pass out and as soon as his eyes flip back open, he will be on the call light again begging. But if this guy is in constant pain, with no relief,,,, he is not getting any relief from these meds.

core0 · 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: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!!

prison medicine is indeed different. as to using methadone with other narcotics. it can be done, but if you are prescribing this you have to ask should it be done. post surgical cases in patients with chronic pain are difficult. you have to continue to control their chronic pain while controlling their acute pain in the face of often significant opiod tolerance. so using a long acting opiate and a short acting opiate treats both. its just more difficult with methadone. on the other hand methadone withdrawl is much worse than other opiate withdrawl. so i could see why someone who is not comfortable with chronic pain would leave someone on methadone and try to add short term opiates. on the other hand the results are usually similar to what you are experiencing.

david carpenter, pa-c

Magsulfate, BSN, RN · Dec 12, 2008

Prison medicine is indeed different. As to using Methadone with other narcotics. It can be done, but if you are prescribing this you have to ask should it be done. Post surgical cases in patients with chronic pain are difficult. You have to continue to control their chronic pain while controlling their acute pain in the face of often significant opiod tolerance. So using a long acting opiate and a short acting opiate treats both. Its just more difficult with Methadone. On the other hand Methadone withdrawl is much worse than other opiate withdrawl. So I could see why someone who is not comfortable with chronic pain would leave someone on Methadone and try to add short term opiates. On the other hand the results are usually similar to what you are experiencing.
David Carpenter, PA-C

One question for you David,,, if you d/c'd the methadone, but pt was still on high doses of opiates, wouldn't it mask the withdrawl symptoms of methodone, or am I completely wrong in this?

core0 · Dec 12, 2008

One question for you David,,, if you d/c'd the methadone, but pt was still on high doses of opiates, wouldn't it mask the withdrawl symptoms of methodone, or am I completely wrong in this?

If they are on the right dose of opiate they won't withdrawl. Withdrawl is simply not having as many opiate receptors bound as they are used to.

The issue is getting the dose right. Not enough and they withdrawl which in a post surgical patient is hard to tell from sepsis or some other badness. Too much and they do the whole sleepy forget to breath thing on you. Then you give them Narcan and real badness happens (think withdrawl all at once). Guessing the right amount of long acting opiate which is the same as the Methadone is the hard part due to the fairly large variability in metabolism.

When we take a chronic pain patient to the OR we get a pain consult before the surgery. We also work with palliative care to design a plan for the patient. Palliative care seems to be better than pain at long term pain management.

David Carpenter, PA-C

nurselsteele · Dec 12, 2008

We use controlled substances very very limited, the ONLY people that we keep on Methadone or Suboxone Or Subutex is the pregnant females, only because the baby will die from withdrawl if we remove the mother from the drug, its a horrible thing to do to a baby, so we have no choice but to send them to the Treatment clinic for their dosing, since we arent permitted to give methadone due to the Clinical Licensing in PA.........

I have seen some hard core detox with methadone but mostly its the "desire for the drug", no altered vitals or overwhelming sx's of withdrawl.......... the most deadly withdrawl that we see is : Heroin & Alcohol....... i have shipped inmates to the ER for intervention when our classic treatments for these withdrawl fail.... but never a deadly withdrawl from methadone... not yet...(knock on wood).......

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.

2nd thought, whats the chances of a blood clot? what about infections? any chance that we have another underlying problem that is causing this severe pain post op?

leslie :-D · Dec 12, 2008

if they don't want to mess w/the methadone, i'd consider narrowing the interval of the ivp ms04 from q4h to q1-2h...

or, increasing the mso4 to 20mg q2-3 hrs.

he doesn't sound med seeking.

something's up.

leslie

Virgo_RN, BSN, RN · Dec 12, 2008

2nd thought, whats the chances of a blood clot? what about infections? any chance that we have another underlying problem that is causing this severe pain post op?

Or compartment syndrome? A good ortho nurse would already have been assessing and reassessing for these things.

Virgo_RN, BSN, RN · Dec 12, 2008

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.

The proper use of Methadone in the treatment of opiate addiction is to replace the opiate with the Methadone, and then taper the dose down gradually. The person also needs psychological and behavioral support to change those thoughts and behaviors that contribute to the addiction.

Virgo_RN, BSN, RN · Dec 12, 2008

if they don't want to mess w/the methadone, i'd consider narrowing the interval of the ivp ms04 from q4h to q1-2h...
or, increasing the mso4 to 20mg q2-3 hrs.
he doesn't sound med seeking.
something's up.
leslie

Those were my thoughts too. If you mess with the Methadone, then you risk the chronic pain becoming out of control. Seems a better approach would be to adjust dosage and frequency of the faster acting meds for the acute pain.

nurselsteele · Dec 12, 2008

or compartment syndrome? a good ortho nurse would already have been assessing and reassessing for these things.

i agree, there has to be something underlying here, my 65 yr old father had the same surgery, and he had pain management for 1 week only then onto anti-inflammatories & mild muscle relaxers, only, and he never screamed in pain, he never had a pca pump or anything like that.

there has to be underlying issues, fluid under the replacement, infection, blood clot? something to cause this excessive pain...

worth looking into? xray the joint, mri , ct... something has to show the reason for the pain..... post op pain is really tough but you have to be willing to exhaust all other options to determine if the pain is being caused by anything else!! good luck

4theBetterGetter, RN · 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 agree with the posts about the methadone and binding the opiates. not an effective mix for acute pain. i work in a joint replacement center and we have a good success rate using oxycodone or norco, flexeril and morphine as prn's with tylenol, ultram and toradol as sched. meds. we also use polar packs and ice packs to the posterior knee. sometimes the occasional pt. gets great relief from putting their leg flat on the bed or sitting on the edge of bed with feet flat on the floor for a brief period. we also encourage lamaze type breathing and relaxation...alot of people don't realize that stress hormones increase pain and can be managed with relaxation in addition to the pain meds. we also discourage alot of visitors the first day so the patient can get some rest and let the meds work! good luck!