methadone

gwenith, BSN, RN · Sep 12, 2003

We use it occasionally in ICU for burns and for conditions where you would want long acting pain control. Seems to work well.

renerian, BSN, RN · Sep 12, 2003

We used it mostly for sickle cell clients. I will ask huby who is a hospice director for a rural county hospice if they use it when he gets home tonight.

renerian

Dave ARNP · Sep 12, 2003

We use alot of Methadone!

It provides good pain control, often better than MS Contin & other long acting Morphine forms.

Typically we start about 1/4 of our cronic pain patients on Methadone; be it cancer or non malig. Reasons include the high response rate, cost of drug, and the fact that almost all insurance covers it without PPA.

If we start the Methadone in the office, we always start at 10mg BID. We add more doeses Q day (TID/QID) before going up in the MG.

Typically, a non-malig. cronic pain patient will maximize pain control on 10mg QID.

It is also to note, though, you will have, and I mean HAVE to use a PRN drug for breakthrough pain. Methadone has a bit of variance in its delivery, and so we never let anyone go home without a PRN.

For PRN's, we start with Lortab 10/500 BID/PRN. If the liver is a problem, we will use Norco 10/325 BID/PRN, or if we are talking about a big conflict with the use of Tylenol in the drug, we will (by last resort) give OxyIR 7.5mg BID/PRN.

We use these CIII drugs for atleast 2/3 months, no less. If, after that, the PT is still complaining of breakthrough pain, we will go the next step, which for us Dilaudid 4mg PO/Q12hrs PRN.

The Dilaudid can then be adjusted over time to the point that the b/t pain is under control. Ofcourse, baseline pain is always controlled with the longer acting drugs. We like to wait two months to show a failure in a drug, as long as the pain is 7, they are to go to ER, (read the following) and we will evaluate them)

Firstly, we are NOT a pain management center. We are family practice. I know it is quite unheard of to be this agressive in pain control in FP, however any pain specialist is a couple hours away, and the MD I work with has a internship in PN Mgnmt, he is also a fellow of the board of PN Mgnmt. I also have extensive training in this area, and our two staff RN's are Pn Mgnmt. certified nurses.

Pain is a big one for us, but to be treated for it, you do pay a price.

(Note, this does not apply to those that are being treated for short, acute pain. If you break an arm, sprain something, take a nasty fall, ect... And the MD writes you a script for Lortab or Percocet... then we don't consider you Pn Mgnmt, even if you get a couple of refills.)

We do consider you Pn MG. if...

You are getting a CII Opioid for more than 1mo

More than 2 CS's for more than 3 wks each, and they are used for pain, and it is not an acute injury.

(others apply, and are determined per/case.)

What the PT has to do:

Bring ALL (Even vitamins that we suggest) to EVERY appointment, even if that appointment is not related to pain.

Attend ALL appointements. Be on TIME for every appointment. Give 48hrs notice if the need to cancel, (if less, they must speak to me or the MD and get approval).

Submit to blood, urine, and hair sample screening PRN, as often as Bi-Weekly. These notices are also, often sent to the patients on weeks that they do not have an appointment, via registered mail.

Submit to all ordered testing once it is agreeded upon, and an ordered is issued. No canceling, unless they speak with MD or myself.

ALL prescriptions filled at ONE pharmacy. NO exceptions. Pharmacy contacts up prior to filling ANY CS Prescription that is labled as a PN MG. Scripts are also labled as Fill ONLY AT : Located At:

PT is to notify us within 24hrs if they change address, phone#, or are charged with any crime-excluding traffic.

-Any non-adherence from this policy will result in discharge from the practice (we usually do give people a few days to get things in order, the first time... we just don't write their meds. We're not MEAN people).

I know this sounds stern, but we only discharge about 5% of PT's from the program. In exchange for compliance, they get treatment from us, that they have failed to get from the prior 3,4,5,6,7,8,ect.... people that they have seen. Our patients overload us with thank you's, gifts, ect... We could literally go ONLY PN MG from referrals from other MD's, pt's, ect... We've now started doing alot of suggestion pain treatment plans to other practitioners, and letting them try things before we see the patient.

Finally, you should also know, that in my expeirence, just because someone reacts badly to Meth, they don't always have a bad expeirence to Morphine. Just something you have to figure out for yourself.

Best wishes for you and your patients on the use of Methadone!

David Adams, ARNP

-ACNP, FNP

renerian, BSN, RN · Sep 12, 2003

Oh yes I forgot to add this. When I worked at the hospital some of the sickle cell clients sold their methadone on the street, would run out and come to ER for more. Several confessed it straight out.

renerian

sassyfrassy · Sep 13, 2003

The Hospice that I work for uses Methadone quite a bit. It really has worked well for some of the patients whose pain has been very difficult to manage. It is also cheap which helps on the business end of things considering some of the opiods are so expensive. We have one MD who really has come to specialize in its use and as I said above, the results are 80-90% favorable.

aimeee, BSN, RN · Sep 13, 2003

We rarely see Methadone and don't have practioners and physicians who are comfortable and knowledgeable about its use. It seems a real shame because everything I have read about it sounds like it can be a really great alternative in many ways.

Rapheal · Sep 13, 2003

This is an interesting thread. I have no knowledge about Methadone for hospice patients. On the floor we use it for recovering heroine addicts. I was surprised at the dosage that MDterminator quoted which equals about 40mg a day. For our recovering addicts the typical a.m. dose is from 100- 120 mg QD. Many of these patients have been receiving this dose for over 3 years. Does anyone have any knowledge about how long recovering addicts are kept on methadone and if and when they start weaning the dosage?

Wren · Sep 14, 2003

We used Methadone several times at a Hospice that I worked for and it worked very well. It was a challenge to get the doc's to prescribe though as they considered it useful only for drug abusers and it took a bit of education to get an order. That was a couple of years ago though and in a smaller more rural area. Maybe trends are changing. I found it to be as effective as MSIR and cheaper.

renerian, BSN, RN · Sep 14, 2003

I talked with hubby and he said yes they use it alot. He was wondering if the other hospices have on staff a paliative pharmacist?

renerian

caffine addict · Sep 14, 2003

Renerian,

We have a few resident on methadone for pain in LTC. Your experiance is my biggist fear. We have recovering addicts living amongst our popuation.

Parish the thought after my night on call!!!!!!

aimeee, BSN, RN · Sep 15, 2003

We do not have a pharmacist on staff but contract with Hospice Pharmacia for those services.