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patients on methadone plus PRN pain meds

Medications   (8,989 Views | 36 Replies)

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Hello,

I have seen several patients on methadone maintenance that are also ordered PRN pain meds such as tramadol or oxycodone. How often do you typically have them wait after administering the methadone to get a PRN pain pill? I'm worried about the interaction of respiratory depression. Thanks!

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CardiacKittyRN has 1 years experience and specializes in Cardiac.

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I'd probably wait about an hour for the tramadol and two hours for the percocet. Depends on the situation, pt, and what is causing the pain too though..

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heron has 40 years experience as a ASN, RN and specializes in Hospice.

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I don't - completely different onset and peak times. You need to do it the old-fashioned way: dose then evaluate in a timely fashion. It is amazingly difficult to suppress respers in people who are already habituated. Pain control 101.

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55 Posts; 3,577 Profile Views

i was thinking that bc methadone has such a long half0life, the methadone will be in their system a long time no matter if you wait an hour or not to give a pain med/controlled med. correct?

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heron has 40 years experience as a ASN, RN and specializes in Hospice.

1 Follower; 2,557 Posts; 39,105 Profile Views

I don't wait - completely different onset and peak times. You need to do it the old-fashioned way: dose then evaluate in a timely fashion. It is amazingly difficult to suppress respers in people who are already habituated.

Opioids work the best when pain is treated early. Whether the methadone is for pain control or addiction management, the answer is the same.

Pain management 101.

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531 Posts; 6,415 Profile Views

If they are on methadone maintenance .. I wouldn't wait to give the prn meds. Not both together. But chances are if your patients are these meds go back and see how they responded. Assess and evaluate. But don't be the nurse neglects pain for conditioned fear.

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annie.rn has 21 years experience.

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You would also take into account whether or not the person takes the prn pain medication at home. We get a lot of Pain Management patients that are very often on a long acting, scheduled opiod (MS Contin, OxyContin, methadone) with a prn opiod for breakthrough pain. If they take both at the same time at home (which most do, in my experience) and tolerate it then I would not have a problem giving both at the same time. Also, I concur w/ what Heron said about the pharmacokinetics being different for the two meds.

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2 Articles; 11,114 Posts; 15,654 Profile Views

You need to understand the concepts of habituation and tolerance. Many folks on methadone or other opioids take regular doses that would make us opioid-naive folks stop breathing, so why is it that they are still alert and well-ventilated?

It's because their bodies are habituated (used) to that level of the drug and so they tolerate it.

If you can take a prn tramadol or oxycodone dose on top of your baseline opioid level (presumably zero) without risk of hypopnea, so can they, and for the same reason. There is no justification whatsoever for making them wait some arbitrary period to prevent a complication that will not occur, and for the same reason that no one should make you wait for prn pain relief if you ask for it when you need it. To do so is punitive and unethical.

Edited by cafeaulait

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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Methadone is relatively long acting and reaches near-steady-state plasma levels after a few days of being on the drug, which makes the particular time it's given essentially irrelevant to when the drug is exerting it's effects, since it's exerting basically the same effect all of the time.

I don't use the time methadone is given as having anything to do with when a prn can be given, particularly a prn like tramadol which has little to any respiratory effects in a non-opioid tolerant person, much less someone on methadone.

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KelRN215 has 10 years experience as a BSN, RN and specializes in Pedi.

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There's no reason to wait any time as other posters have explained very well.

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55 Posts; 3,577 Profile Views

thanks everyone for your responses! very helpful!

What about a patient on suboxone? I have seen PRN Tramadol. If they are well established on suboxone maintenance, would prn tramadol precipitate withdrawal if given a short time before suboxone? Should you wait an hour AFTER taking suboxone to take tramadol, will this help get a better pain effect than taking it shortly after suboxone?

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