patients on methadone plus PRN pain meds

[sassyann85]

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!

[firstinfamily, RN]

I would usually give the methodone at its scheduled time and assess the pt for pain relief, if they were still experiencing pain, then I would give the PRN pain medication regardless of how long ago I gave the methodone. The methodone is usually for pts who are either going through a drug rehab program or a pain management program, therefore they have a high tolerance to this medication and most likely will not be having any respiratory distress.

[Bezoars]

Okay, granted, I'm in Perinatal, so the only time I see this is on Mother-Baby Unit. That being said... the docs don't order anything WITH the methadone or subutex but ibuprophen or Tylenol. That's all they get.

[nurseprnRN, BSN, RN]

Okay, granted, I'm in Perinatal, so the only time I see this is on Mother-Baby Unit. That being said... the docs don't order anything WITH the methadone or subutex but ibuprophen or Tylenol. That's all they get.

You should have a physician, probably an anesthesiologist but maybe a neurologist, with an interest in pain management somewhere in the house. S/he can come and do an inservice on why this is wrong, exactly, and why a surgeon who gives NSAIDs for postop pain (like a Csection) because he doesn't know any better is an abusive SOB. If you don't have someone inhouse, call the local pain management practice or university med school and ask for someone.

[KelRN215, BSN, RN]

Okay, granted, I'm in Perinatal, so the only time I see this is on Mother-Baby Unit. That being said... the docs don't order anything WITH the methadone or subutex but ibuprophen or Tylenol. That's all they get.

This is a perfect example of patients on chronic methadone/suboxone maintenance being undertreated for pain. Just because someone is recovering from an addiction doesn't mean she can't have real pain.

[Here.I.Stand, BSN, RN]

Okay, granted, I'm in Perinatal, so the only time I see this is on Mother-Baby Unit. That being said... the docs don't order anything WITH the methadone or subutex but ibuprophen or Tylenol. That's all they get.

Then they need some CMEs on pain management, forthwith. There is absolutely no reason that someone on long-term methadone shouldn't be medicated for acute pain. Cancer patients are given PRN opioids when the methadone is a maintenance med for chronic pain.

OP, I don't wait, for the reasons PPs don't; I give methadone as scheduled and PRNs, PRN. Someone on long-term methadone isn't going to get oversedated from PRNs any more than the opioid naive pt on the PRNs alone.

[tokmom, BSN, RN]

I compare methadone to long acting insulin. You still give short acting to cover a high BG. I still give Percocet, Vicodin as scheduled, usually for breakthrough or scheduled prn. It bugs the heck out of me that Dr's get all paranoid and won't order pain meds these patients need. They think if the person is on methadone for chronic pain, then the methadone should hold the patient for acute pain, such as abdominal surgery. It doesn't, of course, then I have to battle the MD for appropriate pain meds. I think some docs should go through pain management class. Just my soapbox opinion.

[annie.rn]

This is a perfect example of patients on chronic methadone/suboxone maintenance being undertreated for pain. Just because someone is recovering from an addiction doesn't mean she can't have real pain.

So true! I have a friend who is a recovering heroin addict who is on Methadone. He fell and broke his hip, requiring an ORIF. He said that his pain was insane b/c the doctors didn't want to give him anything due to his past drug abuse and current use of Methadone.

[Bezoars]

I'm have a differing opinion here. I don't have any sympathy for addicts. Maybe if you were a trauma pt or something... but having a baby? No. I'm not empathetic. I'm pretty much not empathetic to the whole culture of "controlling all your pain and your pain is what you say it is". I think that is one of the major things wrong with healthcare today. When we started pushing pain meds on everyone we've created a society of "nothing is ever going to hurt", and that's just not true. We can lesson your pain, but not take it away all together. People don't seem to understand that. Anyway, having just had a baby is not something the vast majority of people need to be all drugged for to get through. I just disagree.

[tokmom, BSN, RN]

I'm have a differing opinion here. I don't have any sympathy for addicts. Maybe if you were a trauma pt or something... but having a baby? No. I'm not empathetic. I'm pretty much not empathetic to the whole culture of "controlling all your pain and your pain is what you say it is". I think that is one of the major things wrong with healthcare today. When we started pushing pain meds on everyone we've created a society of "nothing is ever going to hurt", and that's just not true. We can lesson your pain, but not take it away all together. People don't seem to understand that. Anyway, having just had a baby is not something the vast majority of people need to be all drugged for to get through. I just disagree.

What about those that take meds for chronic pain? Do you carry the same attitude toward them if they are hospitalized for a bowel surgery?

I do agree that some people have the perception they should feel no pain, and I educate to that. However to not medicate those that had their guts rearranged isn't right.

Curious on how many children you have had and if so, where they medicated births? Did the M.D. turn any of children during labor? Use forceps? Or a C section? Fourth degree episiotomy?? Just curious

[Bezoars]

There is a vast difference between those that take meds for "chronic" legitimate pain and drug addicts/users or past history users. No I don't have the same attitude about them... just the addict/user population. To answer your question... I had two children personally. One medicated, one not. Both with episiotomies. Both lady partsl births. I can tell you that I had nothing but Ibuprophen afterwards. None of this Perc 10's crap. To be more clear... I was referring to the mother baby unit I work on... not Labor and Delivery.

[tokmom, BSN, RN]

But what if the addict has bowel surgery? Do you not have any empathy for their pain?

As much as I don't understand why people take drugs they know are addicting, like heroin, I still treat their pain with empathy.

Well call me a weenie but I did have vicodin for a fourth degree tear with one of my children. I have seven children. Five natural and two epidural.

Thankfully the nurse and my OB were kind enough too give me some pain meds during the post partum period and a script at dc.

[KelRN215, BSN, RN]

There is a vast difference between those that take meds for "chronic" legitimate pain and drug addicts/users or past history users. No I don't have the same attitude about them... just the addict/user population. To answer your question... I had two children personally. One medicated, one not. Both with episiotomies. Both lady partsl births. I can tell you that I had nothing but Ibuprophen afterwards. None of this Perc 10's crap. To be more clear... I was referring to the mother baby unit I work on... not Labor and Delivery.

Maybe so but both populations can still have legitimate acute pain requiring analgesics.

Good for you for taking nothing but Ibuprofen post-op. I got through brain surgery on tylenol alone, doesn't mean I expected my patients to do the same when I was working Neurosurgery. Everyone's pain tolerance is different.