IV Methadone: When All Else Fails...

Author: Annas Aljassem

Dr. Hall: I would start off by saying that methadone definitely doesn’t have a sense of humor. I think as a practitioner, you have to not only understand the literature for methadone but also the limitations of what we know of methadone. It can be very unforgiving, and so really having a respect for those limitations when you’re dosing a patient can help push off some safety issues.

Dr. Aljassem: I definitely would agree that methadone needs to be respected. I think the other thing, though, is there is such a negative stigma about it that a lot of practitioners have kind of thrown their hands up saying, ‘I don’t understand this, we’re not going to do it.’ What we learn about are always the negatives; QT prolongation and excess sedation and respiratory depression, but we never learn about its amazing properties and the NMDA antagonism and everything that it potentially could do for patients when the traditional stuff hasn’t worked.

Dr. Aljassem: The indications for IV methadone would include when your traditional stuff has failed and you’re using hundreds, or thousands of milligrams of oral morphine equivalents and your patient really can’t be transitioned to any other level of care. What do you do at that point? I know if I was the patient, I would want some outside the box type of thinking. We’ve been very successful with outcomes in our populations using the IV methadone and eventually rotating them to p.o. methadone.

Dr Hall: And then to further reduce their dose. It’s important to remember when using methadone to not dose adjust more than once a week. There are Department of Defense and Department of Veterans Affairs guidelines that talk about methadone Mondays, if you will, as an easy way to remember how frequently you should adjust the dose. We ask patients to keep a pain diary and to keep track of how much medication they’re using so we can re-evaluate that as clinicians and do the appropriate dose adjustment when we see them in the office. Also, don’t neglect patient and family education about keeping medication locked up and out of reach.

Dr. Aljassem: I think that our biggest educational insight for primary care and caregivers of patients who are transitioned to IV methadone is that this is not like any other opioid. This is not like being on Dilaudid and oxycodone and morphine, and dose titration should not be done unless you have specialized training, unless you are coordinated with a pain specialist. Another point to remember is not to add other traditional opioids to this opioid. When you mix methadone with traditional opioids, that’s when the pharmacokinetics and dynamics of two different opioids can cause trouble.

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