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.
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.
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.