Key Recommendations from the American Pain Society on the
use of methadone for pain
·
Assess likelihood of patient adherence
·
Patient education regarding risk of cardiac
arrhythmias, onset of action, and communicating to health care team about new
prescription or nonprescription drugs
·
Baseline ECG in patients with risk for QTc
prolongation (family history, drug-induced, or electrolyte abnormalities)
·
Follow up ECG
o Within
2 to 4 weeks in those at risk or those with history of QTc prolongation
o If
total daily methadone dose > 30mg
o If
total daily methadone dose > 100mg
o Signs
of ventricular arrhythmia (palpitations, syncope, pre-syncope)
·
Methadone is contraindicated in patients with
QTc >500ms
·
Address reversible causes of QTc prolongation
before starting methadone when QTc is between 450 to 500
·
Methadone is initiated < 2.5mg every 8 hours
in opioid naïve patients
·
Methadone is initiated < 40mg daily in opioid
tolerant patients
·
Dose cannot be titrated up more than every 5 to
7 days
·
Assess adverse effects 3 to 5 days after
initiation of methadone
·
Methadone should be avoided with benzodiazepine
Additional Definitions
·
Misuse – using medication other than as directed
·
Abuse – using a medication for nonmedical
purpose (ex: getting high)
·
Aberrant behavior – departing from strict
adherence to the prescribed plan of care
·
Addiction – impaired control over drug use,
compulsive use, craving
·
Pseudoaddiction – untreated pain exhibit
aberrant behavior, but resolves with adequate pain control
·
Dependence – withdrawal symptoms due to stopping
or decreasing the drug
·
Tolerance – decreased effectiveness of drug over
time. Higher doses needed to get same effect.
·
Diversion – using a drug for recreational
purposes
·
Hyperalgesia – escalating doses of opioids
results in increase in pain severity or change in pain quality
Additional Drugs
·
Treatment of opioid abuse - Naltrexone,
methadone, and buprenorphine
·
Treatment of alcohol abuse - Naltrexone, acamprosate,
and disulfiram
·
Treatment of tobacco addiction - Bupropion, varenicline
Source:
Pharmacy Times. Managing
Opioid Medications for Pain Relief While Preventing Overdose, Diversion, and
Misuse: The Role of the Pharmacist.
http://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction
