Methadone and other analgesics

[manics]

Forgive me for being obtuse but its a question that I have never been able to find an answer to. Perhaps the clinical buffs will help me out.

Why are patients on methadone often prescribed other opioids for pain relief? Many patients are concurrently on codeine, dihydrocodeine and even high strength morphine. Surely as a relatively potent opioid agonist its analgesic properties should be suffiecient except where inflammtion or neuropathic pain is indicated.

Also seen patients on high strength oxycodone,morphine and fentanyl being prescribed remedeine forte. Surely just poor prescribing, or am i missing something?

[bobbin]

Forgive me for being obtuse but its a question that I have never been able to find an answer to. Perhaps the clinical buffs will help me out.

Why are patients on methadone often prescribed other opioids for pain relief? Many patients are concurrently on codeine, dihydrocodeine and even high strength morphine. Surely as a relatively potent opioid agonist its analgesic properties should be suffiecient except where inflammtion or neuropathic pain is indicated.

Also seen patients on high strength oxycodone,morphine and fentanyl being prescribed remedeine forte. Surely just poor prescribing, or am i missing something?

This represents poor prescribing. For patients on methadone, other classes of analgesic such as NSAIDs and paracetamol should be used.

[roper]

I'm also surprised when they ask for a cough medicine. Surely methadone should suppress a cough!

[happy_bunny]

Maybe they have been used to never coughing due to the opiates, then when the dose comes down and they are actually able to cough again they have a lot to clear so it bothers them more than it would someone who always had an unimpaired cough reflex... like when people give up smoking and suddenly their cilia work again so their cough gets worse - just a theory!

[Fleegle]

I'm also surprised when they ask for a cough medicine. Surely methadone should suppress a cough!

Oh please..they are obviously pulling a fast one to try to get some codeine out of you. Junkies neither know nor care that methadone suppresses a cough. In my own experience, junkies only cough profusely in an attempt to disguise the rustle that six packs of Mach 3 blades make while being inserted into the pocket of their shell-suit.

Don't be caught out with the 'I need sugar-free methadone..the other stuff rots my teeth' trick either. SF methadone is easier to inject, and most junkies get a take-away at some stage. Sugared methadone, if injected, results in limb-loss, as many have discovered in the past.

Fleeg.

[manics]

This represents poor prescribing. For patients on methadone, other classes of analgesic such as NSAIDs and paracetamol should be used.

Thats what I thought which asks the question why do so many of these patients complain of chronic pain? What is the solution if NSAIDs contraindicated, paracetamol not strong enough?

Poor prescribing or not it is impossible trying to reason with certain prescribers, I believe many are bullied into giving the co-dydramol, DHC or do they just not understand that all opioids have the same basic pharmacology.

[bleepholder]

i have seen instance swhere IVDUs have been admitted into hospital and they are on methadone and in pain. Doctors have wanted to prescribe opioids for the pain....it does sound odd to give morphine to someone on methadone, but if they are in pain, you can't deny them adequate pain relief?!?!

[Sir_Dispensalot]

as part of routine pain management opiates should be avoided. this of course goes out of the window in emergency situations. The trouble is with large doses of opiates already sloshing round their systems it can be potentially fatal to give them more - breathing should be monitored very closely if they are administered.

As an aside, i have a subutex service user who has severe ulceration and mrsa infection in his legs - he uses tramadol when pain becomes intolerable but is sensible enough to actually come in and let me know when he's taken it, and refuses his supervised dose of subutex when he has taken the tramadol.

[bleepholder]

according to anaesthetic colleagues....giving them the hypothetical scenario of an ex-IVDU coming into hopsital with a fractured femur, how they would manage the pain, given the fact the patient is on 50ml methadone a day??

they responded as

"Add in usuals (NSAID/paracetamol) plus your usual opiate of choice as you would with any other patient. They will probably need a bit more than the usual. I guess depending on stability of patient you will have to review what you do longer term post op."

"Give whatever you would give if they were not on methadone (if they were stable)- it will offer no pain relief
Cont meth at same dose"

"- Continue methadone throughout stay.
- Analgesia requirements may well be greater than opiate naive patient due to tolerance.
** Another major concern for the patient would be receiving opiates now that he is an ex IVDU, risking restarting his drug abuse (I don't have the same concerns with current users, and give them as much analgesia as they need)."

bearing in mind these are from doctors points of view ie the ones doing the prescribing! so it does seem senisble to treat them like any other patient and control their pain. You can't leave them in pain just because they are on methadone

[Itchy Feet]

Just my tuppence worth

1) Apparently methadone users have a higher tolerance to opioids therefore there methadone would give them a baseline and any opioids on top would give them the pain relief they require. Again due to the demographic you can never rule out them wanting more of a "rush" therefore close monitoring is essential, which includes respiratory rates (its funny how quickly doctors change their mind about prescribing opioids when you mention this monitoring lark!)

2) Opioid misusers generally have a higher risk of dental caries which is why SF methadone is prescribed in the first place

3) Finally in terms of pain control I refer all prescribers to the WHO pain ladder, there is no excuse for saying paracetamol is not strong enough lets sidestep, I used to insist that if they were considering opioids the patient should already be on regular full dose paracetamol and NSAID (fi not contraindicated)