How are you guys handling inherited methadone patients?

[Nonphysiologic]

I have some Mehthadone patients I've inherited on like 10 TID for years no ekg and in general don't need to be on high opioids if at all.

I'm trying to clean it up. What is the dose limit you guys are using for Metha done? I've read and calculated one day 10mg BID to be the absolute max in terms of adhering to CDC guidelines.

Methadone has a disproportionately high amount of complications related to it.


Also how are you guys weaning these patients?

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[pmrmd]

10 TID is a lot. I still prescribe methadone but at 5 or 10mg daily. At that dose it’s as safe as anything IMO. The literature showed arrhythmias at 200mg or more. Maybe start weaning by reducing by 5mg a month or convert to morphine at 90mg and include withdrawal meds. No good route.

 

[MD87]

I’m in the same boat as you. Except mine was on 130mg daily when he came to me.

I think based on the calculator that the PDMP uses, 30mg is 90mmeq. This is based on the fact that when I dropped him from 100 to 90 daily it dropped from 300 to 270 mmeq daily. Maybe as I go lower the conversion factor will change.

 

[lobelsteve]

I have some Mehthadone patients I've inherited on like 10 TID for years no ekg and in general don't need to be on high opioids if at all.

I'm trying to clean it up. What is the dose limit you guys are using for Metha done? I've read and calculated one day 10mg BID to be the absolute max in terms of adhering to CDC guidelines.

Methadone has a disproportionately high amount of complications related to it.


Also how are you guys weaning these patients?

I do not Rx methadone and tell patients up front. If they are on methadone they do not see me or get switched. I do not Rx at first visit, so no issues with dealing with withdrawal- that is on the last guy.

 

[Ducttape]

can get QT changes at much lower than 200 mg. had a patient with such changes (but no fatal arrhythmias) at 90 mg that resolved when dose got down to 60 (on the way to off).

conversion factor is of course an estimate. 1:8 at higher doses, 1:4 at lower. i believe not til 40 mg? have to look that up again.

regardless, tapering off methadone is not that heinous. i think i inherited roughly 30-40 patients. have 1 patient left on it, but he is on 5 tid. barring cancer or palliative care diagnosis, wont have anyone else on it.

part of methadone's issues are the vast interactions it has with other drugs and its excessively long half life.

historically speaking 10 tid was not considered a lot. that was part of the problem. you'd start the drug and patients would notice only the short term benefit, ie 4-6 hours and complain that it wasnt working leading to dose escalations.

tapering off methadone is fairly painless due to the prolonged half life. its easier to cut doses down, such as going from 10 tid to 5 qid then 5 tid then cut the 5s in 1/2 tid, over 6 weeks. because of the long half life, patients may not notice any significant withdrawal symptoms for 4-6 days after dose change, and then maybe not at all.

 

[pmrmd]

can get QT changes at much lower than 200 mg. had a patient with such changes (but no fatal arrhythmias) at 90 mg that resolved when dose got down to 60 (on the way to off).

conversion factor is of course an estimate. 1:8 at higher doses, 1:4 at lower. i believe not til 40 mg? have to look that up again.

regardless, tapering off methadone is not that heinous. i think i inherited roughly 30-40 patients. have 1 patient left on it, but he is on 5 tid. barring cancer or palliative care diagnosis, wont have anyone else on it.

part of methadone's issues are the vast interactions it has with other drugs and its excessively long half life.

historically speaking 10 tid was not considered a lot. that was part of the problem. you'd start the drug and patients would notice only the short term benefit, ie 4-6 hours and complain that it wasnt working leading to dose escalations.

tapering off methadone is fairly painless due to the prolonged half life. its easier to cut doses down, such as going from 10 tid to 5 qid then 5 tid then cut the 5s in 1/2 tid, over 6 weeks. because of the long half life, patients may not notice any significant withdrawal symptoms for 4-6 days after dose change, and then maybe not at all.

QT changes can occur at 100mg but documented arrhythmia was higher.

Methadone detox is notoriously difficult. Every patient I changed said it was the roughest time they ever had.

 

[Pain Applicant1]

I personally don't take over high-dose opioids, for the most part, especially methadone. I explain to the pt that I'm not willing to assume the risk of it and I'm sorry but I'm just not comfortable doing it. I also don't like having to clean up someone else's mess and I don't expect someone else to take responsibility for my actions. If they got the pt that high they have to work on tapering them.

With that said, I have a few pts on methadone., probably less than 4. Typically 5mg 2 or 3 times per day. I find that these pts are fairly well-controlled and didn't respond well to other things. EKG on the first visit followed by a repeat every 3-6 months. Just taper slowly if you have to. Explain the long half thing and that they must take the medication only as prescribed. Usually, the first step down and the last step off tend to be the most difficult.

Lastly, I will never take over methadone for dependency issues. I believe you have to be specially licensed for that which I'm not. I use suboxone for that.

 

[kstarm]

As others I don't manage methadone. I've seen too many elderly patients at the hospital that were tolerating it and now that there organs don't work as well they end up with side effects and hospitalizations. I always offer suboxone through our addiction doctors if they are interested. I will provide a bridge dose to the addiction doctor if they are in agreement with suboxone, otherwise do not prescribe. Methadone tapering is usually straight forward until the last 10mg or so. This last part can be very challenging for people to stop.

 

[buddababa]

I do not Rx methadone and tell patients up front. If they are on methadone they do not see me or get switched. I do not Rx at first visit, so no issues with dealing with withdrawal- that is on the last guy.

same, however, i've forcibly inherited patients from my partner who abruptly passed away with so many patients on methadone. What would you have guys done in this situation? Refused to fill? weaned?

 

[drusso]

I have some Mehthadone patients I've inherited on like 10 TID for years no ekg and in general don't need to be on high opioids if at all.

I'm trying to clean it up. What is the dose limit you guys are using for Metha done? I've read and calculated one day 10mg BID to be the absolute max in terms of adhering to CDC guidelines.

Methadone has a disproportionately high amount of complications related to it.


Also how are you guys weaning these patients?

If they're doing well, just leave them alone.

 

[Gnarvin]

I have also somewhat forcibly recently inherited non-cancer pain patients on methadone (many of them just with fibro...). What I have been doing is giving them the whole speech that I don't feel that methadone is appropriate for them and that we are going to start weaning to get them off of a drug that I think the risk of continuing outweighs the benefit. Baseline EKG. I then have been slowly tapering as close as I can get to 20% every month. Anecdotally, I have had a number of the patients do well for the first 2 or 3 months and then start complaining of withdrawal symptoms and then I just held steady for that month and then continued weaning after that month. It has been a long and unpleasant experience for everyone involved.

 

[lobelsteve]

same, however, i've forcibly inherited patients from my partner who abruptly passed away with so many patients on methadone. What would you have guys done in this situation? Refused to fill? weaned?

I would have resuscitated the partner or done the Weekend at Bernie's shtick until the patient's bolted.
Or just let them start withdrawal with COWS>10 and gone buping.

 

[swamprat]

I really don't believe 30 of methadone is only 90 MME. I think we don't have a good conversion for methadone but I treat it as a last resort due to the variable pharmacokinetic profile, drug interactions, QT prolongation and risk for overdose which can be delayed due to the metabolism variability

 

[Ferrismonk]

Methadone conversions are crazy if you follow CDC guidelines, however I would just follow what your PDMP states. Mine says 3:1 so 30mg = 90MMED. That's what the DEA and the State will data mine anyway.

I don't need to go over the risks with Methadone, I think most people here get it. I've seen QTc prolongation as low as 40mg. Get EKG at initiation of therapy, any dose escalations, and at least annually if stable.

Weaning isn't terribly difficult because of it's long half life, however I would caution rotation because Methadone works on both NMDA as well as Mu receptors and it doesn't rotate terribly well.

 

[Ducttape]

i reviewed each inherited patient separately.

personally,
1. i assessed whether patient was appropriate and had appropriate condition for methadone (or any opioid for that matter)
2. there were identified risk factors for use, or that particular dose, and gotten EKGs on any dose
3. reviewed PMP and looked for indicators for addiction, including getting UDS on like all of them.
4. i assessed my commitment to methadone and its use, and determined 20 mg was the max dose i feel comfortable prescribing. much more for palliative care/end of life.
5. i met with each patient and informed them the plan. for some, complete cessation or slow taper. many were not happy. i handed out many preprinted other pain clinic info sheets.

i think i inherited roughly 80? when dust settled, ended up with 20 Legacy patients. over the years, some failed, 3 or 4 dropped out/transferred care, one sadly passed away from cancer, and im left with 1 patient now... none overdosed or developed cardiac arrhythmias.

 

[pmrmd]

If you do continue a patient on methadone, it will be blamed for every ailment a patient develops no matter what. You may have to put on your clinician hat for your patients. IMO it’s a great drug for ESRD/HD patients.

 

[lobelsteve]

If you do continue a patient on methadone, it will be blamed for every ailment a patient develops no matter what. You may have to put on your clinician hat for your patients. IMO it’s a great drug for ESRD/HD patients.

Its not a “great drug” for anything pain related.

 

[pmrmd]

Its not a “great drug” for anything pain related.

It’s 100% hepatically metabolized and excreted and 5mg/d has no more risk than anything else. How about very good for ESRD/HD?

 

[lobelsteve]

If it were good for anything it would get used more. It was good for heroin addicts to keep them from dying. Would offer tramadol tid 100-0 over mtd. Would offer oxy 5 or Dil 4 100-0 over mtd.

 

[Laryngospasm]

And what happens when your inherited methadone patient dies? It’s always your fault.. must be that pain guy prescribing methadone.. it’s the only drug(class) where the prescriber is always blamed.. antiarrhythmic? Blood pressure med? Plum hypertension management? Diabetic med? Nah.. must be the opioid..

 

[bedrock]

And what happens when your inherited methadone patient dies? It’s always your fault.. must be that pain guy prescribing methadone.. it’s the only drug(class) where the prescriber is always blamed.. antiarrhythmic? Blood pressure med? Plum hypertension management? Diabetic med? Nah.. must be the opioid..

Agree. I would never prescribe it.

 

[drusso]

And what happens when your inherited methadone patient dies? It’s always your fault.. must be that pain guy prescribing methadone.. it’s the only drug(class) where the prescriber is always blamed.. antiarrhythmic? Blood pressure med? Plum hypertension management? Diabetic med? Nah.. must be the opioid..

Sometimes "pain-addicts" die. #circleoflife.

 

[DOctorJay]

I’m with Steve and bedrock. No methadone in my office

 

[epidural man]

You guys can send all your methadone patients to me. I’ll take care of it.

Actually, there are still chronic pain patients on long-term opioids? Weird…..

These days, I give a single dose of methadone in the OR. That’s my methadone experience.

When we were treating a lot of phantom limb pain during the thick of the war, we gave it out a lot. People on long term methadone start to have a certain look and personality. It was really strange and very predictable.

 

[Drd105]

I have some Mehthadone patients I've inherited on like 10 TID for years no ekg and in general don't need to be on high opioids if at all.

I'm trying to clean it up. What is the dose limit you guys are using for Metha done? I've read and calculated one day 10mg BID to be the absolute max in terms of adhering to CDC guidelines.

Methadone has a disproportionately high amount of complications related to it.


Also how are you guys weaning these patients?

I currently have one 10 mg bid, two 5 mg bid and one 5 mg tid- all inherited. I had more but one moved out of state, two requested to wean off in order to “try” medical THC (I weaned them off 9-12 mos ago and have not heard from them since), one was tapered off and discharged soon after I met him for acting a fool. The remaining 4 are all excellent “pain patients” who have failed everything else, perfect pill counts every month and perfect UDS- have been on it for 10+ years. If I had read the comments on this thread when I started there I would have weaned them all off at that time. You’re just starting with them so you have the perfect excuse: “I don’t rx it”, and wean off.

 

[Doctodd]

i have one or two and a couple of my local pharmacies say there is a supply chain issue so they cant order....good excuse to wean

 

[Darkside_]

Anyone here use buprenorphine for pain?

 

[lobelsteve]

Anyone here use buprenorphine for pain?

Butrans and Belbuca every day.
Bupe SL or tabs when the above two are not covered. Some pharmacies demand X waiver. FOR CHRONIC PAIN written on the Rx.

 

[Ducttape]

I use butrans and belbuca.

Don't use suboxone or straight buprenorphine.

 

[ateria radicularis magna]

I use Belbuca and butrans a lot

 

[MD87]

I inherited about 30 opioid patients from a doc who left my practice. I have successfully weaned the vast majority of them or a few have gone elsewhere.

I currently have 2 left who are taking > CDC amounts:
1) 70mg of methadone daily (down from 170) - he is fused from c3- t4 and has had lumbar surgery as well. Had injections in the past and some sort of nerve block that almost killed him (sounds like intravascular injection) so he is unwilling to consider any injections, even though they may help (has neck/head pain with edematous c2/3 articular pillars, etc). He is disabled. Has not worked since the stone ages. Never failed UDS or anything.
2) chronic back pain and knee pain, no objective imaging findings. Had a stim (removed). Was on 210 oxy and a fentanyl patch. I got rid of the patch and down to 150mg oxy. Also hasn’t worked since the stone ages. Never failed UDS, etc.

My question is this: patient number 1 has “real” pathology, patient number 2 best case has central sensitization. I was weaning them fairly successfully early on, but now it has become very difficult and they’re extremely resistant, constantly coming in telling me about functional decline, stress, etc. etc. At what point is it just not worth it to further decrease meds? Guy number 2 I almost feel worse for because “we” did this to him… should have never had any sort of intervention in the first place. Is the end goal of getting them to 90mmeq or less worth the amount of stress that I am putting them (…and me) through? If I stop the wean, and knowingly keep them above CDC guidelines, I assume I should just document the hell out of it…

 

[deleted875186]

I inherited about 30 opioid patients from a doc who left my practice. I have successfully weaned the vast majority of them or a few have gone elsewhere.

I currently have 2 left who are taking > CDC amounts:
1) 70mg of methadone daily (down from 170) - he is fused from c3- t4 and has had lumbar surgery as well. Had injections in the past and some sort of nerve block that almost killed him (sounds like intravascular injection) so he is unwilling to consider any injections, even though they may help (has neck/head pain with edematous c2/3 articular pillars, etc). He is disabled. Has not worked since the stone ages. Never failed UDS or anything.
2) chronic back pain and knee pain, no objective imaging findings. Had a stim (removed). Was on 210 oxy and a fentanyl patch. I got rid of the patch and down to 150mg oxy. Also hasn’t worked since the stone ages. Never failed UDS, etc.

My question is this: patient number 1 has “real” pathology, patient number 2 best case has central sensitization. I was weaning them fairly successfully early on, but now it has become very difficult and they’re extremely resistant, constantly coming in telling me about functional decline, stress, etc. etc. At what point is it just not worth it to further decrease meds? Guy number 2 I almost feel worse for because “we” did this to him… should have never had any sort of intervention in the first place. Is the end goal of getting them to 90mmeq or less worth the amount of stress that I am putting them (…and me) through? If I stop the wean, and knowingly keep them above CDC guidelines, I assume I should just document the hell out of it…

In my opinion this always happens with high dose legacy patients, I have them agree to a plan up front or else don’t take them.

 

[deleted875186]

I’ve gotten a few referrals from PCPs where the patient is on mega doses of methadone, I get the impression the PCP doesn’t realize how much methadone they are prescribing. Last one I got was methadone 20mg TID with oxycodone 10mg breakthrough, I offered the guy injections but regretted it, shouldn’t even touch these people, nothing will help them.

 

[MD87]

In my opinion this always happens with high dose legacy patients, I have them agree to a plan up front or else don’t take them.

Problem is that it was a doc within my practice, not an outside referral, so I didn’t really have a choice taking them on. I mean sure, I sort of did, but not really. Plus, even if they agree to it up front, they now tell me they didn’t realize how much pain etc they would be in, etc etc. I guess I’m wondering how much I’m really even helping them. I don’t think they are going to start working again once we hit 90mmeq lol

 

[deleted875186]

Problem is that it was a doc within my practice, not an outside referral, so I didn’t really have a choice taking them on. I mean sure, I sort of did, but not really. Plus, even if they agree to it up front, they now tell me they didn’t realize how much pain etc they would be in, etc etc. I guess I’m wondering how much I’m really even helping them. I don’t think they are going to start working again once we hit 90mmeq lol

Because the other doc did high dose opioids means you have to? You have a responsibility to see them since it’s part of the practice, but if you think it’s inappropriate then tell them so and continue weaning.

Probably I would continue the first patient with legit pathology. I would continue to wean the second and tell them exactly what you said, the opioids have sensitized them to pain and it’s in their best interest to come off.

 

[lobelsteve]

Problem is that it was a doc within my practice, not an outside referral, so I didn’t really have a choice taking them on. I mean sure, I sort of did, but not really. Plus, even if they agree to it up front, they now tell me they didn’t realize how much pain etc they would be in, etc etc. I guess I’m wondering how much I’m really even helping them. I don’t think they are going to start working again once we hit 90mmeq lol

Guy #1 is legacy. Treat him.
Guy #2 is not legacy. He is on wrong treatment. If no objective findings, what are you actually treating. Best you can do is convince yourself he has OUD and rotate to bupe. I had almost 50 patients in 2016 when I started my 90meq rules. Unless palliative care needs or active malignancy, no one should be over 90meq and if no real findings, opiates are not part of care. Open and frank discussion, wean down to fall within guidelines and if he chooses to go elsewhere, better for you. If you PM me, I can threaten you privately as a consultant to your medical board and DEA.

 

[Ferrismonk]

New patient the other day. Retired PCP and new PCP same practice wouldn't continue. I told him I have nothing to offer until his medication issue is resolved. Gave suboxone provider list, list of detox centers in the area, etc.

 

[callmeanesthesia]

New patient the other day. Retired PCP and new PCP same practice wouldn't continue. I told him I have nothing to offer until his medication issue is resolved. Gave suboxone provider list, list of detox centers in the area, etc.

Isn’t oxycodone about $1 per mg street value? Bet that guy drives a nicer car than me.

 

[deleted875186]

New patient the other day. Retired PCP and new PCP same practice wouldn't continue. I told him I have nothing to offer until his medication issue is resolved. Gave suboxone provider list, list of detox centers in the area, etc.

Over 1000 MMEs? Straight diversion, and three times per day Xanax, simply unbelievable.

 

[adiradirim]

Over 1000 MMEs? Straight diversion, and three times per day Xanax, simply unbelievable.

Well imagine how stressed they'd be selling all those pills without the xannies!

 

[RoloTomassi]

I'm most surprised it was the 0.25 and not the 2s

 

[Ferrismonk]

I'm most surprised it was the 0.25 and not the 2s

Well that would obviously be too much.

 

[Ligament]

New patient the other day. Retired PCP and new PCP same practice wouldn't continue. I told him I have nothing to offer until his medication issue is resolved. Gave suboxone provider list, list of detox centers in the area, etc.

Why did you see this patient to speak with him? Seems like a waste of your time and his. Should never have been scheduled.

 

[Doctodd]

I inherited about 30 opioid patients from a doc who left my practice. I have successfully weaned the vast majority of them or a few have gone elsewhere.

I currently have 2 left who are taking > CDC amounts:
1) 70mg of methadone daily (down from 170) - he is fused from c3- t4 and has had lumbar surgery as well. Had injections in the past and some sort of nerve block that almost killed him (sounds like intravascular injection) so he is unwilling to consider any injections, even though they may help (has neck/head pain with edematous c2/3 articular pillars, etc). He is disabled. Has not worked since the stone ages. Never failed UDS or anything.
2) chronic back pain and knee pain, no objective imaging findings. Had a stim (removed). Was on 210 oxy and a fentanyl patch. I got rid of the patch and down to 150mg oxy. Also hasn’t worked since the stone ages. Never failed UDS, etc.

My question is this: patient number 1 has “real” pathology, patient number 2 best case has central sensitization. I was weaning them fairly successfully early on, but now it has become very difficult and they’re extremely resistant, constantly coming in telling me about functional decline, stress, etc. etc. At what point is it just not worth it to further decrease meds? Guy number 2 I almost feel worse for because “we” did this to him… should have never had any sort of intervention in the first place. Is the end goal of getting them to 90mmeq or less worth the amount of stress that I am putting them (…and me) through? If I stop the wean, and knowingly keep them above CDC guidelines, I assume I should just document the hell out of it…

you are risking your license with patient #2

 

[bedrock]

you are risking your license with patient #2

Agree with this.

#2 patient has to be weaned to zero, end of story.

 

[deleted875186]

you are risking your license with patient #2

I wouldn’t say that, he said the patient has been consistent with monitoring. Obviously none of us would start the patient on opioids. Sounds like the OP made a significant amount of progress in weaning. Risking yojr license would be prescribing to a patient that is diverting or unacceptably high risk for addiction, etc.

 

[DOctorJay]

stick with your weaning plan. remind them at every visit they are not bound to your practice, they can seek a second opinion at any time. this is how you run your practice and what you're comfortable with.

 

[lobelsteve]

I wouldn’t say that, he said the patient has been consistent with monitoring. Obviously none of us would start the patient on opioids. Sounds like the OP made a significant amount of progress in weaning. Risking yojr license would be prescribing to a patient that is diverting or unacceptably high risk for addiction, etc.

DEA would ask what are you treating in this patient. If you have normal imaging and no adequate diagnosis, then prescribing is not for a legitimate medical purpose. If he gets arrested, you get in trouble. He OD's, the coroner notifies the medical board.

 

[10KHertz]

Maybe it will be useful on the battle field someday… until then refer to suboxone maintenance .

 

[RoloTomassi]

I inherited about 30 opioid patients from a doc who left my practice. I have successfully weaned the vast majority of them or a few have gone elsewhere.

I currently have 2 left who are taking > CDC amounts:
1) 70mg of methadone daily (down from 170) - he is fused from c3- t4 and has had lumbar surgery as well. Had injections in the past and some sort of nerve block that almost killed him (sounds like intravascular injection) so he is unwilling to consider any injections, even though they may help (has neck/head pain with edematous c2/3 articular pillars, etc). He is disabled. Has not worked since the stone ages. Never failed UDS or anything.
2) chronic back pain and knee pain, no objective imaging findings. Had a stim (removed). Was on 210 oxy and a fentanyl patch. I got rid of the patch and down to 150mg oxy. Also hasn’t worked since the stone ages. Never failed UDS, etc.

My question is this: patient number 1 has “real” pathology, patient number 2 best case has central sensitization. I was weaning them fairly successfully early on, but now it has become very difficult and they’re extremely resistant, constantly coming in telling me about functional decline, stress, etc. etc. At what point is it just not worth it to further decrease meds? Guy number 2 I almost feel worse for because “we” did this to him… should have never had any sort of intervention in the first place. Is the end goal of getting them to 90mmeq or less worth the amount of stress that I am putting them (…and me) through? If I stop the wean, and knowingly keep them above CDC guidelines, I assume I should just document the hell out of it…

I would refer these out. You've taken care of 28/30--I don't think anyone can knock you for that. No need to try to be a saint, you've done more than enough.