Methadone Deaths CDC

[101N]

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0703a1.htm?s_cid=mm61e0703a1_w

Abstract
Background: Vital statistics data suggest that the opioid pain reliever (OPR) methadone is involved in one third of OPR-related overdose deaths, but it accounts for only a few percent of OPR prescriptions.

Methods: CDC analyzed rates of fatal methadone overdoses and sales nationally during 1999–2010 and rates of overdose death for methadone compared with rates for other major opioids in 13 states for 2009.

Results: Methadone overdose deaths and sales rates in the United States peaked in 2007. In 2010, methadone accounted for between 4.5% and 18.5% of the opioids distributed by state. Methadone was involved in 31.4% of OPR deaths in the 13 states. It accounted for 39.8% of single-drug OPR deaths. The overdose death rate for methadone was significantly greater than that for other OPR for multidrug and single-drug deaths.

Conclusions: Methadone remains a drug that contributes disproportionately to the excessive number of opioid pain reliever overdoses and associated medical and societal costs.

Implications for Public Health Practice: Health-care providers who choose to prescribe methadone should have substantial experience with its use and follow consensus guidelines for appropriate opioid prescribing. Providers should use methadone as an analgesic only for conditions where benefit outweighs risk to patients and society. Methadone and other extended-release opioids should not be used for mild pain, acute pain, "breakthrough" pain, or on an as-needed basis. For chronic noncancer pain, methadone should not be considered a drug of first choice by prescribers or insurers.

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[Aether2000]

Very nice stats. And so very true. The reasons for the deaths are unclear but could be due to patient overuse, physician overprescribing, failure to understand the very low therapeutic index during initiation of the medication, the profound effect of hepatic insufficiency on methadone metabolism, etc.

 

[Tenesma]

i think the methadone things is due to
1) PCPs not understanding variability in metabolism/duration of effect, etc - and over-titration
2) Patient's not understanding #1
3) And surprisingly, lately, I have seen a lot more patients on Methadone AND Oxycontin AND benzos --- when I see that cocktail, I know it is just a matter of time before the patient will die by accident... however, convincing patients that this is inappropriate is very hard....

 

[lobelsteve]

BZD free since 2005 (#2 for MRI or flying) (#60 for hospice)
Soma free since getting back from ISIS last year
Methadone free since 2010.
Darvocet free since 2004
Demerol free since forever, except IM in office.

But I don't hold a grudge on any other opiate, as long as the patient's pass due diligence and we can prove a functional benefit, then it is a menu and I'll order for you.

 

[Ducttape]

But I don't hold a grudge on any other opiate

Heroin?

i believe there is limited medical use of heroin in England....

 

[bedrock]

BZD free since 2005 (#2 for MRI or flying) (#60 for hospice)
Soma free since getting back from ISIS last year
Methadone free since 2010.
Darvocet free since 2004
Demerol free since forever, except IM in office.

But I don't hold a grudge on any other opiate, as long as the patient's pass due diligence and we can prove a functional benefit, then it is a menu and I'll order for you.

What was said about Soma at ISIS last year?

I'm not a big fan of Soma anyway, but I missed that lecture-

 

[lobelsteve]

What was said about Soma at ISIS last year?

I'm not a big fan of Soma anyway, but I missed that lecture-

I was in a small group discussion and we were kicking around ideas on how to improve our practices and communities. The idea was thrown out to the group and we all said we'd rather lose a few patients than be part of the bigger problem. Done deal.

No lecture.

 

[Aether2000]

Soma is a very small problem statistically as a co-drug in opioid overdose deaths compared to benzodiazepines. The benzos are 3-6 times the problem of soma looking at death statistics and drugs found in toxicology studies. PCPs have gone crazy prescribing this stuff....with no testing of patients, no demonstration of anxiety, no documentation of anxiety disorders or panic disorders....it is all very subjective- even more than with opioids. Not only did we stop benzos being prescribed in our practice, we have given patients choices to stop the benzos from others otherwise we will reduce the amount of opioid being prescribed. 90% of the time this works (verified by UDS) and the other 10% of the time they keep taking them, and are discharged from our clinic....

 

[bedrock]

Soma is a very small problem statistically as a co-drug in opioid overdose deaths compared to benzodiazepines. The benzos are 3-6 times the problem of soma looking at death statistics and drugs found in toxicology studies. PCPs have gone crazy prescribing this stuff....with no testing of patients, no demonstration of anxiety, no documentation of anxiety disorders or panic disorders....it is all very subjective- even more than with opioids. Not only did we stop benzos being prescribed in our practice, we have given patients choices to stop the benzos from others otherwise we will reduce the amount of opioid being prescribed. 90% of the time this works (verified by UDS) and the other 10% of the time they keep taking them, and are discharged from our clinic....

Wise words, algos.

 

[PinchandBurn]

Soma is a very small problem statistically as a co-drug in opioid overdose deaths compared to benzodiazepines. The benzos are 3-6 times the problem of soma looking at death statistics and drugs found in toxicology studies. PCPs have gone crazy prescribing this stuff....with no testing of patients, no demonstration of anxiety, no documentation of anxiety disorders or panic disorders....it is all very subjective- even more than with opioids. Not only did we stop benzos being prescribed in our practice, we have given patients choices to stop the benzos from others otherwise we will reduce the amount of opioid being prescribed. 90% of the time this works (verified by UDS) and the other 10% of the time they keep taking them, and are discharged from our clinic....

I have one lady that uses Klonipin by her PCP for anxiety. She does have some legit pain, appearing to be facetogenic s/p MVA. RFA didnt work on her. She takes about 2 vicodin 5mg tabs a day. She is a 'worrier'. Calls teh office multiple times a week, and I think it's just more so to talk to someone. She's awaiting consult with a surgeon. I'm wondering if i could use the BDz issue as a way to d/c her opioids. The thing thing is that 10mg of vicodin the whole day isnt that big of a dose.....

 

[bedrock]

I have one lady that uses Klonipin by her PCP for anxiety. She does have some legit pain, appearing to be facetogenic s/p MVA. RFA didnt work on her. She takes about 2 vicodin 5mg tabs a day. She is a 'worrier'. Calls teh office multiple times a week, and I think it's just more so to talk to someone. She's awaiting consult with a surgeon. I'm wondering if i could use the BDz issue as a way to d/c her opioids. The thing thing is that 10mg of vicodin the whole day isnt that big of a dose.....

Has she seen a pain psychologist/psychiatrist? Sounds like she should. Probably do her more good than surgery.

 

[PinchandBurn]

Has she seen a pain psychologist/psychiatrist? Sounds like she should. Probably do her more good than surgery.

Yes, she sees her psych. Basically the pscyhiatrist gives them some klonipin......Patient states, "i dont need to see pysch". THe thing is she's not really a 'drug seeker' and is only on minimal amounts of opioids (as stated 10mg of vicodin the whole day, sometimes even just 5mg). She's done the therapy, CBT,etc stuff before. She does work..

 

[Ducttape]

it sounds as if she is functional, active, participating in her care, seeking coping mechanisms, etc.

i mean darn, shes working. how many of our other patients still work???

why upset the wagon? do you have any "red flags" other than you dont want to prescribe a low but seemingly reasonable dose of vicodin?

 

[PMR 4 MSK]

BZD free since 2005 (#2 for MRI or flying) (#60 for hospice)
Soma free since getting back from ISIS last year
Methadone free since 2010.
Darvocet free since 2004
Demerol free since forever, except IM in office.

But I don't hold a grudge on any other opiate, as long as the patient's pass due diligence and we can prove a functional benefit, then it is a menu and I'll order for you.

So that's four rounds of rehab and you were finally able to kick the last drug? One day at a time, man, one day at a time...

 

[lobelsteve]

So that's four rounds of rehab and you were finally able to kick the last drug? One day at a time, man, one day at a time...

But you'll have to pry the coffee from my cold dead hands.

 

[facets]

Hey that's my line

 

[lobelsteve]

Hey that's my line

Uh oh.

New thread coming on coffee.

 

[bedrock]

But you'll have to pry the coffee from my cold dead hands.

I used to be addicted to coffee, but I hating relying on it.

I started doing procedure mornings, never in the afternoons, and I find that procedures in the AM wakes me up right away, so I'm good the rest of the day.

Now, I just drink coffee socially or on the morning I don't do procedures.

 

[clubdeac]

I used to be addicted to coffee, but I hating relying on it.

I started doing procedure mornings, never in the afternoons, and I find that procedures in the AM wakes me up right away, so I'm good the rest of the day.

Now, I just drink coffee socially or on the morning I don't do procedures.

I do the same and it works great!!

 

[ghost dog]

i think the methadone things is due to
1) PCPs not understanding variability in metabolism/duration of effect, etc - and over-titration
2) Patient's not understanding #1
3) And surprisingly, lately, I have seen a lot more patients on Methadone AND Oxycontin AND benzos --- when I see that cocktail, I know it is just a matter of time before the patient will die by accident... however, convincing patients that this is inappropriate is very hard....

Can someone please explain to me the rationale for :

1. Prescribing Methadone and another long acting opioid ? This seems very inappropriate and dangerous. I don't believe this is an evidence based approach.

If a patient has a co-morbid addictive disorder (i.e. the indication for methadone), this is just plain stupid and asking for trouble.

This just seems all downside.

2. Prescribing 2 long acting opioids together / at the same time (i.e. not methadone)?
I have seen family MDs do this, but does anyone with proper training do this ? Why not just appropriately titrate one long acting opioid and manage side effects accordingly.

This doesn't make sense to me.

 

[lobelsteve]

Can someone please explain to me the rationale for :

1. Prescribing Methadone and another long acting opioid ? This seems very inappropriate and dangerous. I don't believe this is an evidence based approach.

If a patient has a co-morbid addictive disorder (i.e. the indication for methadone), this is just plain stupid and asking for trouble.

This just seems all downside.

2. Prescribing 2 long acting opioids together / at the same time (i.e. not methadone)?
I have seen family MDs do this, but does anyone with proper training do this ? Why not just appropriately titrate one long acting opioid and manage side effects accordingly.

This doesn't make sense to me.

"The concomitant Rx of 2 long acting opiates fails to meet the standard of care for opiate prescribing in Georgia and suggests failure of education or complicit behavior on the part of the prescriber. "

 

[Ducttape]

there is almost on reason to prescribe two separate long acting opioids, imo.

with the possible exception of tapering down one while starting the other.

 

[ghost dog]

"The concomitant Rx of 2 long acting opiates fails to meet the standard of care for opiate prescribing in Georgia and suggests failure of education or complicit behavior on the part of the prescriber. "

Thanks for confirming what I already knew.

I just see this so frequently during opioid reviews, and in consultation, I begin to question my training !

 

[Pharmavixen]

there is almost on reason to prescribe two separate long acting opioids, imo.

with the possible exception of tapering down one while starting the other.

Yes. Where I work (addiction medicine in a jail), we sometimes overlap methadone with LA morphine with the goal of tapering the pt off the morphine.

Pharmacist's opinion: methadone is a poor analgesic choice IMO because its efficacy for pain is only 6-8 h while its t½ is 18-36 h. Also, its levels are slow to peak in the plasma, leading pts to take more drug before its levels have even maxed.

So you've got an opioid that's kinda sorta equivalent to morphine in potency, except its long t½ leads to accummulation, and you're giving it to a population of pts who tend to take drugs more than prescribed. Also, there's only incomplete tolerance between methadone and other opioids, leading some experienced opioid users to misunderestimate their own tolerance.

Aand up to 80% of pts on methadone also use BDZs, whether prescribed or extracurricular.

Aaaand you've got insurance companies that favour the use of methadone because it's off patent and the cheapest LA opioid.

 

[101N]

Complex Persistent Dependency Patients
High Dose Methadone to Suboxone Conversion
6wk Outpatient Protocol

1. Meeting #1 (D1)Discuss conversion.
   Load with gabapentin to 1200mg/d over next 28d.

• Sign material risk/Tx agreement
• Refer to behavioral health (BH).
• Check EKG for QTc
• If male pt. check testosterone level
• Prescribe nasal naloxone
• Obtain UDS/SDS

2. Meeting #2 (D8) Agree to refill 7d dose of existing meds

• Train spouse/SO in nasal naloxone admin

3. Meeting #3 (D15) Conversion to morphine sulfate ER.

Methadone 50mg/day = Morphine Sulfate ER 30mg po TID*
Methadone 75mg/day = Morphine Sulfate ER 30mg po QID
Methadone 100mg/day = Morphine Sulfate ER 45mg po TID + 15mg ER QD
Methadone 120mg/day = Morphine Sulfate ER 45mg po QID

• Give 7d supply of MS04 & schedule weekly f/u visits.
• Start a 7d supply of clonidine, hydroxyzine, relafen, chlordiazepoxide.
• Engage Behavioral Health (BH) for support

4. Meeting #4 (D22) Refill/recheck/adjust.

• Give 6.5d supply of opioid & schedule 7d f/u
• Rx another 7d supply of clonidine, hydroxyzine, relafen, chlordiazepoxide.
• D/W BH

5. Meeting #5 (D29) Suboxone Induction

• Obtain SDS/UDS

6. Meeting #6 (D36) Suboxone Stabilization


7. Meeting #7 (D43) Suboxone Maintenance

*Practical Pain Management Calculator: http://opioidcalculator.practicalpainmanagement.com/disclaimer.php

References:

1. Opioid Dependence vs Addiction: A Distinction Without a Difference? Ballantyne JC, Sullivan MD, Kolodny A.Arch Intern Med. 2012 Sep 24;172(17):1342-3.
2. J Subst Abuse Treat. 2014 Aug;47(2):140-5. doi: 10.1016/j.jsat.2014.03.004. Epub 2014 Apr Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain. Weiss RD1, Potter JS2, Griffin ML3, McHugh RK3, Haller D4, Jacobs P5, Gardin J 2nd6, Fischer D7, Rosen KD.
3. Pain Med. 2014 Dec;15(12):2087-94. doi: 10.1111/pme.12520. Epub 2014 Sep 12. Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients. Daitch D1, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J Jr.
4. JAMA. 2003 May 14;289(18):2370-8. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. Rosenblum A1, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK.
5. J Pain. 2015 Sep;16(9):887-94. doi: 10.1016/j.jpain.2015.06.003. Epub 2015 Jun 21. Pain Among High-Risk Patients on Methadone Maintenance Treatment. Voon P1, Hayashi K2, Milloy MJ3, Nguyen P2, Wood E3, Montaner J3, Kerr T4.
6. Drug Alcohol Depend. 2010 Jun 1;109(1-3):213-9. doi: 10.1016/j.drugalcdep.2010.01.006. Epub 2010 Feb 16. Gabapentin improves cold-pressor pain responses in methadone-maintained patients. Compton P1, Kehoe P, Sinha K, Torrington MA, Ling W.
7. Pain. 2005 Nov;118(1-2):15-22. Epub 2005 Sep 9.Different profiles of buprenorphine-induced analgesia and antihyperalgesia in a human pain model. Koppert W1, Ihmsen H, Körber N, Wehrfritz A, Sittl R, Schmelz M, Schüttler J.
   

 

[lobelsteve]

Complex Persistent Dependency Patients
High Dose Methadone to Suboxone Conversion
6wk Outpatient Protocol

1. Meeting #1 (D1)Discuss conversion.
   Load with gabapentin to 1200mg/d over next 28d.

• Sign material risk/Tx agreement
• Refer to behavioral health (BH).
• Check EKG for QTc
• If male pt. check testosterone level
• Prescribe nasal naloxone
• Obtain UDS/SDS

2. Meeting #2 (D8) Agree to refill 7d dose of existing meds

• Train spouse/SO in nasal naloxone admin

3. Meeting #3 (D15) Conversion to morphine sulfate ER.

Methadone 50mg/day = Morphine Sulfate ER 30mg po TID*
Methadone 75mg/day = Morphine Sulfate ER 30mg po QID
Methadone 100mg/day = Morphine Sulfate ER 45mg po TID + 15mg ER QD
Methadone 120mg/day = Morphine Sulfate ER 45mg po QID

• Give 7d supply of MS04 & schedule weekly f/u visits.
• Start a 7d supply of clonidine, hydroxyzine, relafen, chlordiazepoxide.
• Engage Behavioral Health (BH) for support

4. Meeting #4 (D22) Refill/recheck/adjust.

• Give 6.5d supply of opioid & schedule 7d f/u
• Rx another 7d supply of clonidine, hydroxyzine, relafen, chlordiazepoxide.
• D/W BH

5. Meeting #5 (D29) Suboxone Induction

• Obtain SDS/UDS

6. Meeting #6 (D36) Suboxone Stabilization


7. Meeting #7 (D43) Suboxone Maintenance

*Practical Pain Management Calculator: http://opioidcalculator.practicalpainmanagement.com/disclaimer.php

References:

1. Opioid Dependence vs Addiction: A Distinction Without a Difference? Ballantyne JC, Sullivan MD, Kolodny A.Arch Intern Med. 2012 Sep 24;172(17):1342-3.
2. J Subst Abuse Treat. 2014 Aug;47(2):140-5. doi: 10.1016/j.jsat.2014.03.004. Epub 2014 Apr Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain. Weiss RD1, Potter JS2, Griffin ML3, McHugh RK3, Haller D4, Jacobs P5, Gardin J 2nd6, Fischer D7, Rosen KD.
3. Pain Med. 2014 Dec;15(12):2087-94. doi: 10.1111/pme.12520. Epub 2014 Sep 12. Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients. Daitch D1, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J Jr.
4. JAMA. 2003 May 14;289(18):2370-8. Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. Rosenblum A1, Joseph H, Fong C, Kipnis S, Cleland C, Portenoy RK.
5. J Pain. 2015 Sep;16(9):887-94. doi: 10.1016/j.jpain.2015.06.003. Epub 2015 Jun 21. Pain Among High-Risk Patients on Methadone Maintenance Treatment. Voon P1, Hayashi K2, Milloy MJ3, Nguyen P2, Wood E3, Montaner J3, Kerr T4.
6. Drug Alcohol Depend. 2010 Jun 1;109(1-3):213-9. doi: 10.1016/j.drugalcdep.2010.01.006. Epub 2010 Feb 16. Gabapentin improves cold-pressor pain responses in methadone-maintained patients. Compton P1, Kehoe P, Sinha K, Torrington MA, Ling W.
7. Pain. 2005 Nov;118(1-2):15-22. Epub 2005 Sep 9.Different profiles of buprenorphine-induced analgesia and antihyperalgesia in a human pain model. Koppert W1, Ihmsen H, Körber N, Wehrfritz A, Sittl R, Schmelz M, Schüttler J.

Interesting, so I guess this is not for physicians? Unless you stopped having patient visits and just go to meetings? This is not pain, this is pure addiction. And I would not take on the risk of Rx of morphine ER in a known addict. It is not my education, experience, nor training. This goes to someone with the right credentials. My only job here is to make the referral and have a basic understanding of what that guy might do. All I can do is try and help the patient realize he needs to see that guy.

 

[Ducttape]

What is the point of this? Risk mitigation by taking someone off methadone?

I dont write off label suboxone and would not recommend this practice....

If one does, then i agree with lobel -no point of rotating to morphine.

If i did... Stop methadone. 24- 48 hours later, start suboxone. (Similar to butrans & tapering dose). With long half life of methadone, acute withdrawal unlikely in that first 2 days.

If patient is on 30 mg or less of methadone, then maybe consider rotating to butrans....

 

[101N]

Methadone direct to Suboxone = high incidence of precipitated withdrawal .

 

[Ducttape]

Methadone direct to Suboxone = high incidence of precipitated withdrawal .

Higher than rotating to morphine then rotating to suboxone?

Show me the data.

Fyi, withdrawal was why i would stop methadone for 2 days before initiating suboxone. 72 hours might be more reasonable.

Anyways i have no dog in this fight, since im not writing suboxone...

 

[101N]

Yes, much higher. Too variable a half live for MDT.

 

[lobelsteve]

Methadone direct to Suboxone = high incidence of precipitated withdrawal .

Thats the whole reason we have the MCOWS score as to when to start on Suboxone. Not like i know because i do pain, not addiction.

 

[101N]

You do addiction, you just don't recognize it.

 

[lobelsteve]

You do addiction, you just don't recognize it.

No I don't, I do pain and send addiction to MSW/counseling as well as addiction psych. I just make sure the folks who need it get from the right people.
I also do not do cardiac caths or laparoscopic cholecystectomies. But I know a guy...

 

[Aether2000]

Because of the unpredictability of methadone, we weaned all but one patient off. The fascinating thing about the reduction in dosage is that withdrawal, over a 3-6 month wean, was not seen until the patient got down to 10 mg or less for the entire day. That last 5-10 mg (even with conversion to other opioids) is a bear for patients.

 

[willabeast]

IMHO the deaths from methadone are mostly from limited understanding on the patient's part as to the long onset of action.
solution = teaching.
also IMHO - methadone is by far the best opioid that is currently commonly prescribed in north america for neuropathic pain .
the worst opioid for neuropathic pain is morphine.

 

[lobelsteve]

IMHO the deaths from methadone are mostly from limited understanding on the patient's part as to the long onset of action.
solution = teaching.
also IMHO - methadone is by far the best opioid that is currently commonly prescribed in north america for neuropathic pain .
the worst opioid for neuropathic pain is morphine.

I think youre nuts. No opiate is good for neuropathic pain. Marginsl at best. Never first line.

 

[willabeast]

I think youre nuts. No opiate is good for neuropathic pain. Marginsl at best. Never first line.

Lobelsteve IMHO you have a low threshold for ad hominem attacks. "No opiate is good for neuropathic pain" seems like an odd position to take. i think methadone is probably one of the best choices available for neuropathic pain in patients with terminal cancer. "Suum cuique"

 

[drusso]

It's easier to rotate from methadone to FNT patch, wean patch, then start ADF buprenorphine/naloxone.

 

[Aether2000]

The NMDA receptor antagonism of methadone has been shown to be very short lived in animal models. Methadone is a self inhibitor of hepatic enzymes therefore has unusual pharmacokinetics. Because we cannot control patient's use of alcohol or other doctor's prescribing of benzodiazepines nor patients taking unprescribed controlled substances (common), it is my belief methadone should be banned from clinical use in pain medicine or should be used only extremely rarely and in dosages of 20mg or lower. Even in those low doses, there is a 59% increased death rate compared to morphine equipotent doses. The use of alcohol in our society is 53% and pain patients do not see themselves as incapable of continuing alcohol use while taking prescription opioids. The bottom line: we cannot control what patients use and "education" has little effect- many patients simply don't care about the risks of mixing opioids with other drugs or alcohol. The risk of methadone mixed with other CS is much higher than with other opioids. Given the lack of clear advantages with methadone, I would urge cessation of its use in chronic non malignant pain and conversion to less deadly opioids.

 

[lobelsteve]

Lobelsteve IMHO you have a low threshold for ad hominem attacks. "No opiate is good for neuropathic pain" seems like an odd position to take. i think methadone is probably one of the best choices available for neuropathic pain in patients with terminal cancer. "Suum cuique"

Not ad hominem.

But if the goal is to kill them off as palliative care, i stand corrected. Methadone may be an excellent choice when trying to hasten the death of a cancer patient.

 

[willabeast]

Not ad hominem.

But if the goal is to kill them off as palliative care, i stand corrected. Methadone may be an excellent choice when trying to hasten the death of a cancer patient.

methinks motorcycles are an excellent way to kill off attending physicians. probably better than giving them methadone.
https://en.wikipedia.org/wiki/List_of_motorcycle_deaths_in_U.S._by_year

 

[lobelsteve]

methinks motorcycles are an excellent way to kill off attending physicians. probably better than giving them methadone.
https://en.wikipedia.org/wiki/List_of_motorcycle_deaths_in_U.S._by_year

Lets see if Humana will cover the FZ-09

 

[Ducttape]

Well if the motorcycle wont kill them off, the methadone for chronic postfracture pain will...

 

[101N]

Methadone withdrawal profile.

 

[Ducttape]

Where dis you get that from?

2 points. I suggested starting suboxone at 48 hours - which is half way between 36 and 72. It shouldn't precipitate withdrawal if someone already is withdrawing, eh?

Why is hydrocodone so strong on this chart? 0.5 mg hydrocodone is equivalent to 1 mg methadone and 3-4 of morphine?

 

[lobelsteve]

https://www.naabt.org/documents/NAABT_PrecipWD_HiRes.pdf
COWS score min of 5, 10+ preferable.

Because the guy treating the patient needs to know this, not me.

 

[pastafan]

https://www.naabt.org/documents/NAABT_PrecipWD_HiRes.pdf
COWS score min of 5, 10+ preferable.

Because the guy treating the patient needs to know this, not me.

As mentioned in specific drug section, COWS should be 14+ to be certain to avoid precipitated withdrawal. Precipitated withdrawal is very unlike "normal" withdrawal in severity so err on the side of caution.

 

[Apollyon]

As one of the first patients I saw out of residency said (who got addicted to Lortab, and admitted it), "Methadone should be called 'MethaDON'T'. It's no wonder the Nazis invented it!"

(And I just went all Godwin on y'all there!)

 

[Ducttape]

i dont see where that site is recommending transitioning to morphine then to suboxone...

 

[101N]

1.http://www.ncbi.nlm.nih.gov/m/pubme...and buprenorphine and precipitated withdrawal
2.http://www.sciencedirect.com/science/article/pii/S0376871607001755