Methadone OD = $2 million dollars.

[lobelsteve]

Treatment for Back Pain: High Methadone Dose Causes Brain Damage, $2M Award

A jury in Maine awarded a patient almost $2 million in damages resolving lawsuit alleging that a physician overprescribed methadone for back pain that caused brain damage to the patient when she stopped breathing in her sleep, according to an article in the April 12, 2012, Bangor Daily News (Maine). The 59-year-old patient was referred by her primary care physician to the defendant, a family practice specialist, for treatment of chronic back pain in August 2006. The patient underwent prolotherapy treatment, which involved administering injections around her spine with the intention of causing inflammation to promote healing. The physician prescribed methadone to treat the pain. The patient’s attorney claimed that the methadone dosage prescribed for her back pain was eight times the amount recommended by experts in the field and caused the patient to stop breathing in her sleep two and a half days after she started taking her prescription, resulting in brain damage from oxygen deprivation. The physician argued that according to the U.S. Food and Drug Administration, the 40 mg dose he prescribed was within “an appropriate range” and that both the pharmacist (who verified the prescription over the telephone) and the pharmacy’s computer system had failed to detect any potential complications. The physician claimed that the patient did not mention to the pharmacist that she already had breathing problems and sleep apnea at the time she filled the prescription. In related news, an April 8, 2012, New York Times article discusses several state and other initiatives to reduce the overprescribing of pain medicines. Some patients report having difficulty obtaining needed medications as a result of increased scrutiny.

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[specepic]

Treatment for Back Pain: High Methadone Dose Causes Brain Damage, $2M Award

A jury in Maine awarded a patient almost $2 million in damages resolving lawsuit alleging that a physician overprescribed methadone for back pain that caused brain damage to the patient when she stopped breathing in her sleep, according to an article in the April 12, 2012, Bangor Daily News (Maine). The 59-year-old patient was referred by her primary care physician to the defendant, a family practice specialist, for treatment of chronic back pain in August 2006. The patient underwent prolotherapy treatment, which involved administering injections around her spine with the intention of causing inflammation to promote healing. The physician prescribed methadone to treat the pain. The patient’s attorney claimed that the methadone dosage prescribed for her back pain was eight times the amount recommended by experts in the field and caused the patient to stop breathing in her sleep two and a half days after she started taking her prescription, resulting in brain damage from oxygen deprivation. The physician argued that according to the U.S. Food and Drug Administration, the 40 mg dose he prescribed was within “an appropriate range” and that both the pharmacist (who verified the prescription over the telephone) and the pharmacy’s computer system had failed to detect any potential complications. The physician claimed that the patient did not mention to the pharmacist that she already had breathing problems and sleep apnea at the time she filled the prescription. In related news, an April 8, 2012, New York Times article discusses several state and other initiatives to reduce the overprescribing of pain medicines. Some patients report having difficulty obtaining needed medications as a result of increased scrutiny.

I wonder if the methadone was 40 mg right off the bat (not wise esp in a sleep apnea pt) or was very slowly built up to. IMO low and slow is the way with methadone no matter how tolerant you think they are. I also wonder why they chose methadone? Maine actually has a fairly effective review commitee for cases from what I hear. Sad for doc and patient.

 

[Jcm800]

in my opinion, No and go(away) is the way for methadone...

but yes, starting at 5mg, no matter who and why is the safest...

I wonder if the methadone was 40 mg right off the bat (not wise esp in a sleep apnea pt) or was very slowly built up to. IMO low and slow is the way with methadone no matter how tolerant you think they are. I also wonder why they chose methadone? Maine actually has a fairly effective review commitee for cases from what I hear. Sad for doc and patient.

 

[SSdoc33]

cant feel TOO bad for a family practice doc that is doing prolo on the spine. my guess is that there aer gonna be a few things in this guy/gal's practice that are outside the standard of care....

 

[Jcm800]

family practice specialist...lets not forget...

cant feel TOO bad for a family practice doc that is doing prolo on the spine. my guess is that there aer gonna be a few things in this guy/gal's practice that are outside the standard of care....

 

[drf]

Based on the sermo thread of this lawsuit, the FP doc did start the patient right off the bat at 40 mg and she died on night 2 or 3. I wonder if epocrates or some drug manual told the doc starting with Methadose 40 mg was reasonable for an addict in withdrawal, and this was extrapolated to a pain patient.

With the information presented so far, I think a lawsuit is reasonable. Of course we likely do not have all the pertinent information.

 

[Apollyon]

Based on the sermo thread of this lawsuit, the FP doc did start the patient right off the bat at 40 mg and she died on night 2 or 3. I wonder if epocrates or some drug manual told the doc starting with Methadose 40 mg was reasonable for an addict in withdrawal, and this was extrapolated to a pain patient.

With the information presented so far, I think a lawsuit is reasonable. Of course we likely do not have all the pertinent information.

Apparently, she didn't die.

 

[drf]

I think the suit is over "brain damage." memory loss, loss of concentration and such. Not sure how plaintiff proved that. Also not sure how plaintiff proved she didn't decide to take 80 mg that night.

 

[clubdeac]

Id like to know if she was opioid niave
Lo

 

[PMR 4 MSK]

I do love how juries just hand out other people's money when someone had a bad outcome. I bet you this doc has prescribed like this to dozen of patients without a lawsuit. No one picks 40 methadone out of their @$$ as a starting dose. He had prescribed it before. Not a smart thing to do, but I bet he had a hx of patients doing ok with it.

If he had not given it to her, she probably would have sued him for undertreating her pain.

 

[Aether2000]

Methadone at that starting dose is probably hazardous for most people unless they are very opioid tolerant. However, we are finding an interesting trend: multiple interactive medications being prescribed by multiple physicians. Pain physician will prescribe methadone, the psychiatrist will prescribe klonopin, and the PCP soma. There you have a lethal concoction with three different cooks in the kitchen, and none want to decrease or eliminate the prescriptions being prescribed by one of the other physicians. Nearly 40% of those receiving opioids for chronic pain and with substance abuse history are also receiving sedatives. 29% of those without a substance abuse history receiving chronic opioids are also receiving sedatives. Given the interactions between these drugs, and given the Miami coroners data showing nearly 80% of those who have overdosed with prescription opioids listed as the cause of death are also taking benzodiazepines. It would be surprising in this particular lawsuit on this thread if the patient were not taking other sedatives that would potentially interact lethally with the opioids.

 

[Ducttape]

i dont know, i cannot agree with anything that this family practice specialist did. he didnt have pain training, otherwise that would have been noted. he gave methadone, a notorious long acting primary chronic pain agent, for acute pain from the procedure he did, which is of questionable therapy, and he used a huge dose. im not so sure that even if she were not on anything other meds, the patient would have suffered consequences. anoxic brain damage is obviously devastating.

in the end, this is nothing that any of us would do. and in the end, it is always what is presented to the jury and how it is presented that determines what the verdict is.

The verdict is not always the "truth", its what the jury believes is the "truth".

 

[lobelsteve]

i dont know, i cannot agree with anything that this family practice specialist did. he didnt have pain training, otherwise that would have been noted. he gave methadone, a notorious long acting primary chronic pain agent, for acute pain from the procedure he did, which is of questionable therapy, and he used a huge dose. im not so sure that even if she were not on anything other meds, the patient would have suffered consequences. anoxic brain damage is obviously devastating.

in the end, this is nothing that any of us would do. and in the end, it is always what is presented to the jury and how it is presented that determines what the verdict is.

The verdict is not always the "truth", its what the jury believes is the "truth".

Nope. Analgesia for 4-6 hrs. Half life is 10-139 hrs, but it is still a short acting opiate. Useful in preventing withdrawal for heroin addicts due to half life, but it only treats pain as well as Lortab or Percocet.

 

[Ducttape]

Nope. Analgesia for 4-6 hrs. Half life is 10-139 hrs, but it is still a short acting opiate. Useful in preventing withdrawal for heroin addicts due to half life, but it only treats pain as well as Lortab or Percocet.

thats most likely wrong, but what is commonly taught. now i start very few patients on methadone (amongst the very few patients i start on opioids), but im not adverse to it.

there is a little summary in the American Pain Society website that discusses a couple of studies done in the past with methadone. 2 studies mentioned in this site found that, when patients were allowed to self-administer their own methadone, the average dosing interval (and length of pain relief) was 10 hours, not 4-6.

and from other standpoint, it may be preferable than lortab or percocet, for two reasons. now this is my opinion, of course, but i find much fewer patients get the "high" or buzz from methadone than lortab. second, there may be some theoretical (i admit, not actually proven) benefits from NMDA antagonism and possibly also preventing windup.

in my particular community, it has a very low street value.

oh and finally, because of the risks of Torsades and sudden death, most patients readily agree not to go up too high. a lot fewer patients will demand doses above 60 mg a day, compared to those who pester to take more than 12 percocet 10/325s or equivalent...

 

[lobelsteve]

thats most likely wrong, but what is commonly taught. now i start very few patients on methadone (amongst the very few patients i start on opioids), but im not adverse to it.

there is a little summary in the American Pain Society website that discusses a couple of studies done in the past with methadone. 2 studies mentioned in this site found that, when patients were allowed to self-administer their own methadone, the average dosing interval (and length of pain relief) was 10 hours, not 4-6.

and from other standpoint, it may be preferable than lortab or percocet, for two reasons. now this is my opinion, of course, but i find much fewer patients get the "high" or buzz from methadone than lortab. second, there may be some theoretical (i admit, not actually proven) benefits from NMDA antagonism and possibly also preventing windup.

in my particular community, it has a very low street value.

oh and finally, because of the risks of Torsades and sudden death, most patients readily agree not to go up too high. a lot fewer patients will demand doses above 60 mg a day, compared to those who pester to take more than 12 percocet 10/325s or equivalent...

WHen patients were left to self-administer... Huh? Dosing interval does not equate to pain relief. NMDA never proven and not backed up by other NMDA drugs- DM, Namenda are two that come to mind that are flops for pain. As far as not getting a high from it... just check the forums.opiophile.org Probably just need a little grapefruit juice and baking soda. Street value does not correlate with drug preference and abuse potential, it correlates with supply and demand. If all the oxy went away, meth prices would soar.

 

[Ligament]

Just a remider:

1. There is NO equianalgesic conversion of Methadone
2. The more/longer patients are on standard opioids, the more sensitive they are to Methadone.
3. Don't **** with Methadone!

 

[Ducttape]

WHen patients were left to self-administer... Huh? Dosing interval does not equate to pain relief. NMDA never proven and not backed up by other NMDA drugs- DM, Namenda are two that come to mind that are flops for pain. As far as not getting a high from it... just check the forums.opiophile.org Probably just need a little grapefruit juice and baking soda. Street value does not correlate with drug preference and abuse potential, it correlates with supply and demand. If all the oxy went away, meth prices would soar.

the studies allowed patients to change their own interval of medicating based on their own pain requirements. In their case, dosing interval equated to requirements for pain medication.

I stated that NMDA antagonism was a theoretical advantage. however, in terms of NMDA, i find ketamine a very useful adjunct, at doses not considered "analgesic".

I did just read A thread on opioiphile.org. Its a thread named IV done rush. The first line: "I have heard a lot of sentiment around here that IV methadone provides no rush, or a very weak one."

on average, posters were saying methadone was $2 for a 10 mg pill ($0.20/mg). Oxys were quoted as $1/mg.

Street value does indeed correlate with drug preference. its in the demand part of the limited view of supply/demand equation. Theres no street value for nexium because there's no demand, because there is no "drug preference".

As far as I am concerned, methadone is by far the most dangerous opioid that we prescribe. However, there is a limited role of methadone and it can be invaluable if used judiciously and wisely. I often rotate people failing huge doses of opioids and unwilling to stop altogether to methadone, with a max dose of 30 mg a day. I dont increase for at least 4 weeks, and then only 20-30%. If in the rare circumstance that I have to rotate again, then it is based on the 30 mg/day dose of methadone, not the original dose of opioids. all within "standard of care", btw.

 

[drf]

I would say that based on my experience, most older patients get by on methadone BID and younger patients get by on TID dosing. This likely relates to age related slowing of metabolism and excretion. The only folks I've seen on QID have had some red flag behaviors in the past.

For single dosing i would call methadone analgesic for 6-8 hours as opposed to 3-4 with morphine.

That stated, I definately agree with Steve regarding the analgesic response being much shorter than the preventing withdrawal response. A QD dose will prevent withdrawal for close to 24 hours but will be analgesic for only a third of that time. For maintenance patients having surgery I generally only have to TID their dose, not escalate it, and they do ok after surgery with only addition or prns on top of regular dose methadone TID. I don't like to alter methadone maintenance doses in the hospital.

 

[wscott]

Just a remider:

1. There is NO equianalgesic conversion of Methadone
2. The more/longer patients are on standard opioids, the more sensitive they are to Methadone.
3. Don't **** with Methadone!

Well put.