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  • BDD Moderators: Keif’ Richards | negrogesic

Methadone and pain management.

Dagda Mochta

Dagda Mochta

Bluelighter
Joined
Dec 19, 2012
Messages
288
Location
Brooklyn
I have cancer and I'm in pretty bad pain. None of the pain medication they have given me, up to 80 mg morphine er daily, has any effect because I'm on methadone maintenance. I'm currently tapering off because of this, dropping 10 mg per week. I was maintaining at 210 mg a day for about 4 years but I'm now down to 50 mg a day. At what dose do you think I'll start to be able to get pain relief from other opioids? Do I have to wait until I'm off the methadone completely? Thank you in advance.
 
Dagda Mochta said:
I have cancer and I'm in pretty bad pain. None of the pain medication they have given me, up to 80 mg morphine er daily, has any effect because I'm on methadone maintenance. I'm currently tapering off because of this, dropping 10 mg per week. I was maintaining at 210 mg a day for about 4 years but I'm now down to 50 mg a day. At what dose do you think I'll start to be able to get pain relief from other opioids? Do I have to wait until I'm off the methadone completely? Thank you in advance.
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You should be able to get relief from other opioids at 50mg/day of methadone.

Have you tried fentanyl patches? I bet a 100ug/hr fentanyl patch would bring you some relief.

But yeah getting pain relief while on methadone can be tricky. I shattered my ankle while maintained on 380mg/day of methadone and had to have extensive surgery to rebuild it. When they discharged me they gave me darvocet for pain (which can't even be combined with methadone due to a serious interaction). So it was like getting nothing at all. Given the giant incision and newly installed plate/screws in my ankle, the pain was brutal.
 
My doctor ordered me fentanyl patches but they're on back order at every pharmacy. I suggested oxycodone to him yesterday. What dose do you think would work?
 
Dagda Mochta said:
I have cancer and I'm in pretty bad pain. None of the pain medication they have given me, up to 80 mg morphine er daily, has any effect because I'm on methadone maintenance. I'm currently tapering off because of this, dropping 10 mg per week. I was maintaining at 210 mg a day for about 4 years but I'm now down to 50 mg a day. At what dose do you think I'll start to be able to get pain relief from other opioids? Do I have to wait until I'm off the methadone completely? Thank you in advance.
Click to expand...
You don’t have to wait to be completely of methadone but just need to be really, really careful. Given your situation you should up the dose until the pain become bearable, with any given medicine you get. Sure if you come to the point where a lot of nasty side-effects kick in you should not continue upping the dose but change medicine.

Are you fine with weed? Oil made properly helps/ed just about any person I know with cancer no matter if he/she used it before or not. I’m not claiming miracle effects but at least less nausea and potentially less pain etc.
 
Dagda Mochta said:
My doctor ordered me fentanyl patches but they're on back order at every pharmacy. I suggested oxycodone to him yesterday. What dose do you think would work?
Click to expand...

Hard to say, i would say 40mg twice a day to start, but I don't think thats enough frankly, depending on the severity and type of cancer pain (which can manifest quite differently depending on cancer type, stage etc).

That said I don't think oxycodone would be the best choice here, fentanyl being much preferable in this case. Another option, which you won't like, would be to actually increase the dose of methadone and split the dose three times a day. This would of course would undo all the hardwork you've done tapering, so its a last resort.

You might also see some relief adding in something like pregabalin.
 
negrogesic said:
Hard to say, i would say 40mg twice a day to start, but I don't think thats enough frankly, depending on the severity and type of cancer pain (which can manifest quite differently depending on cancer type, stage etc).

That said I don't think oxycodone would be the best choice here, fentanyl being much preferable in this case. Another option, which you won't like, would be to actually increase the dose of methadone and split the dose three times a day. This would of course would undo all the hardwork you've done tapering, so its a last resort.

You might also see some relief adding in something like pregabalin.
Click to expand...
I have stage 4 rectal cancer with metastases to my liver and lungs. But my rectal tumor is the most painful, about a 8 on the pain scale. I thought of oxycodone because it has a much better oral bioavailability than morphine which isnt working. Dilauded doesn't do much either and also has horrible oral bioavailability. Im at a loss because my doctor doesn't really have experience treating methadone maintenance patients.
 
It makes no sense to me that the streets are flooded with fentanyl yet no pharmacy I've tried can get it. Its infuriating.

Edit:
I forgot to mention that I have an ileostomy and most of the little morphine beads end up in my pouch so I dont get the full effect of the drug regardless of my methadone tolerance. The pills are supposed to last 12 hours but they only work a little for about 5 or 6 hours. So whatever my dr orders must be instant release.
 
Yeah oxycodone would be preferable to morphine, you just might need quite abit. From what I understand oxycodone is in short supply too so you might have trouble filling it. Oxymorphone is another option, which is around twice the strength of oxycodone.

Given the advanced stage of the cancer and distance of the metastasis, higher doses of methadone divided 3x a day might be a fairly decent option, but it is a gamble if it doesn't work well for you since it will increase your tolerance to other opioids tremendously.
 
If you are on methadone maintenance, especially at such a large dose the first step would be to swap 1 dose every 24 hours to half the dose every 12 hours - that will already increase analgesia (the T1/2 of methadone is 8.5 hours and although normethadone prevents withdrawal, it isn't an analgesic).

Mixing opioids is absolutely contraindicated and given that methadone is also an NMDA antagonist, it's actually a very GOOD opioid for treating cancer pain.

IF the doctor insists on swapping you to another drug then Levo-Dromoran (Levorphanol) is just about the best option. It can be administered BID and not only is it x16 methadone in potency, it's a more potent NMDA antagonist. It's also typically given BID. 8mg/day is the official limit is 8mg/day but frankly, it's going to be the SAFEST and most appropriate option.

You really should go to a pain clinic because they should know just what is best but more importantly, they deal with strong opioids every day and so they are not afraid to advise your doctor who, having been advised, is going to be more comfortable prescribing the large doses that will be required.

Oxycodone is just the drug doctors are familiar with, it isn't appropriate for someone on methadone maintainence. Why on earth they are insisting on reducing the methadone is a mystery to me.

Methadone in Cancer Pain - PMC

Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Send him the above link. As long as you have had an EEG then their shouldn't be an issue. If not when you are on 210mg/day suggests a level of ignorance I find astounding. Notice how methadone's analgesic activity increases in a non-linear fashion to the extent that a small increase and BID dosing would provide the analgesia of simply HUGE doses of morphine.

As it is, 200mg of methadone is a LOT but it's T1/2 means it has to be taken twice a day.

Hope this helps.
 
AlsoTapered said:
If you are on methadone maintenance, especially at such a large dose the first step would be to swap 1 dose every 24 hours to half the dose every 12 hours - that will already increase analgesia (the T1/2 of methadone is 8.5 hours and although normethadone prevents withdrawal, it isn't an analgesic).

Mixing opioids is absolutely contraindicated and given that methadone is also an NMDA antagonist, it's actually a very GOOD opioid for treating cancer pain.

IF the doctor insists on swapping you to another drug then Levo-Dromoran (Levorphanol) is just about the best option. It can be administered BID and not only is it x16 methadone in potency, it's a more potent NMDA antagonist. It's also typically given BID. 8mg/day is the official limit is 8mg/day but frankly, it's going to be the SAFEST and most appropriate option.

You really should go to a pain clinic because they should know just what is best but more importantly, they deal with strong opioids every day and so they are not afraid to advise your doctor who, having been advised, is going to be more comfortable prescribing the large doses that will be required.

Oxycodone is just the drug doctors are familiar with, it isn't appropriate for someone on methadone maintainence. Why on earth they are insisting on reducing the methadone is a mystery to me.

Methadone in Cancer Pain - PMC

Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Send him the above link. As long as you have had an EEG then their shouldn't be an issue. If not when you are on 210mg/day suggests a level of ignorance I find astounding. Notice how methadone's analgesic activity increases in a non-linear fashion to the extent that a small increase and BID dosing would provide the analgesia of simply HUGE doses of morphine.

As it is, 200mg of methadone is a LOT but it's T1/2 means it has to be taken twice a day.

Hope this helps.
Click to expand...
I WAS on 210 mg of methadone. Now I'm only on 50 mg and still running into tolerance issues.
 
Truly - given BID or TID methadone is a VERY good analgesic - often used to treat cancer pain at least in the UK.

But given once a day it only provides relief for 8 or 9 hours.

Just pass the link to your doctor. The very last thing you should have to worry about is analgesia. BTW in the UK opioids are not prescribed for pain. The BNF states that they are prescribed to treat 'unacceptable suffering' which is a very faint line in the sand.

If you look at the paper, you see how effective methadone IS. 100mg BID is a lot (usually it's 10-20mg) but if you have such a serious illness, shouldn't you have the right to live a decent life?

God forbid but the most extreme I have seen is an in-patient who was on a sufentanil drip. She was in stage 4 and her tolerance meant that only something x500M worked.

I should also add that previous opioid (ab)use should have NOTHING to do with you receiving appropriate analgesia.

Forget juice - Physeptone tablets or better Levo-Dromoran tablets should be effective.

Hint - oral methadone has 38-72% bioavailability... but snorting the pills reliably produces 87% bioavaiability and kicks in... well, in seconds.

I hope your treatment goes well. If I can help, PM. I'm prepared to provide documents that a doctor would HAVE to consider.
 
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