(UK - NHS) Titrating Methadone: Switchin From Oxycodone to Methadone

[Rybee]

Hi All,

Currently take only ~50mg per day of Oxycodone for chronic sciatica from a pars defect. Saw my pain management consultant this morning and he has referred me to see a Psychiatrist who will be responsible for titrating my 50mg Oxycodone to a suitable dose of Methadone.

Which is fine... but what exactly does this entail? I get the impression that the initial switch will be under quite a lot of supervision and it's not as easy as just converting the dose, giving me a bottle and sending me on my way.

How many appointments should I expect to have? Will I have to take time off of work? How long does it take etc...

Any information at all will be really great. I only had 15 minutes to talk to him today and switching to Methadone was raised towards the end of our consultation so I didn't get to talk to him about how that's actually done in practice?

Thanks all,

 

[pasha]

Basic -> European & African Drug Discussion

 

[cuivre]

Honestly I can't help a whole lot here, mostly from not being super familiar with NHS-- possibly a bit-- but could you clarify if this is a switch to methadone for continuing pain management or a switch for maintenance? It sort of sounds like it's for pain but I can't make sense of why a Psychiatrist would be fielding that. Maybe this would make more sense already to someone who did know more about the NHS

 

[Eveleivibe]

It's a shame englandzg74 wasn't around cause he'd probably be best suited to answering this.

Evey

 

[pasha]

It's a shame englandzg74 wasn't around cause he'd probably be best suited to answering this.

Evey

I'm sure he's the only person on maintenance in Europe.

 

[Shambles]

^ He's not on maintenance. He was on extensive pain management meds for a long time (including methadone and oxy) and works as a paramedic in the NHS though so probably would have some insight.

 

[Eveleivibe]

^ He's not on maintenance. He was on extensive pain management meds for a long time (including methadone and oxy) and works as a paramedic in the NHS though so probably would have some insight.

Agreed!

I'm sure he's the only person on maintenance in Europe.

Of course not, Baooozs but englandzg74 was on methadone for pain as opposed to addictive reasons; similar to OP. And in Europe our services are different for people who use maintenance type drugs than say, morphine.

So in this instance, englandz (n others with similar circumstances are better equipped to offer advice, that's all.

Evey

 

[blondin]

The problem with trying to work out doses of different drugs in term of equivalencey is that there re many variables and most of the tables Iv'e seen produced by the medical proffesion are IMO subjective and complcated by 1/2 lives, rate of absorbsion ROA etc. However having binged on oxy's a fair few times and then going back on to methadone FOR ME it would be about 1-1 so 40mg or so (some tables have it more like 100mg or more)BUT when they titrate you they will start low and build up - trouble with that is the half life of methadone is 24-36 hours so you dont get full blood plasma levels until a few days have passed - so it may be an uncomfortable first few days.
It seems weird they have a trickcyclist working with you and why are they changing your meds anyway if they work?

 

[Rybee]

Hey guys, thanks for the replies. Didn't expect much uptake on this thread so quickly so I appreciate that.

Honestly I can't help a whole lot here, mostly from not being super familiar with NHS-- possibly a bit-- but could you clarify if this is a switch to methadone for continuing pain management or a switch for maintenance? It sort of sounds like it's for pain but I can't make sense of why a Psychiatrist would be fielding that. Maybe this would make more sense already to someone who did know more about the NHS

Sorry, to clarify, yes it is to carry on my pain management for neuropathic pain.

Yeah I didn't get that either. From what I have found out, even if I was to go on Methadone for pain management, I need to go through the local alcohol and drugs service who will prescribe it for me, and part of that process involves seeing a Psychiatrist from such service to evaluate my suitability to Methadone. I assume it is this Psychiatrist who deals with all of the MMT users in my region so is well versed in initiating a dose for Methadone users/patients.

At least, that's my understanding of it - and please could anyone correct me if they know better?

It's a shame englandzg74 wasn't around cause he'd probably be best suited to answering this.

With the risk of putting my foot in it, where is he? He used to post often in the pain management megathread with some great insight. I've not regularly been on BL for the last ~3 months. Is he ok?

^ He's not on maintenance. He was on extensive pain management meds for a long time (including methadone and oxy) and works as a paramedic in the NHS though so probably would have some insight.

Oh wow, never knew he was a paramedic too!

The problem with trying to work out doses of different drugs in term of equivalencey is that there re many variables and most of the tables Iv'e seen produced by the medical proffesion are IMO subjective and complcated by 1/2 lives, rate of absorbsion ROA etc. However having binged on oxy's a fair few times and then going back on to methadone FOR ME it would be about 1-1 so 40mg or so (some tables have it more like 100mg or more)BUT when they titrate you they will start low and build up - trouble with that is the half life of methadone is 24-36 hours so you dont get full blood plasma levels until a few days have passed - so it may be an uncomfortable first few days.
It seems weird they have a trickcyclist working with you and why are they changing your meds anyway if they work?

Yeah I agree, and I think that's why my pain management doctor can't just change me from Oxy to Methadone like he has from Morphine to Fentanyl, and Fentanyl to Oxycodone - and subsequently, why I have to go through a Psychiatrist at the local drugs & alcohol service.

As you say, it's complicated by other factors, such as the fact that I also take Sertraline. I've read several times that Sertraline can increase the blood levels of Methadone by anywhere up to 40% (if even anything at all) which is just crazy, that's such a big variation to get wrong.

 

[Eveleivibe]

I don't think you're putting your foot in it. I think he's doing a course.

Evey

 

[Shambles]

From what I have found out, even if I was to go on Methadone for pain management, I need to go through the local alcohol and drugs service who will prescribe it for me, and part of that process involves seeing a Psychiatrist from such service to evaluate my suitability to Methadone.

I have been round and round the houses in regards to pain management for quite some time now (decades ) and one thing I have learnt over that period is that doctors will do anything within their power to shunt pain management patients off onto mental health and/or addiction services. This would seem to be fine (albeit less than ideal) because these services will indeed prescribe for such cases... as long as you will lie to them about why you are under these services.

However, once shifted over into mental health and/or addiction services you are no longer treated as a genuine pain management patient but rather as a fantasist, an addict or a drug seeker. Or probably all three. I'd be cautious cos it sounds to me like you are about to be shafted.

I may be being cynical but this is precisely why I have spent many, many years being shunted from one service to another with none taking responsiblity and all passing me on - round and around again and again - because once the label shifts it tends to fall off completely and it's a case of hot potato. I have no particular advice to avoid this fate given I am stuck in and endless loop of it but I would be deeply, deeply concerned about being put on methadone for pain management without some serious insight into why this was and why a psychiatrist need be invovled given it's - presumably - a physical issue.

Best of luck. Expect the worst

 

[Rybee]

I have been round and round the houses in regards to pain management for quite some time now (decades ) and one thing I have learnt over that period is that doctors will do anything within their power to shunt pain management patients off onto mental health and/or addiction services. This would seem to be fine (albeit less than ideal) because these services will indeed prescribe for such cases... as long as you will lie to them about why you are under these services.

However, once shifted over into mental health and/or addiction services you are no longer treated as a genuine pain management patient but rather as a fantasist, an addict or a drug seeker. Or probably all three. I'd be cautious cos it sounds to me like you are about to be shafted.

I may be being cynical but this is precisely why I have spent many, many years being shunted from one service to another with none taking responsiblity and all passing me on - round and around again and again - because once the label shifts it tends to fall off completely and it's a case of hot potato. I have no particular advice to avoid this fate given I am stuck in and endless loop of it but I would be deeply, deeply concerned about being put on methadone for pain management without some serious insight into why this was and why a psychiatrist need be invovled given it's - presumably - a physical issue.

Best of luck. Expect the worst

Sorry to hear that buddy, I'm only 25 and have only been on the pain management train for 2 years now and have already faced the stigma from taking opiates. I used to get help from my doctor and then a pain management consultant on the NHS but even with a fresh MRI showing a clearly herniated spinal disc and a Pars defect, they all thought I was milking it for the high. I got fed up with being judged by everyone from the prescribing doctor pulling faces to the dispensing pharmacist asking what I was using it for, so I ended up paying to see a pain consultant privately and he's been absolutely brilliant.

As you say, when he wrote to my doctor and asked them to refer me to this service to carry on my treatment, the progress came to a halt and since that was request in November 2014 I've just been palmed off by one doctor to another, to some chump at the drug and alcohol service saying I wasn't eligible unless I was on Heroin. It's just been ridiculous and reminded me why I bother paying to go private. I'm due to go back to my doctor on Monday morning to ask what the hell is going on with my referral for the 5th time this year.

So yeah I appreciate the forewarning and it's something I'm already experiencing, I really had to think twice about the whole Methadone thing because of the extra stigma attached to it. I get interrogated by Pharmacists all over the place before they are prepared to dispense my Oxycodone/Fentanyl prescription, I used to get het up and explain my story to them, to try and reassure them, but now I just politely remind them that I need not disclose any information unless they have concerns over the validity of the prescription. Sometimes I get refused by hey ho.

So yeah... If that's what I get now for Oxycodone/Fentanyl, then I can already imagine being treated like a third class citizen when they see it's for Methadone.

 

[BigG]

Hi guys, I've not.been on for a while as I've been going through some awful shit at work that I'll not bore you with suffice to say that posting hasn't really been on my mind for a while.

I saw this thread though and thought I might be able to offer some insight as rybee's situation sounds very much like my own some time ago.

Firstly with the conversion ratio between oxy and methadone, it seems to vary widely in opiate conversion tables and my pain specialist says that doctors hate converting to and from methadone since the rate varies depending on the dose. e.g. The ration for say 200mg of methadone is different from the rate at 20mg and the same the other way round. I can only assume that this is because methadone is metabolised differently at different doses. I made a switch from 400mg of oxy to methadone many years back and they just started me on 60mg (waaay too low)and titrated up 10mg per day until they got to 180-200mg which obviously took awhile and was less than ideal. They just seem to want to put you on the lowest possible dose and then titrated upwards for safety reasons.....same thing when I titrated to any new opiate that I'd never had before be than fentanyl or whatever.....start really low and titrated rapidly up. As blondin mentioned though with methadone having such a long half life it takes a few days for your plasma levels to build up anyway so dont expect to find your optimum dose for a few weeks. The best you can hope for is that the dose you start on doesn't leave you in WDs. I would imagine though since the dose of oxy you're on is fairly low they will start you on around 30mg and titrated from there until you're comfortable (probably around 40-60mg I'd guess but to be honest it's hard to say).

I'd be super wary of being transfered to drug and alcohol though. That happened to me a few years back even though I've never used illicit drugs in my life and they knew that. They used to make me just through all sorts of embarrassing hoops like take a dose supervised in the chemist and make me take drug tests all the time (which I always passed and they knew I'd pass but made me take them anyway). Drug and alcohol services vary but some treat you like absolute scum. The one I was forced to see eventually kicked me out since I didn't fit their criteria of a drug using patient and I was eventually re-reffered back to the pain clinic and my prescribing continued from the Gp who'd sent me to drug and alcohol in the first place.

As shambles says, when your a pain patient who's been given the run around and sent to drug and alcohol they just don't know what to-do with you and it's so frustrating.

The other thing that used to wind me up was them constantly insisting I attend their appointments and meetings with "key workers" (a misnomer if ever there was one) which were utterly pointless as thevpurpose of these meetings were to see how you were managing to stay off the drug that got you referred to them in the first place I.e.heroin...and if you don't take heroin then what's the point of the meetings? Drug and alcohol are totally not geared up to have pain patients referred to them and it is shocking that GPs are doing it.... I think the reason is that many GPs simply will bot prescribe methadone without input from D&A regardless of the reason it's being prescribed.

One of the reasons I stopped opiate pain manage after 18years was that my GP retired and my new one wanted to deny me my methadone tablets, put me on Linctus and send me back through the drug and alcohol merry-go-round even though I had letters from them saying thatvtheyll wasn't appropriate for them to treat me and also letters from my pain management doctor telling my Gp to prescribe me methadone tablets (which my old doctor was happy to do).

One final thing about methadone is that while it is very effective for pain, particularly neuropathic pain (due to it being an NMDA agonist as well as a mu agonist) it is an insidious drug that is a NIGHTMARE to come off. I don't know your full situation but I'd be very careful and mindful of my options before going down that route.....

Hope any/some of that was of use to you and take care.... Let me know how you get on x

 

[Shambles]

I'd be super wary of being transfered to drug and alcohol though. That happened to me a few years back even though I've never used illicit drugs in my life and they knew that. They used to make me just through all sorts of embarrassing hoops like take a dose supervised in the chemist and make me take drug tests all the time (which I always passed and they knew I'd pass but made me take them anyway). Drug and alcohol services vary but some treat you like absolute scum. The one I was forced to see eventually kicked me out since I didn't fit their criteria of a drug using patient and I was eventually re-reffered back to the pain clinic and my prescribing continued from the Gp who'd sent me to drug and alcohol in the first place.

As shambles says, when your a pain patient who's been given the run around and sent to drug and alcohol they just don't know what to-do with you and it's so frustrating.

The other thing that used to wind me up was them constantly insisting I attend their appointments and meetings with "key workers" (a misnomer if ever there was one) which were utterly pointless as thevpurpose of these meetings were to see how you were managing to stay off the drug that got you referred to them in the first place I.e.heroin...and if you don't take heroin then what's the point of the meetings? Drug and alcohol are totally not geared up to have pain patients referred to them and it is shocking that GPs are doing it.... I think the reason is that many GPs simply will bot prescribe methadone without input from D&A regardless of the reason it's being prescribed.

This.

I'd suggest you are fortunate in being able to afford private treatment cos I can tell your for a fact that you will almost certainly be screwed if this was on the NHS. Pain management specialists who don't consider their primary role to be sending you to mental health and/or addiction services is in itself a minor miracle but a GP who will actually prescribe what even a consultant tells them to is in actual second coming territory.

Lube up... cos this may well sting...

 

[BigG]

I was one of the naive few who actually believed that My GP would have to continue the prescribing started by the pain consultant...Ohhhhh no!

While my first GP did, my second decided to completely ignore the consultant's letter and do his own thing anyway.

It really is a horrible situation. One so horrible it contributed largely to my leaving pain management after many, many years as i just couldn't face going through that shit again.

The way I stopped pain management wasn't the correct way by any means...I just stopped dead with no help from my doctors at all and dealt with the pain the way I thought best. If that sounds extreme then that should give you some idea of the nightmare that is being a pain patient trapped in the jaws of addiction specialists and the lengths I was prepared to go to in order to avoid that.

I doubt we're filling you with optimism here rybee but unfortunately it's the truth....

 

[F.U.B.A.R.]

Hey Englandgz, not seen you around for a while.. Sorry to hear you've been having problems. But as I've said before, you're one resilient mo'fo' so I'm sure you'll bounce back


Anyway, as you all were...

 

[Rybee]

Hey all - thanks so much to everyone for taking the time out of your busy lives to spare me some advice on this issue because it has really been worrying me lately and it's nice to have that open and honest support from people who've been in my shoes before.

I doubt we're filling you with optimism here rybee but unfortunately it's the truth....

No, you're not! But I knew that I'd get honest advice from you guys on BL and that matters way, way more to me than a sympathetic, sorry and misleading reply that could lead me to initiating Methadone without being as informed as I should be.

Sorry for the late reply, but I really appreciate your detailed reply here mate, especially as you've got pressing matters at work to deal too. As you say, no - it really doesn't fill me with confidence, but it does confirm what I already thought about initiating Methadone. After reading the replies from this thread, I saw my pain doc yesterday (Friday 20th) and opened up to him about my concerns and worries regarding Methadone and he was very understanding. I know he's also uncomfortable about rotating me on to it and he's always been very adamant that it would be his last choice of opiate to try.

I can't believe you were on 400mg of Oxycodone! That's absolutely jaw-dropping. I think I'm quite fortunate that I've managed to bring my opiate load down to just 50mg Oxycodone, which is relatively low in contrast to some people, and still much lower than the 200mg of MS Contin that I was taking in September 2013. So in that respect, I think I've actually made some pretty good progress with regards to pain management over the last 18 months and that did leave me with the option to wriggle out of starting Methadone for the time being because I still had the option of increasing my opiate dosage back up a little bit more.

I do plan on going away for quite a few months later on this year and I'm really concerned about obtaining Methadone abroad because of the stigma attached to it and the problems in obtaining it in a foreign country. As you say, it's hard enough to obtain it in England without being treated like absolute scum, so I don't know how I'd be treated in Thailand/Indonesia/Cambodia/Australia - even if it is for pain management.

So on that basis, during our consultation yesterday, we both felt that it was best that he rotated me back round to a 25mcg Fentanyl patch, and we're also going to give Pregabalin another shot to supplement the Fentanyl. I was on Pregabalin last year (100mg twice daily I think?) and whilst I used to find it very effective for relieving a good chunk of the neuropathic pain, it really did make me feel foggy in the brain and I was studying for my masters at the time so I really struggled with the negative effects on my cognitive functioning. Other than that, it was brilliant for pain so I'm happy to give it another shot now that I'm in a fairly stress-free 9-5 job quite local to home. I've also gone back to having intensive physiotherapy 2x weekly which has really helped with reducing and relieving the pain, as well as strengthening my core muscles, and since doing so, I've not experienced any severe breakthrough pain for the last 2 weeks. I just get that horrible dull-achey feeling down through my lower back, bum, quads, hamstrings and calves - so I guess that's also another factor helping to deter me from starting Methadone at the moment.

I've also been referred to a spinal consultant for a surgical opinion on whether he can actually fix the Pars defect permanently, or just do carry out some surgery on it to help reduce the pain that I experience. I guess I'm quite lucky in the sense that I do actually have clear, verified, physical damage to the lower spine that *may* be fixed by surgery. A lot of neuropathic pain sufferers don't have the option of surgery to actually fix the root cause of their pain so I guess that's something to be grateful for.

I'm really grateful for you guys to take time out of your busy lives and bother providing me with the advice I was after, and it's good to know that I still have a few options left before Methadone becomes my last and only choice. Once again, thanks to everyone who's taken the time out to show concern and reply to this thread with information on your own experiences. It's something that's really been playing on my mind over these past few weeks, and I really don't have any shame in putting my hands up and admitting that I'm genuinely terrified at the thought of initiating Methadone - so thanks!

Rybee

 

[Eveleivibe]

That's ok. Helping people is good. My Mam has osteoporosis and is amazing the way she gets on with it. I had an S1/L5 disc herniation ffs n acted a complete wimp n compared to what she's going through but she just gets on with it.

Take care,

Evey

 

[Erikmen]

I was one of the naive few who actually believed that My GP would have to continue the prescribing started by the pain consultant...Ohhhhh no!

While my first GP did, my second decided to completely ignore the consultant's letter and do his own thing anyway.

It really is a horrible situation. One so horrible it contributed largely to my leaving pain management after many, many years as i just couldn't face going through that shit again.

The way I stopped pain management wasn't the correct way by any means...I just stopped dead with no help from my doctors at all and dealt with the pain the way I thought best. If that sounds extreme then that should give you some idea of the nightmare that is being a pain patient trapped in the jaws of addiction specialists and the lengths I was prepared to go to in order to avoid that.

I doubt we're filling you with optimism here rybee but unfortunately it's the truth....

Like you mentioned in your previous post, I also had been on Methadone for too many years.
Have recently come off after struggling with it for almost 3 months.
At the end I have managed to jump to zero for a little over a month now.
Must confess it's still quite difficult even after withdraws diminished. It was an extremely long w/d!!
Did you succeed in quitting Methadone and the other opiates? How are you now?

 

[Erikmen]

It's a shame englandzg74 wasn't around cause he'd probably be best suited to answering this.

Evey

Indeed, as I read his posts more convincing he was and so were you. Excellent reviews actually..