Methadone remains one of the most useful weapons in the arsenal against pain. Not only is this medication cheap like water, this medication has special powers that can help tame nerve pain like no other opioids on the market. Additionally, the sustained-release effect of methadone helps to prevent opioid-induced hyperalgesia. Those doctors who learn how to prescribe find methadone very advantageous. Those patients who are using methadone successfully swear by it. However, the story about methadone is not all rosy. In the past decade, methadone-related deaths have risen by astronomical amounts. The FDA and leading experts in the field of pain medicine are now calling for additional precautions.
Cardiac Screening: In 2009, a groundbreaking consensus statement was published regarding screening for methadone use in patients. Because of the potential for causing cardiac arrhythmias, electrocardiograms need to be ordered prior to initiating methadone treatment, 30 days after initiating methadone treatment, and yearly. Patients should be made fully aware of the potential cardiac risks and screened for histories of arrhythmias, syncope, or mechanical heart disease. With this precaution, patients who are at high risk for cardiac complications can be steered away from methadone.
Sleep Study: Methadone has long been known to contribute to central sleep apnea. Thus, those who are at high risk for sleep apnea like those with COPD or obesity should consider undergoing a sleep study, as a screening tool prior to initiating methadone treatment. If identified has already having sleep apnea, the individual would not be considered good candidate for methadone because of the risk of further respiratory compromise.
Medication Check: Many drugs have the potential for interacting with methadone. Some drugs like amitriptyline (Elavil) are also known to cause cardiac arrhythmias and the additive effect with methadone would be ill advised. Other drugs like paroxetine (Paxil) can interact with methadone leading to serotonin syndrome. Because methadone is metabolized through the cytochrome P450 system, many drugs like clarithromycin which inhibit this system can cause increased levels of methadone and potential toxicity. But far and away the worst chemicals to mix with methadone are alcohol and benzodiazepine drugs; thus, drug screening tests are imperative for anyone prescribed methadone.
Start Very Slowly: Methadone has a unique metabolism and long half life which should to be greatly respected. Conversion from one opioid to methadone is very tricky especially if the individual is taking more than 100 milligram equivalents of morphine. A very low dose is initiated and titration to a higher dose occurs no more frequently than weekly. The recommended ceiling dose of methadone is no more than 100 milligrams per day. Some even recommend monitoring of therapeutic blood levels to insure that one is not approaching levels (forensic levels) known to be involved with methadone-related deaths.
These precautions are primarily intended for the initiation of methadone treatment. Given the advantages of this drug for the treatment of pain, methadone remains useful as long as doctors and patients enter into the treatment with certain disclosures and precautions in mind. For those who are already taking methadone, please review your medication list with your doctor, please obtain an electrocardiogram, consider obtaining a sleep study, and try to use the least amount as possible. As more doctors and patients become further educated, hopefully less deaths will occur and methadone will remain in our arsenal against pain.
Specialist in Pain Management and Spine Rehabilitation