Take time to educate patients about methadone and its risk of mortality if not used as prescribed.
Methadone is less frequently prescribed than other opioids, yet it is more frequently associated with death from overdose. Though there is a risk of overdose and death with any opioid, managing methadone is more difficult. A desperate chronic pain patient may self-escalate their methadone without proper insight into the consequences.
Remember the logarithmic relationship methadone doses have with their morphine equivalency. The following highlights how deceiving the numbers are: 50 mg of methadone is about 100 mg of morphine-equivalent, but 100 mg of methadone is about 1,000 mg of morphine-equivalent, or 10 times as strong.
From 1999 to 2005, methadone-related deaths increased by 468%.2 If the patient doesn’t seem to understand these risks, they are not a good candidate for methadone treatment.
A little local anesthetic (and some steroid) goes a long way.
Hospitalists should offer an assortment of diagnostic and therapeutic injections to chronic pain patients. First, be sure you’ve done your due diligence:
- What procedures do you have privileges to do?
- Do you need to be proctored first?
- How do your local specialists feel about you doing injections?
In light of these considerations, hospitalists should be able to train and be credentialed to offer such procedures as trigger-point injections, joint injections (knees, shoulders), or even a peripheral nerve injection (e.g. lateral femoral cutaneous nerve or ilioinguinal nerve injection). Some hospitalists might even want to learn ultrasound-guided sacroiliac joint injections for chronic unexplained back pain.
Offering an indicated and effective injection is a good nonopioid option. And local anesthetic injections can help hospitalists establish an elusive diagnosis. For example, many patients spend years getting worked up for head and neck pain when dry-needling with a small volume (1 cc) of local anesthetic into a neck muscle trigger point can break their pain generator, eliminating their pain.
Addiction to opioids is not rare.
The use, misuse, and diversion of opioids and all the associated complications have appropriately received considerable media attention. A seminal paper by Porter and Jick titled “Addiction Is Rare in Patients Treated with Narcotics” is one of many tipping points associated with the boom in opioid prescribing.3 Whether it’s a three-day supply of hydrocodone, 24 hours on a PCA, or an opioid rotation, any exposure to opioids can put a patient on the runway to addiction.
There are only 3,071 board-certified addiction specialists certified by the American Board of Addiction Medicine, so access to an addiction specialist might be difficult.4
Nonetheless, do not become complacent and just continue the opioid therapy in a difficult opioid-addicted patient. Express your concerns to the primary opioid prescriber, or help patients who don’t have an opioid prescriber get access and treatment. Otherwise, you have no choice but to taper the opioids.
Ideally, chronic pain management should be delivered in the outpatient arena where long-term monitoring can take place.
Safely changing opioid regimens requires good math and good judgment.
During training and practice, hospitalists become accustomed to rapidly analyze objective data, such as ABGs, ECGs, anion gaps, and vent settings. A hospitalist should become similarly efficient at calculating morphine equivalencies (cautiously with methadone and fentanyl), making dose reductions, and rotating opioids. The more comfortable you are with morphine equivalencies, the faster and safer you will be at rotating opioids. Whatever morphine-equivalence table you feel comfortable with is the one you should use consistently.
We see many providers who unwittingly take, for example, a patient who has become resistant to hydrocodone/acetaminophen 10/325 mg PO TID (30 mg of morphine) and convert them to oxycodone/acetaminophen 10/325 mg PO QID (60 mg of morphine—a doubling), when doubling could cause respiratory depression or a faster path to addiction and dependency.