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In this 262nd episode I welcome Dr. Evan Kharash to the show to discuss the use of methadone perioperatively instead of more commonly used opioids such as fentanyl and dilaudid. We discuss the safety of methadone, how it works, and the evidence for superiority in terms of pain control, total opioid use, and patient satisfaction.
CME: Link
Random Recs:
Thank you for bringing more attention to the use of methadone in routine clinical practice. I am a practicing cardiothoacic anesthesiologist and have been an outspoken proponent of methadone use in my clinical practice. I was curious if there was any information regarding the risk of serotonin syndrome specifically in the cardiac surgical population when methylene blue is also used? Would you recommend deferring to B12 in cases which methadone was given (0.3 mg/kg)? Thank you for your thoughts.
Hi Oliver,
Dr. Kharash said he is not aware of an issue with methylene blue and methadone and a 2019 review of medications causing issues with serotonin did not mention it (The anaesthetist, opioid analgesic drugs, and serotonin toxicity: a mechanistic and clinical review
Brian A. Baldo and Michael A. Rose). He has heard of cases of problems with methadone and linezolid however. Certainly interested to hear if others have thoughts or experience with this question.
Very interesting and wonderful lecture! Thank you! What have you found using it, if at all on existing patients. For example, ortho trauma on multi modal in the ICU coming down for open pelvic surgery. They seem like they would be the ideal candidate for this yet worry that the existing pain mgmt may complicate this.
That’s a great and complicated question. I would definitely talk with the ICU and pain management team (if there is one) and make sure everyone is on board. Also, if the patient will remain intubated you have much more leeway.
I was so intrigued by this lecture. For general cases when using methadone in the operating room let’s say for robotic prostatectomy. The only opioid being used is methadone? No fentanyl? This would be a major change at my hospital and not sure how to incorporate usage of other IV opioids in addition to methadone?
Correct. No other opiods at all. No fentanyl, no Dilaudid, just methadone. It works incredibly well.
Thank you for this very informative lecture! In Canada, many provinces don’t have access to IV methadone, only PO. Most of the discussion was for IV, but can you suggest equipotent PO doses for the perioperative methadone doses? (there seems to be a wide range of conversion doses when I searched).
We use double the IV dose. So 20 IV would be 40 PO but I would certainly recommend running it by your pharmacists.
I am considering its use in same day surgery total knee having general anesthesia. Frequently before these patients get oxycodone 5-10 mg before discharge. Do you have any experience with methadone and oxycodone?
Great episode! It seems like a no brainier to use methadone for long spine cases or other long cases without regional anesthesia – avoid having to redose, avoid unfavorable context sensitive half time of fentanyl infusion, and avoid hyperalgesia with remifentanil. I’m interested in using it for other cases too. Thanks to others who commented.