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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.
Excellent episode! After listening to the podcast and digging into the research I pitched it to my anesthesia group and pharmacists. We were very impressed and are planning on trialing it in a select patient population. I was hoping to get some copies of Methadone PACU order sets and a pharmacy point of contact so we don’t need to reinvent the wheel. Any help would be greatly appreciated. Thanks for improving our practice!
From Dr. Kharash:
I’ll try and get a pharmacy contact.
For PACU Here is what we’ve used for ~5 yr
methadone 10 mg/mL injection 2 mg
2 mg, Intravenous, Every 10 min PRN, moderate pain (4-6), severe pain (7-10).
Max dose 6 mg. If, after 6 mg, pain remains severe (7-10), notify anesthesiologist.
The rationale is that after the 10, 15, 20 mg dosing, needing more than 6 mg is rare. More specifically, we do not want things like bladder spasm after prostatectomy being mistaken for pain and treated with methadone (bladder spasm does not respond to opioids). I am not sure that “the call” should only be for severe pain (7-10). The risk is that pain will be undertreated. Respecting that pain scores are horribly unreliable, and based on experience, I believe we should be more deliberate about treating PACU pain. I see all my pts in the PACU, and have found that simply asking a patient if they have pain or soreness, and if the former whether they want more pain RX, is the best indicator, and I will give more (as long as RR is >=10 or so). This is all about physician and PACU RN education.
Thanks so much! This is extremely helpful information. Currently our pharmacy is only able to find a 200 mg/20 mL MDV which costs $350. We are discussing ways in which we can divide this MDV into 10-20 mg doses to make it more cost effective. Right now our pharmacists are willing to do this but we just wanted to see if there was a more efficient way. Appreciate all your efforts!
OR Pharmacy contact
Wendy Rycek
Thought provoking episode!
I will pitch it at my current hospital.
Some concerns that I heard/read in other editorials/lectures are that most of the studies did exclude certain risk groups like the patient with obesity or the elderly (‘frail’) patient.
Are there any groups that you would withhold methadone use and instead use different opioids? For example the groups above and like you mention in the podcast (prolonged QT-segment). I’m unaware if certain medication also prohibits the use of methadone.
I do not exclude the elderly but do reduce the dose, as dose Dr. Kharash. For obese patients I think it works great if you don’t overdo it and may actually be better since they’ll need less total post op opioids.
I found your excellent podcast episode after having started trying out methadone after learning about it at a conference last year, and it is really a game changer, especially for a few tricky patient groups.
Some patients are already on Oxycodein, anything from 10mg x2 to 30-40mg x 2 for some of our chronic back pts. Would you just continue this as per usual when giving perioperative methadone i, or hold it on the day of the surgery?
Until now I’ve just let them have the oxycontin as they’re usually adapted to the dose and it is pretty weak sauce compared to the methadone anyways… So far, so good!
What are your thoughs?
Also, thanks for an awesome podcast!
I agree, I have them take their home dose and add the methadone on top of that. Thanks for the kind words!