Long-Term Care Survey Alert

Capitalize on the upsides of methadone while mitigating the risks.

Methadone can be just what you're looking for to manage residents' cancer and other chronic, serious pain. But to reap the many benefits of the medication and avoid the potential problems, nursing facilities should follow a protocol for administering and monitoring it.

Know the benefits: Methadone  is very cost effective and has a long half-life of 120 hours, so you don't have to give it as often as other medications, says Jeffrey Behrens, MD, CMD, medical director for VITAS Hospice in Ft. Lauderdale, FL, who works in nursing facilities.

"A lot of elderly patients can take doses as low as 5 mg BID and get good pain relief with meth- adone," adds Karl Steinberg, MD, CMD, a medical director for skilled nursing facilities in Oceanside, CA.

Other perks: Methadone has fewer side effects than the other narcotics, adds Behrens. And it "works very well for neuropathic pain."

Titrate the Dose Carefully

If the patient is "narcotic naïve," then you'd start him on a much lower dose than if he is taking a narcotic or has in the recent past, advises Behrens. But that applies to any opioid, he adds.

The starting dose for methadone is 10 to 20 mg, according to Behrens in a presentation on pain management at the March 2006 American Medical Directors Association meeting in Dallas. And the clinician should escalate the dose slowly. But to achieve optimal pain relief, "there's no maximum dose," says Behrens, noting that's also true for morphine and Dilaudid. The dose depends "on the person's weight, metabolism, how long she has taken the drug, tolerance, pain level, etc." By contrast, "codeine does have a maximum dose" Behrens tells Eli. And "Tylenol has a maximum dose. If you give someone 16 grams of Tylenol a day, you will wipe out the person's liver no matter how slowly you titrate it."

Know This Warning Sign

Given its long half-life of 120 hours, methadone can "sneak up on you" where the patient overdoses days after the physician increases the dose, cautions Behrens.

The solution: "Nurses have to monitor the patient for sedation which will be the first sign that the patient has received too much medication," counsels Behrens.

"If the patient becomes a little sedated, you'd cut back on the dose and continue to monitor the person for additional sedation and signs of respiratory depression," Behrens says. For example, the person may become more sedated the following day or the day after that. If so, the clinician may have to stop the medication and/or administer Narcan, he says. "Narcan will reverse the overdose but Narcan has a short half life, so within a few hours, the problem may return -- in that case, you'd continue to give the patient Narcan," says Behrens.

Watch for drug-drug interactions: The same enzymatic pathway metabolizes methadone as a number of other medications, says Behrens. Thus a patient taking methadone and those other drugs (see  the clip 'n' save article in this issue for a list) may experience increased blood levels of the medications, including methadone, he warns.

Thus, "it's not a bad idea for the consulting pharmacist to review the patient's medications to look for potential drug-drug interactions," advises Behrens.

Tip: If the facility will be giving patients methadone, consider collaborating with a hospice to tap its expertise in administering the drug, suggests Behrens.