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GETTING COMFORTABLE WITH IT’S USE IN THE HOSPICE PATIENT

Presented by Nicolle Shumaker RN,CHPNAvera McKennan Hospice

Describe pharmacological properties and side effects from p pmethadoneDiscuss nursing care and follow up recommended for patients on methadoneIdentify patients who could b fi f h d ibenefit from methadone pain management

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Cost effective medication for painGood alternative when concerned Good a te at e e co ce edabout drug diversion – little street valueMinimal side effects

Methadone 2mg TID #90 tablets$14 00$14.00

MS Contin 30mg BID #60 tablets$82.00

Oxycontin 20mg BID #60 tablets$170.00

Duragesic Patch 50mcg #10 g gpatches $215.00

(6/14/11)

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Synthetic opioidReceptors:ecepto s◦ Mu opioid agonist◦ Inhibit serotonin and

norephinephrine neuronal re-uptake and inhibit NMDA receptor

Absorption:DistributionMultiple routes

Metabolized- in liverHalf life=2-3 Multiple routes

◦ PO,SL,PR, SQ, IV , G Tube

Lipophilic60-90% bound to alpha-1-acid glycoprotien

hoursBeta-half-life( slow elimination phase)- of 15-60 hours ( up to 130 hours reported)

Excretion FecalExcretion- Fecal excretion majority, urinary minor

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INHIBITORSKetoconazole, fluconazole,

Itraconazolel d h

INDUCERSRifampinRifabutinAnticonvulsants phenytoinMacrolides – erythromycin,

clarithromycinQuinolones- ciprofloxacin,

norfloxacinAntiviral – ritonavir,

nelfinavirSSRI’s –fluvoxamine,

fluoxetine, paroxetine, sertraline

NefazodoneCCB’s – diltiazem, verapamil

Anticonvulsants – phenytoin,fosphenytoin,

carbamazepine, phenobarbital

HIV Antivirals – amprenavir, efavirenz, nevirapine,ritonavir, abacavir

Corticosteroids – prednisone, dexamethasone

EstrogenRisperidoneAmiodarone

CimetadineDiazepamGrapefruit juice (large

amounts)

RisperidoneSt. John’s WartAlcohol abuse

Sedation, nausea and vomiting, respiratory depression dizzinessrespiratory depression, dizziness, pruritis, constipationSubcutaneous administration-inflammatory skin reaction at injection siteArrhythmia-QTC Prolongationy gContraindications: known allergy to methadone/MAOI use(??)

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Tablets: 5mg, 10mg, 40 mgab ets 5 g, 0 g, 0 g

Solution: 5mg/5ml, 10mg/5ml, 10mg/ml

Injection: 10mg/mlj g/

Special dose compounding

SUBSET OF PATIENTS WITH PAIN UNRESPONSIVE TO MORPHINE OR OXYCODONESUBSET OF PATIENTS WITH DOSE LIMITING TOXICITIES (NAUSEA, MYOCLONAS, DELIRIUM, SEDATION)USE IN PATIENTS WITH LOWEREDUSE IN PATIENTS WITH LOWERED RENAL FUNCTION

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LACKS NEUROACTIVE METABOLITES THAT ACCUMULATE IN RENAL FAILUREHAS LONG AND SHORT ACTING PROPERTIES? ACTIVE IN NEUROPATHIC PAIN SYNDROMES (N-METHYL-D-(ASPARTATE) NMDA RECEPTORS

ORAL BIOAVAILABILITY 80% (3X GREATER THAN MORPHINE)ELIMINATED BY NON RENALELIMINATED BY NON-RENAL ROUTESDOES NOT ACCUMULATE IN RENAL FAILURECAN BE GIVEN RECTALLY WITH ORAL:RECTAL DOSING 1:1ONSET OF ANALGESIA: 30 60ONSET OF ANALGESIA: 30-60 MIN DURATION OF ANALGESIA INITIALLY 3-6 HOURS, BUT INCREASES TO 8-12 HR WITH CHRONIC USE

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HIGH DOSE ANALGESICS AND NOT RESPONDINGINTOLERANT TO OTHERSCOMPONENT OF NEUROPATHIC PAINRENAL FAILURECOST CONCERNS

TRUE ALLERGYSEVERE RESPIRATORY S S ODEPRESSION? EKG SHOWING PROLONGED QT INTERVAL (? >200 MG/D OF METHADONE)? NO CAREGIVER TO MONITOR PATIENT

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EQUIANALGESIC DOSE WITH MORPHINE VARIES DEPENDING ON THE AMOUNT OF MORPHINE EQUIVALENTS USED/24 HOURS

INITIAL DOSING (OPIOID NAÏVE): 0.5 MG Q 8 HOURS SCHEDULED, FRAIL/ELDERLY WITH DOSEFRAIL/ELDERLY WITH DOSE CHANGES EVERY 5-7 DAYS

UK HOSPICE MODEL

MILAN MODEL

EDMONTON CONVERSION MODEL

Next slide Avera McKennanNext slide Avera McKennan Hospice Conversion table used.

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No more than every 4 days-literature recommends 5-7 daysyBreakthrough dosing recommendations varied based on client’s current PRN use

Conversion factors for commonly used narcotics

PO: IV/SCMorphine 3:1 (30mg PO = 10mg IV)Dilaudid 5:1 (7.5mg PO = 1.5mg IV)

PO: POPO Oxycontin: PO Morphine 2:3 (40mg Oxycontin = 60mg Morphine)PO Hydrocodone: PO Morphine 1:1 these are equivalent in dosing

Transdermal:POFentanyl patch: Morphine PO 1:3 (25mcg Fentanyl patch = 75mg Morphine PO)

IV:IVIV Dilaudid: IV Morphine 1:7 (1.5mg Dilaudid = 10mg Morphine)

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Patient assessmentDetermine total daily dose of ete e tota da y dose ocurrent opioidDecide treatment plan- which opioid to switch toIndividualize dosePatient monitoring and reassessment

Current opioid no longer effectiveeffectiveIntolerable side effectsPatient status changeOther reasons:◦ Current therapy expensive◦ Safety of narcotics in homey

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If pain is not managed in current setting /level of care consider gacute care stay and drug conversionIf transitions at home: Home visits at least 3 times per week ( more often if needed for patient monitoring)monitoring)Phone contact daily if not visiting patient

Lack of caregiver to monitor patientpatientVery limited prognosisReceiving medications that inhibit or induce methadone metabolism- administer lower doseRisk of QT prolongation

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Monitor for side effects:Cognition changesSedation Monitor for palpitations p pof syncope with patients at risk for QTc prolongation

How to use:Take this

Missed doses:If you miss aTake this

medicine by mouth with a drink of water. If the medicine

If you miss a dose take it as soon as you can. Do not take double or

upsets your stomach, take it with food.

extra doses.

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Side effects to report :Skin rash, itching or hives, S as , tc g o es,swelling of the face lips or tongueBreathing problemsChest painConfusionUnusually fast or slow heart beatUnusually weak or tired.

Drowsy but arousable during conversation- consider reducing gdose 25%Somnolent, minimal or no response to physical stimulation-hold dose until able to wake-drop dose by 50%P i C b k h h dPain-Convert break through dose every 4-6 days into daily dose or increase methadone 25-50%

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ConcernsS i

BenefitsMultiple administrationStigma to

addiction therapyAccumulation and toxicityLack of d i

administration routesVery effective for neuropathic painLong half lifeLower costeducation

Lack of experience

Lower costNo active metabolite accumulationLow incidence of side effects

Fast Facts: www.eperc.mcw.edu

www.clinical pharmacology

Handout from Nicole Paterson, PharmD BCPSToombs, JK, Dral,L (2005) , J , , ( )American Family Physician 71,7,1352-1538