Methadone Management in a Patient With Pain and History Of Addiction
Question: A woman is in a local methadone program for heroin addiction. She has severe spine pain unresponsive to nonopioid treatments. She hasn’t used heroin in 10 years. The patient is transferred to a pain clinic. Do you leave the patient on methadone? Refuse to prescribe opioids?
Answer: This is a question about a situation I’ve had repeated experience with, as a local methadone clinic referred several long-term compliant patients to me because of their chronic pain. Methadone is an excellent drug for treating chronic pain. However, although its long serum half-life is well suited to once-daily dosing for prevention of cravings and withdrawal, it is not a long-acting analgesic. Chronic pain patients who are given their entire methadone dose in the morning often report getting adequate pain relief in the morning, but a return of pain by the afternoon. This is entirely consistent with the analgesic activity of this drug. My usual recommendation in such cases is to split the patient’s current dose into three doses per day, perhaps increasing each one a little, and then titrating upwards if needed. Of course, if the patient has not already had a diagnostic workup for her back pain, this should be part of the treatment plan developed at the first visit. So should physical therapy and an exercise plan.
For patients with a history of illicit drug abuse/addiction, I do not prescribe short-acting opioids for breakthrough pain, as I believe that the rapid variations in serum levels found with such formulations result in increased euphoria and relapse potential compared with sustained-release opioids. It’s important to let the methadone clinic know that the patient is now under your care in order to eliminate the possibility of her continuing to get methadone at the clinic. Assuming the patient has been getting daily dosing at the methadone clinic, I will start by giving a 1-week supply, and then, if the patient is compliant, I will see her monthly. Patients referred from methadone clinics who have a good long-term record with the clinic are usually very grateful to be able to get their methadone monthly in a regular medical clinic rather than daily, and are thus very motivated to be “good” patients. However, it is prudent to get frequent urine drug screens and to keep careful track of quantities and dates prescribed.
The US Drug Enforcement Administration’s rules do not permit prescribing methadone for maintenance of opioid addiction. However, when a patient has both pain and opioid addiction, it is perfectly legal to prescribe methadone for pain. You should write “for pain” on each methadone prescription to make this clear.
Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management