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Updates, Alerts, Corrections

Alerts

July 14, 2016

"New study highlights risks of combining benzodiazepines and opioids"
https://www.pharmacist.com

"Don't Use Oral Liquid Docusate Stool Softener in Any Patient, CDC Warns"
http://www.medscape.com

Updates

May 2015

Methadone changes and additions

  • delete parenteral values as they are highly variable
  • change PO equianalgesic dose to highly variable, and starting dose to 2.5-5 mg
  • Safest starting dose for adults is 5 mg, for opioid tolerant as well as opioid-naive. For opioid-naive patients over 70 yrs and/or with chronic illness, lower the starting dose to 2.5 mg.
  • Be sure to provide adequate breakthrough meds during titration.
  • Titrate slowly, do not increase daily dose by more than 25-50%, or more frequently than every 7 days. 

References:
Webster LR. Methadone Side Effects: Constipation, Respiratory Depression, Sedation, Sleep-Disordered Breathing, and the Endocrine System. In: Cruciani RA, Knotkova, eds. Handbook of Methadone Prescribing and Buprenorphine Therapy. New York, NY: Springer; 2013:59-72. 
Webster LR. Eight Principles for Safer Opioid Prescribing. /ww.painmed.org. Pain Med. 2013;14:959-61.

Methadone Statistics from the CDC - PDF

  • 5,000 people die every year of overdose related to methadone 
  • Methadone contributed to nearly 1 in 3 prescription opioid deaths in 2009 
  • Only 2% of opioid analgesic prescriptions were for methadone 

Reference
CDC. Prescription Painkiller Overdoses. Use and Abuse of Methadone as a Painkiller. CDC Vital Signs. www.cdc.gov/vitalsigns/. July 2012.
Webster LR.  Responsible Prescribing of Methadone for Pain Management: Safety First. Providers’ Clinical Support System for Opioid Therapies (PCSS-O). pcss-o.org. Salt Lake City, UT: April 14, 2015.

Methadone ≠ Drug of First Choice (Excerpt from: The Evidence Against Methadone as a “Preferred” Analgesic) - PDF

  • Methadone should not be considered as a drug of first choice for chronic pain 
  • It should only be prescribed by providers experienced in its use 
  • Methadone belongs in the armamentarium of pain medications, but specific medical education is necessary to prescribe it safely 

Reference
The Evidence Against Methadone as a “Preferred” Analgesic: A Position Statement from the American Academy of Pain Medicine. ww.painmed.org. 2014. 
Webster LR.  Responsible Prescribing of Methadone for Pain Management: Safety First. Providers’ Clinical Support System for Opioid Therapies (PCSS-O). pcss-o.org. Salt Lake City, UT: April 14, 2015.

Guidelines for QTc Interval Screening in Methadone Treatment - PDF

Krantz,MJ. QTc Interval Screening in Methadone Treatment Center for Substance Abuse Treatment (CSAT) Guideline. http://annals.org. Ann Intern Med. 2009;150:387-395. 

February 2015 

Change in ABSTRAL package insert: In November 2014, the manufacturer added conversion instructions when switching patients from ACTIQ to ABSTRAL, in section 2.2 - PDF


Corrections

2015 BPM printed edition and BPM Online
Pharmacology Pearl
  

Incorrect:  The dose and analgesic effect of most mu agonist opioids have no known ceiling. Exception: meperidine and methadone, due to active metabolites. Side effects, however, may be limiting. 7-Wrede-Seaman, p. 183
Explanation: Delete methadone. Methadone does not have active metabolites.
Reference: 1-Lexicomp Online, Lexi-Drugs. Hudson, OH: Lexi-Comp, Inc., 2015.

2015 edition, web address for GlobalRPH (online opioid dosage calculator)

The web address was misspelled – it should be the following: http://www.globalrph.com

2008 edition BPM, Pearl 9
2011 edition BPM, Pearl 10

Incorrect: “Hydromorphone (Dilaudid): a better drug choice for patients with renal insufficiency, due to it’s short
half-life (2-3 hrs) and no active metabolites. 3-McCaffery, p. 226”
Explanation: H3G is an active metabolite of hydromorphone. It has no analgesic properties and upon accumulation (as can occur with renal insufficiency), can cause neuroexcitatory symptoms: tremor, agitation, myoclonus, allodynia, seizures, cognitive dysfunction. Rotation to a structurally dissimilar opioid (ie: methadone or fentanyl) usually results in a resolution of these neuro symptoms over a period of hours to days.
References: Journal of Palliative Medicine. 2011 Sept; 14(9): 1029-1033.
Life Science. 2001 Jun 15; 69(4): 409-420.
Clinical and Experimental Pharmacology & Physiology. 2000 July; 27(7): 524.