Methadone Deaths CDC

SDN Members don't see this ad. (About Ads)

http://www.cdc.gov/mmwr/preview/mmwr...=mm61e0703a1_w

Abstract
Background: Vital statistics data suggest that the opioid pain reliever (OPR) methadone is involved in one third of OPR-related overdose deaths, but it accounts for only a few percent of OPR prescriptions.

Methods: CDC analyzed rates of fatal methadone overdoses and sales nationally during 1999–2010 and rates of overdose death for methadone compared with rates for other major opioids in 13 states for 2009.

Results: Methadone overdose deaths and sales rates in the United States peaked in 2007. In 2010, methadone accounted for between 4.5% and 18.5% of the opioids distributed by state. Methadone was involved in 31.4% of OPR deaths in the 13 states. It accounted for 39.8% of single-drug OPR deaths. The overdose death rate for methadone was significantly greater than that for other OPR for multidrug and single-drug deaths.

Conclusions: Methadone remains a drug that contributes disproportionately to the excessive number of opioid pain reliever overdoses and associated medical and societal costs.

Implications for Public Health Practice: Health-care providers who choose to prescribe methadone should have substantial experience with its use and follow consensus guidelines for appropriate opioid prescribing. Providers should use methadone as an analgesic only for conditions where benefit outweighs risk to patients and society. Methadone and other extended-release opioids should not be used for mild pain, acute pain, "breakthrough" pain, or on an as-needed basis. For chronic noncancer pain, methadone should not be considered a drug of first choice by prescribers or insurers.

Very nice stats. And so very true. The reasons for the deaths are unclear but could be due to patient overuse, physician overprescribing, failure to understand the very low therapeutic index during initiation of the medication, the profound effect of hepatic insufficiency on methadone metabolism, etc.

i think the methadone things is due to
1) PCPs not understanding variability in metabolism/duration of effect, etc - and over-titration
2) Patient's not understanding #1
3) And surprisingly, lately, I have seen a lot more patients on Methadone AND Oxycontin AND benzos --- when I see that cocktail, I know it is just a matter of time before the patient will die by accident... however, convincing patients that this is inappropriate is very hard....

BZD free since 2005 (#2 for MRI or flying) (#60 for hospice)
Soma free since getting back from ISIS last year
Methadone free since 2010.
Darvocet free since 2004
Demerol free since forever, except IM in office.

But I don't hold a grudge on any other opiate, as long as the patient's pass due diligence and we can prove a functional benefit, then it is a menu and I'll order for you.

Originally Posted by lobelsteve

But I don't hold a grudge on any other opiate

Heroin?

i believe there is limited medical use of heroin in England....

Originally Posted by lobelsteve

BZD free since 2005 (#2 for MRI or flying) (#60 for hospice)
Soma free since getting back from ISIS last year
Methadone free since 2010.
Darvocet free since 2004
Demerol free since forever, except IM in office.

But I don't hold a grudge on any other opiate, as long as the patient's pass due diligence and we can prove a functional benefit, then it is a menu and I'll order for you.

What was said about Soma at ISIS last year?

I'm not a big fan of Soma anyway, but I missed that lecture-

Originally Posted by bedrock

What was said about Soma at ISIS last year?

I'm not a big fan of Soma anyway, but I missed that lecture-

I was in a small group discussion and we were kicking around ideas on how to improve our practices and communities. The idea was thrown out to the group and we all said we'd rather lose a few patients than be part of the bigger problem. Done deal.

No lecture.

Soma is a very small problem statistically as a co-drug in opioid overdose deaths compared to benzodiazepines. The benzos are 3-6 times the problem of soma looking at death statistics and drugs found in toxicology studies. PCPs have gone crazy prescribing this stuff....with no testing of patients, no demonstration of anxiety, no documentation of anxiety disorders or panic disorders....it is all very subjective- even more than with opioids. Not only did we stop benzos being prescribed in our practice, we have given patients choices to stop the benzos from others otherwise we will reduce the amount of opioid being prescribed. 90% of the time this works (verified by UDS) and the other 10% of the time they keep taking them, and are discharged from our clinic....

Originally Posted by algosdoc

Soma is a very small problem statistically as a co-drug in opioid overdose deaths compared to benzodiazepines. The benzos are 3-6 times the problem of soma looking at death statistics and drugs found in toxicology studies. PCPs have gone crazy prescribing this stuff....with no testing of patients, no demonstration of anxiety, no documentation of anxiety disorders or panic disorders....it is all very subjective- even more than with opioids. Not only did we stop benzos being prescribed in our practice, we have given patients choices to stop the benzos from others otherwise we will reduce the amount of opioid being prescribed. 90% of the time this works (verified by UDS) and the other 10% of the time they keep taking them, and are discharged from our clinic....

Wise words, algos.

Originally Posted by algosdoc

Soma is a very small problem statistically as a co-drug in opioid overdose deaths compared to benzodiazepines. The benzos are 3-6 times the problem of soma looking at death statistics and drugs found in toxicology studies. PCPs have gone crazy prescribing this stuff....with no testing of patients, no demonstration of anxiety, no documentation of anxiety disorders or panic disorders....it is all very subjective- even more than with opioids. Not only did we stop benzos being prescribed in our practice, we have given patients choices to stop the benzos from others otherwise we will reduce the amount of opioid being prescribed. 90% of the time this works (verified by UDS) and the other 10% of the time they keep taking them, and are discharged from our clinic....

I have one lady that uses Klonipin by her PCP for anxiety. She does have some legit pain, appearing to be facetogenic s/p MVA. RFA didnt work on her. She takes about 2 vicodin 5mg tabs a day. She is a 'worrier'. Calls teh office multiple times a week, and I think it's just more so to talk to someone. She's awaiting consult with a surgeon. I'm wondering if i could use the BDz issue as a way to d/c her opioids. The thing thing is that 10mg of vicodin the whole day isnt that big of a dose.....

Originally Posted by PinchandBurn

I have one lady that uses Klonipin by her PCP for anxiety. She does have some legit pain, appearing to be facetogenic s/p MVA. RFA didnt work on her. She takes about 2 vicodin 5mg tabs a day. She is a 'worrier'. Calls teh office multiple times a week, and I think it's just more so to talk to someone. She's awaiting consult with a surgeon. I'm wondering if i could use the BDz issue as a way to d/c her opioids. The thing thing is that 10mg of vicodin the whole day isnt that big of a dose.....

Has she seen a pain psychologist/psychiatrist? Sounds like she should. Probably do her more good than surgery.

Originally Posted by bedrock

Has she seen a pain psychologist/psychiatrist? Sounds like she should. Probably do her more good than surgery.

Yes, she sees her psych. Basically the pscyhiatrist gives them some klonipin......Patient states, "i dont need to see pysch". THe thing is she's not really a 'drug seeker' and is only on minimal amounts of opioids (as stated 10mg of vicodin the whole day, sometimes even just 5mg). She's done the therapy, CBT,etc stuff before. She does work..

it sounds as if she is functional, active, participating in her care, seeking coping mechanisms, etc.

i mean darn, shes working. how many of our other patients still work???

why upset the wagon? do you have any "red flags" other than you dont want to prescribe a low but seemingly reasonable dose of vicodin?

Originally Posted by lobelsteve

BZD free since 2005 (#2 for MRI or flying) (#60 for hospice)
Soma free since getting back from ISIS last year
Methadone free since 2010.
Darvocet free since 2004
Demerol free since forever, except IM in office.

But I don't hold a grudge on any other opiate, as long as the patient's pass due diligence and we can prove a functional benefit, then it is a menu and I'll order for you.

So that's four rounds of rehab and you were finally able to kick the last drug? One day at a time, man, one day at a time...

Originally Posted by PMR 4 MSK

So that's four rounds of rehab and you were finally able to kick the last drug? One day at a time, man, one day at a time...

But you'll have to pry the coffee from my cold dead hands.

Hey that's my line

Originally Posted by facets

Hey that's my line

Uh oh.

New thread coming on coffee.

Originally Posted by lobelsteve

But you'll have to pry the coffee from my cold dead hands.

I used to be addicted to coffee, but I hating relying on it.

I started doing procedure mornings, never in the afternoons, and I find that procedures in the AM wakes me up right away, so I'm good the rest of the day.

Now, I just drink coffee socially or on the morning I don't do procedures.

Originally Posted by bedrock

I used to be addicted to coffee, but I hating relying on it.

I started doing procedure mornings, never in the afternoons, and I find that procedures in the AM wakes me up right away, so I'm good the rest of the day.

Now, I just drink coffee socially or on the morning I don't do procedures.

I do the same and it works great!!

Originally Posted by Tenesma

i think the methadone things is due to
1) PCPs not understanding variability in metabolism/duration of effect, etc - and over-titration
2) Patient's not understanding #1
3) And surprisingly, lately, I have seen a lot more patients on Methadone AND Oxycontin AND benzos --- when I see that cocktail, I know it is just a matter of time before the patient will die by accident... however, convincing patients that this is inappropriate is very hard....

Can someone please explain to me the rationale for :

1. Prescribing Methadone and another long acting opioid ? This seems very inappropriate and dangerous. I don't believe this is an evidence based approach.

If a patient has a co-morbid addictive disorder (i.e. the indication for methadone), this is just plain stupid and asking for trouble.

This just seems all downside.

2. Prescribing 2 long acting opioids together / at the same time (i.e. not methadone)?
I have seen family MDs do this, but does anyone with proper training do this ? Why not just appropriately titrate one long acting opioid and manage side effects accordingly.

This doesn't make sense to me.

Originally Posted by ghost dog

Can someone please explain to me the rationale for :

1. Prescribing Methadone and another long acting opioid ? This seems very inappropriate and dangerous. I don't believe this is an evidence based approach.

If a patient has a co-morbid addictive disorder (i.e. the indication for methadone), this is just plain stupid and asking for trouble.

This just seems all downside.

2. Prescribing 2 long acting opioids together / at the same time (i.e. not methadone)?
I have seen family MDs do this, but does anyone with proper training do this ? Why not just appropriately titrate one long acting opioid and manage side effects accordingly.

This doesn't make sense to me.

"The concomitant Rx of 2 long acting opiates fails to meet the standard of care for opiate prescribing in Georgia and suggests failure of education or complicit behavior on the part of the prescriber. "

there is almost on reason to prescribe two separate long acting opioids, imo.

with the possible exception of tapering down one while starting the other.

Originally Posted by lobelsteve

"The concomitant Rx of 2 long acting opiates fails to meet the standard of care for opiate prescribing in Georgia and suggests failure of education or complicit behavior on the part of the prescriber. "

Thanks for confirming what I already knew.

I just see this so frequently during opioid reviews, and in consultation, I begin to question my training !

Originally Posted by Ducttape

there is almost on reason to prescribe two separate long acting opioids, imo.

with the possible exception of tapering down one while starting the other.

Yes. Where I work (addiction medicine in a jail), we sometimes overlap methadone with LA morphine with the goal of tapering the pt off the morphine.

Pharmacist's opinion: methadone is a poor analgesic choice IMO because its efficacy for pain is only 6-8 h while its t½ is 18-36 h. Also, its levels are slow to peak in the plasma, leading pts to take more drug before its levels have even maxed.

So you've got an opioid that's kinda sorta equivalent to morphine in potency, except its long t½ leads to accummulation, and you're giving it to a population of pts who tend to take drugs more than prescribed. Also, there's only incomplete tolerance between methadone and other opioids, leading some experienced opioid users to misunderestimate their own tolerance.

Aand up to 80% of pts on methadone also use BDZs, whether prescribed or extracurricular.

Aaaand you've got insurance companies that favour the use of methadone because it's off patent and the cheapest LA opioid.