methadone and pain management adjuncts

[daisy87876]

Hi everyone.

I am pre-pharmacy, so please excuse if this is a simplistic question for many of you. I have tried to find more info online, but have been unable to find anything that really answers my questions. Say a patient is on methadone maintenance in a daily dose. If they are prescribed PRN, let's say, oxycodone, does it matter how long after they take the methadone that they wait to take the oxcodone? I'm concerned in terms of suppressing their respers etc. I am guessing it doesn't make much of a difference since I know methadone has a pretty long half-life, so it will be in their system anyway, correct? Same thing if they are prescribed PRN lorazepam. Does it matter if they take them at the same time vs waiting an hour?

Also, one other thing. In patient's on suboxone maintenance....I have seen them prescribed PRN tramadol for pain control. Does it make a difference how long after they take their sub maintenance that they go ahead and take their PRN tramadol? Like say they get their schedule suboxone daily at 8am. Does it matter if they take a PRN ultram at 6am? Could then taking the suboxone "kick" the ultram off their receptors and cause a withdrawal? If not, could taking them too close together cause any other ill effect?

Thanks!

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[Carboxide]

Hi everyone.

I am pre-pharmacy, so please excuse if this is a simplistic question for many of you. I have tried to find more info online, but have been unable to find anything that really answers my questions. Say a patient is on methadone maintenance in a daily dose. If they are prescribed PRN, let's say, oxycodone, does it matter how long after they take the methadone that they wait to take the oxcodone? I'm concerned in terms of suppressing their respers etc. I am guessing it doesn't make much of a difference since I know methadone has a pretty long half-life, so it will be in their system anyway, correct? Same thing if they are prescribed PRN lorazepam. Does it matter if they take them at the same time vs waiting an hour?

Also, one other thing. In patient's on suboxone maintenance....I have seen them prescribed PRN tramadol for pain control. Does it make a difference how long after they take their sub maintenance that they go ahead and take their PRN tramadol? Like say they get their schedule suboxone daily at 8am. Does it matter if they take a PRN ultram at 6am? Could then taking the suboxone "kick" the ultram off their receptors and cause a withdrawal? If not, could taking them too close together cause any other ill effect?

Thanks!

You are right about the methadone. The half-life is extremely long, so it is at steady state and won't make a difference. Lorazepam doesn't have an effect on mu receptors, so it also wouldn't matter because...totally different drugs/classes/MOAs.

As for Suboxone, what is the purpose of the naloxone? Because you are pre-pharm, I will give you the answer - it is to prevent injection abuse because the injected naloxone would block all effects of the buprenorphone. Naloxone is not absorbed from the GI tract. It won't have an effect on the tramadol. Tramadol will also not affect the efficacy of the buprenorphine - one of the benefits of buprenorphine is that it binds extremely tightly to mu receptors and would not be significantly replaced by tramadol. HOWEVER - it is a good idea to question the risk/benefit of using an opioid in a patient with documented substance abuse issues. Until the re-classification of tramadol, I think a lot of docs did not really understand that tramadol is, in fact, an opioid and can cause serious addiction problems just like hydrocodone or oxycodone.

By the way - these are some very good questions. You are already thinking like a pharmacist. Keep studying hard and I bet you will be a great pharmacist someday!

 

[daisy87876]

You are right about the methadone. The half-life is extremely long, so it is at steady state and won't make a difference. Lorazepam doesn't have an effect on mu receptors, so it also wouldn't matter because...totally different drugs/classes/MOAs.

As for Suboxone, what is the purpose of the naloxone? Because you are pre-pharm, I will give you the answer - it is to prevent injection abuse because the injected naloxone would block all effects of the buprenorphone. Naloxone is not absorbed from the GI tract. It won't have an effect on the tramadol. Tramadol will also not affect the efficacy of the buprenorphine - one of the benefits of buprenorphine is that it binds extremely tightly to mu receptors and would not be significantly replaced by tramadol. HOWEVER - it is a good idea to question the risk/benefit of using an opioid in a patient with documented substance abuse issues. Until the re-classification of tramadol, I think a lot of docs did not really understand that tramadol is, in fact, an opioid and can cause serious addiction problems just like hydrocodone or oxycodone.

By the way - these are some very good questions. You are already thinking like a pharmacist. Keep studying hard and I bet you will be a great pharmacist someday!

thanks you so much for your reply! it really helped me. I just wanted to clarify so I make sure I understand....it doesn't really make a difference if a patient took the tramadol before OR after taking their scheduled suboxone? I get that the suboxone is bound pretty tightly to the receptor, so tramadol won't be able to come and knock sub off the receptor if someone takes tramadol after they take their suboxone dose....but what about if tramadol was taken before suboxone? Would the suboxone come and displace the tramadol from the receptor and could this cause any precipitated withdrawal? thanks again!

 

[PolarPop]

Tramadol is different story because 2/3 of its pain relief comes from SNRI rather than mu agonism. But yea buprenorphine would likely bump almost all other opioids (including tramadol) from the mu receptor.

The funny thing is that buprenorphine actually has higher affinity for the mu receptor than naloxone does. This is why people naive to opiates can still get a high from injecting it... and why it's abused so much