Methadone and TCAs

[ghost dog]

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I saw a pt today on Methadone, and never prescribe the stuff. She was taking it for opioid maitenance TX / addiction, at 38 mg OD.

She complained of depression + insomnia, in addition to her pain and I was wondering about a trial of elavil as both an analgesic + sedating agent. She also seemed to have frequent migraines.

Keeping in mind the QT prolongation issue associated with methadone, and that Elavil can make this worse, what would people do here ? Definite no / contraindicated ?

Close watch on her EKG on a low dose? Not worth it?

On a related note, I was wondering about Flexeril, as this has TCA like properties. Same question as above (more for academic interest, than it's clinical utility).

 

[pmrmd]

I thought the QTc prolongation was only something to worry about at higher doses, over 100mg QD.

 

[ParaVert]

QT prolongation is dose dependent. Personally, I wouldn't worry at those doses. That being said, I avoid TCAs if possible in the elderly due to a dose-independent increase in sudden death risk. Young patient on < 100mg methadone and/or <100mg of TCA, I wouldn't even get a EKG.

 

[psychbender]

Dealing with an otherwise healthy, young, post-trauma population with amputations and phantom or neuropathic pain, we regularly put inpatients on methadone and TCAs (almost everyone gets started on nortriptyline and gabapentin when they roll off the plane, and a handful each month are changed from Oxy-SR to methadone), and have yet to see any significant issues. Total methadone does not exceed 60mg daily (20mg TID), and the nortriptyline is usually 25-50mg nightly, only. May not be able to extrapolate this to the outpatient setting, however.

 

[ziggyziggy]

I saw a pt today on Methadone, and never prescribe the stuff. She was taking it for opioid maitenance TX / addiction, at 38 mg OD.

She complained of depression + insomnia, in addition to her pain and I was wondering about a trial of elavil as both an analgesic + sedating agent. She also seemed to have frequent migraines.

Keeping in mind the QT prolongation issue associated with methadone, and that Elavil can make this worse, what would people do here ? Definite no / contraindicated ?

Close watch on her EKG on a low dose? Not worth it?

On a related note, I was wondering about Flexeril, as this has TCA like properties. Same question as above (more for academic interest, than it's clinical utility).

First of all, I will get baseline EKG to get baseline QTc. The future course of adding something which can increase QTc will depend of what baseline is (450, 500 or 550 ms etc)

Second, why choose elavil (even though serious qtc prolongation is a danger at toxic dose only) ? Elavil is only adjunctive medication for pain and there are better safer meds to address depression and insomnia together.

 

[epidural man]

I saw a pt today on Methadone, and never prescribe the stuff. She was taking it for opioid maitenance TX / addiction, at 38 mg OD.

She complained of depression + insomnia, in addition to her pain and I was wondering about a trial of elavil as both an analgesic + sedating agent. She also seemed to have frequent migraines.

Keeping in mind the QT prolongation issue associated with methadone, and that Elavil can make this worse, what would people do here ? Definite no / contraindicated ?

Close watch on her EKG on a low dose? Not worth it?

On a related note, I was wondering about Flexeril, as this has TCA like properties. Same question as above (more for academic interest, than it's clinical utility).

Most problems are with induction of methadone. Start the TCA.

 

[Ducttape]

First of all, I will get baseline EKG to get baseline QTc. The future course of adding something which can increase QTc will depend of what baseline is (450, 500 or 550 ms etc)

Second, why choose elavil (even though serious qtc prolongation is a danger at toxic dose only) ? Elavil is only adjunctive medication for pain and there are better safer meds to address depression and insomnia together.

Such as? TCAs at low dose are effective for neuropathic pain, and a ton easier to prescribe than, say, Cymbalta or Savella (from insurance standpoint). Maybe the calcium channel blockers, but patients complain about the daytime sedation or weight gain, and i have had quite a few quit because it made their mood worse.

 

[ziggyziggy]

Such as? TCAs at low dose are effective for neuropathic pain, and a ton easier to prescribe than, say, Cymbalta or Savella (from insurance standpoint). Maybe the calcium channel blockers, but patients complain about the daytime sedation or weight gain, and i have had quite a few quit because it made their mood worse.

use good old gabapentin for neuropathy and slight insomnia. Add any SSRI for depression and insomnia. Sticking to something just because it will be multi-use is not a good strategy when you are so worried about the lethal side effects (even though, TCA is not cardiotoxic at low dose and I would go ahead with TCA prescription in the above said case. ).

In the above said case, we all are assuming that its neuropathic pain.

I am just curious, what is this patient's problem set?

 

[michaelrack]

consider sleep apnea (particularly central) as a possible etiology of the insomnia in a person on chronic opioids.

 

[ziggyziggy]

consider sleep apnea (particularly central) as a possible etiology of the insomnia in a person on chronic opioids.

since you are the expert on this, what will you use for insomnia like this and in this case?

 

[onewithpain]

Don't forget REM suppression in patients on TCAs.