Methadone Usage

[kbrown]

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hey all,

I don't have much experience with Methadone other than the basic knowledge that we all have. If anyone feels like they are qualified to answer these questions, please chime in.

What I know:
-methadone is an opioid agonist that is chemically different from morphine, but acts on same receptor.
-commonly used in heroin/opioid detox or chronic pain management
-half life about 24 hours thus good for once daily dosing in most patients

What I don't know:
-can it be picked up in a UDS? If not, how can it be detected?
-if someone uses methadone who doesn't have a history of opioid/heroin abuse or chronic pain, will they still get the "high"?

Questions:
1. See under "what I don't know?"
2. What is the normal dosing regimen? Is 30mg PO QID a lot?


Thanks for your help. You can see my credentials on my signature, I will be a EMP soon. I have a close friend whose son stole some methadone, took it and is now in an inpatient psych center. The UDS only showed cannabis, not opiates (which makes sense b/c methadone is chemically different from opiods). she just wants some info, when she asked the personnel at the treatment facility (Nurse and PA), they didn't know what methadone was. I found that kind of odd, but whatever. So I am trying to gather some info for her.

 

[SoCuteMD]

hey all,

I don't have much experience with Methadone other than the basic knowledge that we all have. If anyone feels like they are qualified to answer these questions, please chime in.

What I know:
-methadone is an opioid agonist that is chemically different from morphine, but acts on same receptor.
-commonly used in heroin/opioid detox or chronic pain management
-half life about 24 hours thus good for once daily dosing in most patients

What I don't know:
-can it be picked up in a UDS? If not, how can it be detected?
-if someone uses methadone who doesn't have a history of opioid/heroin abuse or chronic pain, will they still get the "high"?

Questions:
1. See under "what I don't know?"
2. What is the normal dosing regimen? Is 30mg PO QID a lot?


Thanks for your help. You can see my credentials on my signature, I will be a EMP soon. I have a close friend whose son stole some methadone, took it and is now in an inpatient psych center. The UDS only showed cannabis, not opiates (which makes sense b/c methadone is chemically different from opiods). she just wants some info, when she asked the personnel at the treatment facility (Nurse and PA), they didn't know what methadone was. I found that kind of odd, but whatever. So I am trying to gather some info for her.

We talked a little about it in behavioral science, so I can tell you what my little MS1 mind understands. Methadone is an opiate. If you divide them into three categories: natural (morphine), semi-synthetic (heroin), and synthetic (demerol, methadone). As I understand it, methadone can be used as a "step-down" for patients who are addicted to opiates because it gives the patient the same feelings as morphine/heroin except potentially with slightly less intensity (and longer-lasting). Anecdotally, one of my friends told me that when her grandfather was dying of cancer and lasted longer than anybody expected he ended up getting addicted to morphine. They gave him methadone for the morphine withdrawal and then weaned him from methadone. It sounds as if it was a process, however. Also anecdotally, I know a number of women through a shadowing experience who were addicted to heroin previously and who were being maintained over periods of years on methadone. I don't know that their doctors ever intended to stop the medication fully.

Another drug to look into the pharmacokinetic profile of may be buprenorphine. It's being used in other countries (and perhaps here by now) for those addicted to opiates as well (I'm not saying that your friend's son is, btw). It's a mixed agonist/antagonist of the mu receptor (same receptor as opiates).

 

[Idiopathic]

A UDS will not pick up methadone. We had a case of a non-responsive prison inmate who had a sketchy response to Narcan but was UDS negative for opiates. However, we learned that methadone was the culprit, and we had to do a separet UDS for that. Extremely long half life, cheap and somewhat resistant to tolerance due to some NMDA-antagonist effect. However, I believe that people taking chronic methadone will tell you its pretty addictive.

 

[kbrown]

thanks for the above. did you just special order a different UDS to get the methadone? what metabolite does it pick up? how did you order it?

yeah, i know it's pretty addictive. several heroin addicts have said that they would rather be coming off heroin than methadone.

 

[Idiopathic]

I dont remember what exactly we ordered, but the typical UDS opiate breakdown just doesnt have it. I think you just order a urine methadone, since it shows up in the urine unchanged primarily.

edit: after checking the metabolite is EDDP, but still I believe its just urine methadone.

 

[Anasazi23]

What I don't know:
-can it be picked up in a UDS? If not, how can it be detected?
-if someone uses methadone who doesn't have a history of opioid/heroin abuse or chronic pain, will they still get the "high"?

1. Yes, methadone can be picked up in most hospital UDSs. It can differentiate between opiate and methadone.
2. Theoretically, those on methadone are not experiencing the same high as they are on heroin. Those taking it for chronic pain normally are on lower dosing regimens than those taking it for opiate addiction.

Questions:
1. See under "what I don't know?"
2. What is the normal dosing regimen? Is 30mg PO QID a lot?

30mg QID would be considered a rare dosing regimen, but not unheard of for some conditions. It's normally given QD dosing for opiate addiction.

Urine drug screen will sometimes miss the offending substance depending on when they present, when they took the substance, for how long, the amount, the route, and what else they're taking with it.

 

[Idiopathic]

1. Yes, methadone can be picked up in most hospital UDSs. It can differentiate between opiate and methadone.

Ive seen it missed at two county hospitals. Our UDS at both places did not assess for methadone. Maybe this is not the norm?

 

[Anasazi23]

Ive seen it missed at two county hospitals. Our UDS at both places did not assess for methadone. Maybe this is not the norm?

Could be. Then again, I'm in residency in NYC. It's pretty much needed here.
It very well could be a local thing - depending on how the hospital lab runs it.

 

[DOtobe]

Ive seen it missed at two county hospitals. Our UDS at both places did not assess for methadone. Maybe this is not the norm?

The UDS at our hospital doesn't pick up methadone either. You need to test for it separately.

 

[Tenesma]

Methadone

1) Not commonly picked up on most UDS - check with your local toxicology lab first as they may ask you to add that request to your UDS order

2) It can give you a high... In fact, it is becoming increasingly abused as its frequency of prescription has increased. The cost of methadone on the street in my neck of the woods is the same as the cost of oxycontin (both are about $1/mg) which tells you something right there.

3) Methadone 30mg QID is very high - and would kill almost anybody who is opioid-naive, or at least put them into a serious case of acidosis from the rhabdomyolysis from laying in a coma for an extended period of time before being found down... odds are that the kid has been doing narcs for some time...

 

[Anasazi23]

Methadone

1) Not commonly picked up on most UDS - check with your local toxicology lab first as they may ask you to add that request to your UDS order

2) It can give you a high... In fact, it is becoming increasingly abused as its frequency of prescription has increased. The cost of methadone on the street in my neck of the woods is the same as the cost of oxycontin (both are about $1/mg) which tells you something right there.

3) Methadone 30mg QID is very high - and would kill almost anybody who is opioid-naive, or at least put them into a serious case of acidosis from the rhabdomyolysis from laying in a coma for an extended period of time before being found down... odds are that the kid has been doing narcs for some time...

It's a big first dose, but really not that big. I routinely see dosages well over 200 daily.

 

[kbrown]

not a first dose, he took it from his father who has 'chronic back pain' and has been on methadone for years. the kid only took one 10mg tab he says. thanks for all of your help. i don't think that he got much 'high' from it b/c it is such a long acting drug. usually the drugs that people get highs from have short t1/2's dumping a lot of drug quickly. methadone stays around for 24h, so the effects are strung out over a long time, thus less chance of high. that's why they give it to heroin/opioid addicts. doesn't cause them to get sick from withdrawl, but also doesn't give them the euphoric sensation.

 

[Dr_Feelgood]

not a first dose, he took it from his father who has 'chronic back pain' and has been on methadone for years. the kid only took one 10mg tab he says. thanks for all of your help. i don't think that he got much 'high' from it b/c it is such a long acting drug. usually the drugs that people get highs from have short t1/2's dumping a lot of drug quickly. methadone stays around for 24h, so the effects are strung out over a long time, thus less chance of high. that's why they give it to heroin/opioid addicts. doesn't cause them to get sick from withdrawl, but also doesn't give them the euphoric sensation.

You nailed it right there.

 

[Anasazi23]

not a first dose, he took it from his father who has 'chronic back pain' and has been on methadone for years. the kid only took one 10mg tab he says. thanks for all of your help. i don't think that he got much 'high' from it b/c it is such a long acting drug. usually the drugs that people get highs from have short t1/2's dumping a lot of drug quickly. methadone stays around for 24h, so the effects are strung out over a long time, thus less chance of high. that's why they give it to heroin/opioid addicts. doesn't cause them to get sick from withdrawl, but also doesn't give them the euphoric sensation.

Dosing routes for opiate addiction and pain are different - Tablets for pain, liquid for opiate agonist therapy given at a methadone clinic where it and drug status is monitored.

 

[Hurricane]

At our hospital, the standard urine tox screen does not pick up methadone, but there is a "comprehensive drug screen" you can order that does. I suspect it's quite variable from place to place, but a quick call to the lab should give you a definitive answer.

 

[tiredmom]

How did he take the methadone? We had a guy crush it and place it rectally to get a rush. For pain control, we've started patients on 10 mg BID, but I've seen patients in methadone programs on 100 mg q day. It also sucks to try to get a baby off it in the nursery... takes about 3 weeks to get past the initial withdrawals.

 

[Anasazi23]

Who's got the methadone record in your residency program?

Meaning, what's the highest you've seen a patient on it (verified)?

 

[MBK2003]

The analgesic effect of Methadone generally lasts 6-8 hrs, whereas the opioid receptor binding lasts >24 hours. When you dose Methadone purely for the analgesic effect (end stage Ca, chronic pain) it's not unusual to dose Q6-8 hours. When you dose Methadone for opiate withdrawal/dependence Q24h is sufficient to prevent withdrawal sxs. The thing to keep in mind when dosing Methadone for pain is that the t 1/2 is so long (days) that if you titrate up the dose q1-2 days for analgesic effect you won't see the respiratory suppression for 1-3 more days as the plasma level continues rise. Moral of the story, titrate up methadone dose q3-5 days as indicated by pain relief.

MBK2003

 

[Tenesma]

half-life of the drug have little to do with whether it leads to euphoria or not...

example: pentobarbital has a very long half-life 35-50 hours.... and pts can get nice high from it.

so you can throw that theory away.

the reason why methadone is used for heroin addicts is that it reduces their cravings by allowing for longer periods of opioid receptor binding. It doesn't eliminate their craving for a high though, and that is why you see a high failure rate w/ methadone maintenance programs

Methadone 30mg QID is a high dose whether you like it or not - just because you see doses of 200mg on a regular basis doesn't mean it isn't high. By the way, i think it is malpractice for somebody to be on that much methadone - probably a poorly run methadone addiction program that has allowed the patients to dictate their care...

 

[kbrown]

Who's got the methadone record in your residency program?

Meaning, what's the highest you've seen a patient on it (verified)?

not sure if you are asking, but this guy is on 120mg/day verified, which according to epocrates is the max daily dose

 

[kbrown]

half-life of the drug have little to do with whether it leads to euphoria or not...

example: pentobarbital has a very long half-life 35-50 hours.... and pts can get nice high from it.

so you can throw that theory away.

the reason why methadone is used for heroin addicts is that it reduces their cravings by allowing for longer periods of opioid receptor binding. It doesn't eliminate their craving for a high though, and that is why you see a high failure rate w/ methadone maintenance programs

Methadone 30mg QID is a high dose whether you like it or not - just because you see doses of 200mg on a regular basis doesn't mean it isn't high. By the way, i think it is malpractice for somebody to be on that much methadone - probably a poorly run methadone addiction program that has allowed the patients to dictate their care...

unfortunately this individual is not going through a methadone clinic. he goes through a doc that he knows in a smaller town outside of where we live (malpractice in my book too). i personally would rather see this guy seek out medical attention to correct (surgically or through physical therapy) his underlying problem...back pain. This constant dependence on methadone is ridiculous. because his son stole approx 10 of his pills he ran out before his script was able to be refilled...yikes!!!! just like heroin withdrawl, so uncomfortable to watch.

thanks to whoever cleared up the long t1/2 and no high theory. sorry my misunderstanding.

 

[Anasazi23]

Methadone 30mg QID is a high dose whether you like it or not - just because you see doses of 200mg on a regular basis doesn't mean it isn't high. By the way, i think it is malpractice for somebody to be on that much methadone - probably a poorly run methadone addiction program that has allowed the patients to dictate their care...

I tend to agree, though it entirely depends.

--how long they've been on it
--their current craving level
--their last opiate usage

As much as I hate methadone mills, studies show a decreased rate of crime and relapse with heroin while on it. The theory is that you'd rather have a doped up former heroin addict on 180 of meth than doing 15 bags/day busting out car windows and selling the radios on Canal street to afford it. The mills, of course, stand to make money off increasing the dosage, since the pt. then has less of a chance of coming off it. I've gotten more than one furious call from a mill after I discharged a person on a lower dose or d/c the stuff.

 

[OldPsychDoc]

Could be. Then again, I'm in residency in NYC. It's pretty much needed here.
It very well could be a local thing - depending on how the hospital lab runs it.

Yes, it really depends on how your hospital "packages" their UDSs. If it's not a part of the "standard" screen, then it's not going to show up.

 

[kbrown]

Yes, it really depends on how your hospital "packages" their UDSs. If it's not a part of the "standard" screen, then it's not going to show up.

THANKS EVERYONE!! I APPRECIATE IT.

 

[Gyric]

Most hospital tox labs offer some variation on a stat urine drug screen. In bigger labs this is often an immunoassay based screening test. Mine picks up amphetamines (1mg/L min), barbiturates (0.2 mg/L min), benzos (0.2 mg/L min), cocaine metabolites (0.3 mg/L), opiates (2 mg/L min). All of these, except cocaine and barbiturates, you really should treat as “a possible positive” since the specificity is far from perfect.

Methadone is not detected and does not cross react with the opiate level in a UDS. If you want to test for methadone in particular you order a urine methadone (EDDP), CDS is a waist of money if you are only interested in methadone (testing >400 drugs by EIA, HPLC, LCMS etc). EDDP is useful since as a metabolite you can tell if a patient is actually taking the drug you give them versus just selling it all (they try and cheat by putting a small amount of methadone in their urine and if you just test for the drug you can be fooled).

 

[gutonc]

Who's got the methadone record in your residency program?

Meaning, what's the highest you've seen a patient on it (verified)?

I saw a pt. in pain mgmt. clinic who was on 80mg q4. I doubt that's the highest ever but I was impressed.

Also saw a guy who wore 6 - 75mg Fentanyl patches at a time.

That clinic was good times.

BE

 

[DOtobe]

Not a methadone record, but an Ativan record:

One of my DT'ers in the ICU had his Ativan gtt set at a whopping 65 mg/hr. 😱

I would be dead if I took some of the high doses of meds that some of our patients do.

 

[Tenesma]

DOtobe... that is malpractice to keep a patient on an ativan gtt at that rate!!!!! the preservative of polyethylene glycol is bound to cause ATN (sometimes irreversible).... there are far better ways to manage DTs without poisoning them w/ preservatives (sounds like MICU management to me).

 

[DOtobe]

Incidentally, not long after he got to that rate, we found that he had a metabolic acidosis with a gap of 18...due to the polyethylene glycol. At that point his drip was d/c'd (changed him to Versed, which I guess doesn't have the high polyethylene glycol content?). His kidney function/acidosis recovered (luckily, he was a young guy who was pretty healthy). He could have done a lot worse...it's amazing how many iatrogenic problems there are with our patients.

The intensivist knew that the gtt was going at that rate. It was the pharmacist who rounds with us who said, "Um, you might want to wean him off the Ativan at that rate and change to something else..."

 

[Tenesma]

usually anything over 16-20/hour of ativan starts becoming risky - propofol, versed etc are better options

 

[carrigallen]

Who's got the methadone record in your residency program?

Meaning, what's the highest you've seen a patient on it (verified)?

My materno-fetal medicine attending occasionally sees pregnant mothers on doses in the 200 mg/day range, the record being 450 mg/day. Withdrawal is much more harmful in pregnancy than methadone. I don't think any teratogenic effects have conclusively been proven for methadone. Also, studies have proven that there is absolutely no correlation between the methadone dosage and the rate of neonatal abstinence syndrome - interestingly it is the same whether they receive a dose of <50/day or >120/day.
Of course, routine dosing for MMT is in the 50-100 mg/day range, but you rarely wean pregnant moms.
Incidentally, I've had ER attendings try to tell patients to STOP taking their methadone because the B-HcG was positive.