Ketamine and Methadone: Is more of a good thing better?

I’ve done a good deal of research on the benefits of an ERAS and Cardiac ERAS protocol to help with decreased length of hospital stay as well as early extubations and perioperative adjuvant pain control with ketamine, methadone, regional anesthesia, adjuvants to regional, etc.

What about ketamine and methadone in combination to aid decreased postoperative narcotic use?

  • Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi: https://doi.org/10.1097/ALN.0000000000003743.
    • 0.2 mg/kg of methadone (based on ideal body weight, up to a maximal dose of 20 mg)250 mg of ketamine was added to the dextrose 5% in water bag (total volume 500 ml). 500 ml bags were connected to a pump that was programed to deliver an infusion of ketamine dosed at ideal body weight (or an equal volume of dextrose 5% in water) at a rate of 0.3 mg · kg−1 · h−1 from induction of anesthesia until surgical closure, at which time the infusion was decreased to 0.1 mg · kg−1 · h−1. The infusion was maintained at a rate of 0.1 mg · kg−1 · h−1 in the postanesthesia care unit (PACU) and for the next 48 postoperative hours. Dosing of ketamine was based on recommendations in the literature17,18  and from clinical experience at our institution.
  • From Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi: https://doi.org/10.1097/ALN.0000000000003743.

    Management of Neuropathic Chronic Pain with Methadone Combined with Ketamine: A Randomized, Double Blind, Active-Controlled Clinical Trial. Pain Physician. 2017 Mar;20(3):207-215.

    Role of Ketamine and Methadone as Adjunctive Therapy in Complex Pain Management: A Case Report and Literature Review. Indian J Palliat Care. 2017 Jan-Mar; 23(1): 100–103.

    Ketamine: an introduction for the pain and palliative medicine physician. Pain Physician. 2007 May;10(3):493-500.

    Prescription of Controlled Substances: Benefits and Risks. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.2020 Jun 27.

    The perioperative combination of methadone and ketamine reduces post-operative opioid usage compared with methadone alone. Acta Anaesthesiol Scand. 2012 Nov;56(10):1250-6.

    The similarities and differences in impulsivity and cognitive ability among ketamine, methadone, and non-drug users. Psychiatry Res. 2016 Sep 30;243:109-14.

    Comparison of ketamine-dexmedetomidine-methadone and tiletamine-zolazepam-methadone combinations for short-term anaesthesia in domestic pigs. Vet J. 2015 Sep;205(3):364-8.

    A Systematic Review of NMDA Receptor Antagonists for Treatment of Neuropathic Pain in Clinical Practice. Clin J Pain. 2018 May;34(5):450-467.

    [Drugs for postoperative analgesia: routine and new aspects: Part 2: opioids, ketamine and gabapentinoids]. Anaesthesist. 2008 May;57(5):491-8.

    Buprenorphine

    Depths of Anesthesia podcast: Should buprenorphine be discontinued preoperatively?

    From the articles below (updated Feb 2021):

    • Consider continuing current or decreased buprenorphine dose
    • Consider non-opioid therapies: ketamine, gabapentin, acetaminophen, regional, lidocaine infusions, etc.
    • Team management with pain physician, surgeon, anesthesiologist, nurses, and patient
    • When mild to moderate acute pain is anticipated for a short period of time (e.g. dental extraction), consider treating the pain with buprenorphine and nonopioid analgesics such as NSAIDs.  The total daily dose of buprenorphine can be increased (to a maximum of 32 mg sublingual/day); it should be given in divided doses every 6-8 hours.  
    • When opioid analgesic therapy is expected to be required for a short period of time for moderate to severe pain, federal guidelines recommend holding the buprenorphine and starting short acting opioid agonists.  While the buprenorphine’s effects diminish (20-60 hours), the patient should be monitored carefully for the first several days as higher opioid doses may be needed to compete with the presence of buprenorphine on mu-opioid receptors.  Before restarting buprenorphine, the patient should be opioid-free for 12-24 hours, otherwise the reinitiation of buprenorphine could precipitate withdrawal.  This process should be overseen by an approved buprenorphine provider. 
    • Another option is to continue buprenorphine and use short-acting opioid agonists at high enough doses to overcome buprenorphine’s partial agonism.  One retrospective chart review found decreased opioid requirements in patients who were continued on buprenorphine during and after surgery.  Opioids that have a higher intrinsic activity at the mu-opioid receptor, including morphine, fentanyl, or hydromorphone, are all options, while opioids with less efficacy such as hydrocodone or codeine should be avoided.  
    • If a patient is expected to have an ongoing, long-term need for opioid analgesia (e.g. cancer progression), consider replacing buprenorphine with methadone.  Then, other as needed ‘full’ mu-opioid receptor agonists can be added for breakthrough pain without problems related to use of a partial opioid agonist.

    Treatment of Acute Pain in Patients Receiving Buprenorphine/Naloxone – 2014

    CA Bridge Program Acute Pain and Buprenorphine – ED and Crit Care – Nov 2019

    A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery. June 2020.

    From Mayo Clinic Proceedings. 2020.

    Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction. Jan 2018

    To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. June 2017.

    https://pubs.asahq.org/view-large/figure/1228784/31ff01.png
    https://pubs.asahq.org/view-large/figure/1228791/31ff02.png

    Update:

    Nov 2021: (includes Oct ASA annual mtg recommendations)

    Buprenorphine is a good analgesic.  Some patients prefer it to other opioids, even post-op. It is not recommended to stop buprenorphine, which can lead to relapse in 50% of patients.  There is a significant increase in mortality in patients in the first month after buprenorphine is stopped.

    Regional Anesthesia & Pain Medicine journal recommends no weaning.

    Mass General considers high dose to be more than 16 mg daily.  

    Different approach suggested in Anesthesiology 2016 paper.

    If patient is on 32 mg, only 5% of mu receptors are left for anesthesiologist to work with. If patient is on 16 mg, 20% of mu receptors are available. If patient is on 8-10-12 mg, 50% of mu receptors are available, which is why this is considered optimal by some. Need to overcome receptors with opioids that are high potency, high affinity and titratable, fentanyl and hydromorphone.

    Multimodal Analgesia Pain Management

    Methadone: perioperative use; acute and chronic pain

    Buprenorphine

    Orthopedic Surgery

    Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin. 2018 Sep;36(3):361-373.

    Enhanced Recovery After Surgery (ERAS)

    ERAS for general surgery

    Cardiac ERAS

    Non-Opioid Analgesics

    Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017 Jul 1;152(7):691-697.

    Preemptive Analgesia Decreases Pain Following Anorectal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Dis Colon Rectum. 2018 Jul;61(7):824-829.

    Gabapentinoids

    Ketamine

    Lidocaine

    Regional Anesthesia

    TAP block

    Regional for Cardiothoracic Anesthesia

    PECS and serratus blocks

    Thoracic blocks: ESP, PVB, TEA block

    Paravertebral catheters

    Regional Anesthesia catheters

    Adjuncts to prolong regional anesthesia

    Methadone: perioperative pain use

    Methadone for perioperative pain #methadone #pain #ERAS

    There’s a lot of great data that methadone use decreases postoperative narcotics use in cardiac surgery patients, and I believe it would really be a beneficial drug in an ERAS pathway for early extubation, decreased LOS in ICU and hospital, and better patient satisfaction.  Please see the articles below/attached for references.

    Methadone for cardiac surgery: 0.2-0.3 mg/kg prior to incision – perhaps different metabolism on CPB so consider split dosing pre-pump and post-pump. Dose adjustment with age and other co-morbidities. At induction, one half of the study opioid (either 0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was administered via an infusion pump over 5 min. The remainder of the study opioid (0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was infused over the next 2 h. Either 0.3 mg/kg of methadone (maximum dose of 30 mg) or 12 μg/kg of fentanyl (maximum dose of 1200 μg) was added to 100-ml bags of normal saline (total volume 100 ml).

    Methadone for non-cardiac surgery: 0.2mg/kg prior to incision. REVIEW: Intraoperative Methadone in Surgical Patients: A Review of Clinical Investigations. Anesthesiology 9 2019, Vol.131, 678-692.

    Methadone for obesity: 0.15 mg/kg IBW+20% at induction. J Pain Res. 2018; 11: 2123–2129. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study.

    Methadone for outpatient surgery: 0.15 mg/kg ideal body weight. Anesth Analg. 2019 Apr; 128(4): 802–810. Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

    OVERALL: A variety of doses have been used in clinical trials, ranging from 0.1 to 0.3 mg/kg, with the majority of studies using a dose of either 0.2 mg/kg or a fixed dose of 20 mg.

    Methadone has a long elimination half-life (1–2 days). It is cleared predominantly by hepatic metabolism, primarily via N-demethylation to 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), which is pharmacologically inactive, and thence secondarily to 2-ethyl-5-methyl-3,3-diphenylpyrroline (EMDP).

    Together these investigations established that a) CYP3A has no influence on single-dose intravenous or oral methadone plasma concentrations, b) CYP3A plays a minimal (if any) role clinically in single-dose methadone N-demethylation and clearance, c) methadone is not a clinical CYP3A substrate, and d) clinical guidelines stating that methadone is a CYP3A4 substrate and warning about CYP3A4 drug interactions needed revision. In addition, CYPs 2C9, 2C19, and 2D6 do not appear to contribute materially to clinical methadone N-demethylation and clearance.

    In summary, it is now obvious that CYP2B6 a) is a predominant catalyst of methadone metabolism in vitro; b) mediates clinical methadone metabolism, clearance, stereoselective disposition, and drug-drug interactions; and c) genetic polymorphisms influence methadone disposition. Thus, both constitutive variability due to CYP2B6 genetics, and CYP2B6-mediated drug interactions, can alter methadone disposition, clinical effect, and drug safety. Rewritten clinical guidelines stating that methadone is a CYP2B6 substrate and warning about CYP2B6 drug interactions may improve methadone use, treatment of pain and substance abuse, and patient safety.

    FDA Drug Datasheet

    From Anesthesiology 5 2015, Vol.122, 1112-1122.
    From Anesth Analg. 2019 Apr; 128(4): 802–810.

    What I’m doing these days:

    • March 2021
      • Cardiac: Ketamine current pt weight (non-adjusted) 0.2mg/kg/hr start after induction (after lines placed) + 0.35 mg/kg 5-10 minutes prior to incison. Change from 0.2mg/kg/hr to 0.1mg/kg/hr when rewarming. Infusion off when driving sternal wires. Methadone currently not available.
      • Non-cardiac (cases 2+ hours duration) Ketamine: 0.3mg/kg (non-adjusted, current weight) at induction. Methadone currently not available.
      • Outpatient: ketamine not currently available for use.
    • July 2020
      • Cardiac: Ketamine IBW 0.3mg/kg total: 0.2mg/kg prior to incision + 0.1mg/kg when separate from CPB
      • Excel spreadsheet dosing


    Adult Cardiothoracic

    Adult Non-Cardiac

    From Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi: https://doi.org/10.1097/ALN.0000000000003743.

    Adult Outpatient

    Pediatric Surgery

    Methadone Pharmacology & Effects

    Prescription of Controlled Substances: Benefits and Risks. [Updated 2020 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537318/

    The role of methadone in opioid rotation-a Polish experience. Support Care Cancer. 2009 May;17(5):607-12.

    Ketamine for intraoperative and postoperative analgesia

    I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

    This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

    ketamine_hydrochloride_050

    Ketamine: (different doses I’ve seen in the literature below)

    • Induction: 0.2-0.5 mg/kg

    • Infusion: 0.1mg/kg/hr before incision

    ◦ 2mcg/kg/hr x 24hr (spine)

    ◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

    ◦ 2mcg/kg/min

    ◦ 2-8mcg/kg/min

    Overall, moderate evidence supports use
    of subanesthetic IV ketamine bolus doses (up to 0.35 mg/kg) and infusions (up to 1 mg/kg per hour) as adjuncts to opioids
    for perioperative analgesia (grade B recommendation, moder-
    ate level of certainty).

    From Regional Anesthesia and Pain Medicine • Volume 43, Number 5, July 2018

    What I’m using nowadays:

    • Oct 2017:
      • Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved.  Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol.  Patients are more comfortable and require less pain medication.
    • Dec 2018:
      • Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming.
    • July 2020:
      • Cardiac open hearts: induction infusion 0.3mg/kg/hr + 0.5mg/kg right before incision. 0.2mg/kg/hr when commence CPB. 0.1mg/kg/hr when re-warming. Stop infusion when driving wires.
      • Main OR: induction 0.35mg/kg + 0.2mg/kg/hr or 3mcg/kg/min = extubate patient in OR. Stop infusion when closing.
      • **Excel spreadsheet for dosing**
    • August 2020:
      • Cardiac open hearts: induction infusion 0.2mg/kg/hr + 0.35mg/kg right before incision. 0.1mg/kg/hr when re-warming. Stop infusion when driving wires.
      • Main OR: induction 0.35mg/kg + 0.1mg/kg/hr = extubate patient in OR. Stop infusion when starting to close. If fast closure, consider stopping infusion 30min to 1 hour prior to end of case.
    • March 2021:
      • Cardiac: 0.2mg/kg/hr after induction and lines placed + 0.35mg/kg 5-10 minutes before incision. 0.1 mg/kg/hr when re-warming. Stop infusion when placing sternal wires.
      • Non-cardiac (2+ hr duration case): 0.3mg/kg at induction.

    fg01_e6952
    Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

    Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

    Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia. J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

    Ketamine for Perioperative Pain Management. Anesthesiology 2005; 102:211–20.

    CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY. NHS Royal Cornwall Guidelines June 2015.

    Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial. HSS Journal: Volume 4, Number 1.

    The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. Pain Medicine Volume 16, Issue 2, pages 383–403, February 2015.

    Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review. BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

     

    Ketamine in Pain Management. CNS Neuroscience & Therapeutics 19 (2013) 396–402.

    Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059.

    Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

    A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

    00213
    Acute and Chronic Post-Thoracotomy Pain, modes of treatment

    Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.


    ***UPDATE July 8, 2018 ***

    AnesthesiologyNews: July 2018: New Consensus Guidelines Issued for Use of IV Ketamine for Acute Pain.

    • Question 1: Which patients and acute pain conditions should be considered for ketamine treatment?
      Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
    • Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain?
      Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
    • Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia?
      Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
    • Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings?
      Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
    • Question 5: What is the evidence to support nonparenteral ketamine for acute pain management?
      Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
    • Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain?
      Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.

    New guidelines for the use of IV ketamine infusions for acute pain management have been published as a special article in Regional Anesthesia and Pain Medicine (2018;43[5]:456-466).

    The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.


    Update Nov, 30, 2018

    Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 456–466

    Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.  Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 521–546


    Updated July 2020

    Analgesic effect of subanesthetic intravenous ketamine in refractory neuropathic pain: a case report. Pain Med. 2010 Jun;11(6):946-50.

    Ketamine: An Introduction for the Pain and Palliative Medicine Physician. Pain Physician 2007; 10:493-500.

    Non-opioid IV adjuvants in the perioperative period: Pharmacological and clinical aspects of ketamine and gabapentinoids. Pharmacological Research. Volume 65, Issue 4, April 2012, Pages 411-429.

    Clinical application of perioperative multimodal analgesia. Curr Opin Support Palliat Care. 2017 Jun;11(2):106-111.

    A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50.

    Adjunct low-dose ketamine infusion vs standard of care in mechanically ventilated critically ill patients at a Tertiary Saudi Hospital (ATTAINMENT Trial): study protocol for a randomized, prospective, pilot, feasibility trial. Trials. March 2020; 21: 288.

    Safety and Efficacy of Ketamine-dexmedetomidine versus Ketamine-propofol Combinations for Sedation in Patients after Coronary Artery Bypass Graft Surgery. Ann Card Anaesth. 2017 Apr-Jun; 20(2): 182–187.

    Ketamine Infusion in Post-Surgical Pain Management after Head and Neck Surgery: A Retrospective Observational Study. The Open Anesthesia Journal. Formerly: The Open Anesthesiology Journal. ISSN: 2589-6458 ― Volume 14, 2020.

    Ketamine to facilitate weaning from mechanical ventilation: A case report. J of Anaesthesia and Critical Care Case Reports. Vol 3 | Issue 1 | Jan-Apr 2017 | page: 11-13.

    Impact of Low-Dose Ketamine on the Usage of Continuous Opioid Infusion for the Treatment of Pain in Adult Mechanically Ventilated Patients in Surgical Intensive Care Units. J of Intensive Care Medicine. May 2017. Volume: 34 issue: 8, page(s): 646-651.

    Ketamine-Based Anesthetic Protocols and Evoked Potential Monitoring: A Risk/Benefit Overview. Front. Neurosci., 16 February 2016.

    Ketamine: A Versatile Tool in the Perioperative Period and Beyond. ASRA News, Feb 2017.

    Update March 2021

    Methadone and Acute and Chronic Pain Management

    We had a journal club where we discussed this article: Anesthesiology, May 2017; Clinical effectiveness and safety of intraoperative methadone in patients undergoing posterior spinal fusion surgery: a randomized, double-blinded, controlled trial.

    • IV Methadone 0.2 mg/kg vs IV hydromorphone 2mg at surgical closure in 2+ level spinal fusion
    • Decreased postop IV and opioid requirements and pain scores.  Improved patient satisfaction

    Questions:

    1. Is there a pain service following these patients postoperatively?
    2. Exclusions: do you include OSA and BMI>45 patients?
    3. Is ETCO2 and PCA enough to combat respiratory depression on the floor?
    4. Are any discharged on the same day after receiving this dose — think total knees and single level lamis?
    5. Will this improve or worsen the opioid epidemic?
    6. Are surgeons on board with tackling pain multimodally for the benefit of the patient?
    7. For pain follow-up, are there psychiatry, homeopathy, palliative care, PT, holistic approaches for the patient?

    Methadone Dose Conversion Guidelines

    Intraop Lidocaine for postop pain

    Intraop Ketamine for postop pain

    Literature search:

    Sys Rev 2014: Effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment protocol.

    Am j of Pub Health, Aug 2014. Determinants of Increased Opioid-Related Mortality in the United States and Canada, 1990–2013: A Systematic Review.

    Br J Clin Pharmacol. 2014 Feb; 77(2): 272–284. Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?

    PLoS One. 2014; 9(11): e112328. Methadone Induction in Primary Care for Opioid Dependence: A Pragmatic Randomized Trial (ANRS Methaville).

    Curr Psychiatry Rev. 2014 May; 10(2): 156–167. Genetics of Opioid Dependence: A Review of the Genetic Contribution to Opioid Dependence. 

    Drug Alcohol Depend. 2016 Mar 1; 160: 112–118. Methadone, Buprenorphine and Preferences for Opioid Agonist Treatment: A Qualitative Analysis. 

    Croat Med J. 2013 Feb; 54(1): 42–48. Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia. 

    J Med Toxicol. 2016 Mar; 12(1): 58–63. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon”. 

    Syst Rev. 2014; 3: 45. Sex differences in outcomes of methadone maintenance treatment for opioid addiction: a systematic review protocol.

    Methadone and acute and chronic pain management

    We had a journal club where we discussed this article: Anesthesiology, May 2017; Clinical effectiveness and safety of intraoperative methadone in patients undergoing posterior spinal fusion surgery: a randomized, double-blinded, controlled trial.

    • IV Methadone 0.2 mg/kg vs IV hydromorphone 2mg at surgical closure in 2+ level spinal fusion
    • Decreased postop IV and opioid requirements and pain scores.  Improved patient satisfaction

    Questions:

    1. Is there a pain service following these patients postoperatively?
    2. Exclusions: do you include OSA and BMI>45 patients?
    3. Is ETCO2 and PCA enough to combat respiratory depression on the floor?
    4. Are any discharged on the same day after receiving this dose — think total knees and single level lamis?
    5. Will this improve or worsen the opioid epidemic?
    6. Are surgeons on board with tackling pain multimodally for the benefit of the patient?
    7. For pain follow-up, are there psychiatry, homeopathy, palliative care, PT, holistic approaches for the patient?

     

    Methadone Dose Conversion Guidelines

    Intraop Lidocaine for postop pain

    Intraop Ketamine for postop pain

     

    Literature search:

    Sys Rev 2014: Effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment protocol.

    Am j of Pub Health, Aug 2014. Determinants of Increased Opioid-Related Mortality in the United States and Canada, 1990–2013: A Systematic Review.

    Br J Clin Pharmacol. 2014 Feb; 77(2): 272–284. Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?

    PLoS One. 2014; 9(11): e112328. Methadone Induction in Primary Care for Opioid Dependence: A Pragmatic Randomized Trial (ANRS Methaville).

    Curr Psychiatry Rev. 2014 May; 10(2): 156–167. Genetics of Opioid Dependence: A Review of the Genetic Contribution to Opioid Dependence. 

    Drug Alcohol Depend. 2016 Mar 1; 160: 112–118. Methadone, Buprenorphine and Preferences for Opioid Agonist Treatment: A Qualitative Analysis. 

    Croat Med J. 2013 Feb; 54(1): 42–48. Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia. 

    J Med Toxicol. 2016 Mar; 12(1): 58–63. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon”. 

    Syst Rev. 2014; 3: 45. Sex differences in outcomes of methadone maintenance treatment for opioid addiction: a systematic review protocol.