Tag Archives: Chronic Pain

I’m a fan of methadone

One of the more interesting parts of spending time on the pain management services was getting more comfortable using methadone.  Methadone is a synthetic opioid (mu-receptor agonist) which was developed in Germany in the 1930s since there were predictions of opium shortages.  Methadone has a very long duration of action (making it well-suited for recovering addicts) and it also is a NMDA-receptor antagonist.  This means it may help prevent some tolerance to opioids, and it can quell central nervous system responses to pain.

One of my patients was a young man with sickle cell disease, which leads to painful “vaso-occlusive” crises.  These crises happen when the shape of the red blood cells becomes distorted, leading to obstruction of small vessels.  Patients typically develop pain in their chest, shoulders, hips, and knees.

This particular patient had been in the hospital for nearly two weeks by the time I inherited him (as I came on the Chronic Pain Service on a Tuesday).  He’d been intermittently refusing his long-acting oral morphine and insisted on using his substantial intravenous patient-controlled analgesia (PCA)  pump.  When I asked him why he refused his oral medications, he said they didn’t work for him.  I explained that I believed the oral medicine did work for him, because when he took his medicine consistently, he required less intravenous medicine.  The morphine was long-acting, so it didn’t produce a “rush” or “high”, but I explained that it provided a baseline level of pain control.  He still seemed doubtful.  I also told him that my goal was to get him off intravenous medications by the next day, and I was able to get him to agree to take his oral medicine.

Sure enough, by the next day, he’d refused a couple more doses of morphine.  The cynic found within all pain specialists may interpret this as a sly move to exchange the pain control afforded by long-acting medicines for the euphoria of intravenous medications.  Since one side-effect of opioids is sedation, if a patient is too sedated, he won’t push the pump’s button.  This is the elegant safety feature inherent to PCAs.  If a patient refuses long-acting medicine, that means he can get more intravenous medicine more frequently without becoming sedated.

At this point, I called the pain fellow to make sure he was on the same page as me, and then I lay down the law.  No more intravenous medications.  We’re starting methadone.  The patient would have shorter-acting oral medicines available too, but only if he took his methadone.  With the fellow, I did a multi-step conversion to determine the appropriate starting dose.

I was in for a surprise when I went to see the patient by the next day.  He had received three doses of methadone by that point (one dose every eight hours).  I’d double checked the nursing medication administration record to make sure he hadn’t refused them.  And then I walked into his room.  The patient was sitting in bed, awake, alert, and smiling.  He stated that this was the first day in two weeks that he wasn’t in pain.  Not only that, but since starting the methadone, he had not required any additional doses of shorter-acting oral medication.

Given the long half-life of the medication, it could potentially be building up in his system for days, so I titrated the dose down a tad.  He was still comfortable the next day, so I recommended that he was okay for discharge with close follow-up with his hematologist.

Another satisfying success story for methadone!

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Pain and palliation

Today was a rewarding day.  I was called by a primary care team to assist with the care of a 25 year-old girl who is dying of cancer.  This was a situation that, as unfortunate as it was, had been made more complicated by growing distrust on the part of the family.  As the resident told me her story, he mentioned that the patient was being seen by the Palliative Care Service.  This was unusual, since the same pain specialist oversees both the Palliative Care Service and the Chronic Pain Service.

I agreed to come, not as a formal pain consultant (since my boss was already technically on the case), but as someone that might visit with the family and offer another perspective.  This was mainly a psycho-social consultation.  I did meet briefly with the patient, but spent most of my time in the family room with the father, the rabbi, and the primary care physician.  When I arrived, they were on the verge of signing Do Not Resuscitate/Do Not Intubate orders, and the father wanted to make sure that in spite of signing the paperwork, the family would still have a voice in the medical care.

This, of course, was easy.  I assured him that these measures simply meant we would not take aggressive measures to unnaturally prolong his daughter’s life.    They absolutely would not change the quality or quantity of their interaction with their physicians.

I spent the next thirty minutes asking about their goals and expectations, listening to their fears and frustrations, and assuring them that we would in no way abandon them in the face of the daughter’s rapidly deteriorating health.  I say “them” because in this case, my role of physician seemed to explicitly extend to include the patient, her parents, and the rabbi.  We clearly definited several goals: comfort & pain control, avoiding sedation, tolerating oral medications, being able to go home.

Tangibly, I was rewarded by being able to accomplish what the primary team and the regular Palliative Care Team had been unable to do, that is, to adjust the pain regimen that might facilitate comfort and be a step closer to home.  I attribute this not to any special skill, but to being willing to take the time to build a “therapeutic alliance” which involved the family’s trusting me that I had no interest in pushing the patient out of the hospital.  I clearly expressed that in the setting of rapidly progressing cancer, avoiding sedation might conflict directly with comfort, but that we would do everything possible to accomplish both.

Practically, this meant increasing the transdermal fentanyl dose, changing the intravenous pain medicine to avoid some untoward side effects, and supplying some potent non-intravenous medications as a trial run for out-of-hospital care.

But I felt most satisfied when I rose at the end of the conversation and the father and the rabbi both stood and eagerly shook my hand and, with damp eyes and choked voices, emphatically thanked me.  Here I was, telling them that yes, the daughter was dying, and that I could keep her comfortable but maybe not awake and she may never leave the hospital, and they were thanking me.  That’s ironic.  But I also told them that I would walk with them, that I wouldn’t abandon them, that I cared about what was important to them, and that I understood them; and they responded to that.  It was here, in practicing the art of medicine, that I connected with the family’s experience at the same time that I connected with physicians who, through the millenia millennia, have eased suffering and done no harm.  And that made my day.

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