Expert: William J. Walker, Pharm.D. - 7/9/2004

Question
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Followup To
Question -
would 40 mg of methadone 4 times a day be too high of a starting dose for pain, given to a person for fibromyalgia, person also has emphysema, copd and pnuemonia, (changing from lortab to methadone) also taking xanax, soma, ambien, geodon, ritalin, bumex, advair, nexium and zithromax for pnuemonia? shouldn't methadone dose be lower? and person monitored because of copd, emphysema, pnuemonia and the other drugs they are taking? you opinion would be greatly appreciated

Thank you
Terry
Answer -
Usually the answer here would be yes.    This is a very large dose to start with for pain management.

However,  the mystery here lies in the details that are missing.    Since this is a replacement for Lortab the inference is that there has been a long standing use of narcotic analgesics already.    And typically this leads to tolerance,  dependence,  and a difficult time in tapering down.     The longer the duration of use and the higher the dosage only compounds this problem.    And in cases where there is poly-pharmacy it can lead to an increased metabolism of various other agents.    Or at least increasing the threshold for tolerance.

It would be imperative to find out what the history is here.   Including the doses used of each agent.   Before I can readily and accurately render an opinion.    I have many cases where the methadone dose is this high in pain management.    Even higher in some cases.    Admittedly these are mostly cases of very profound drug abuse over years and years complicated by the presence of some very real pain syndromes.

You also have not given me any other information,   such as the age of the patient in question.    Please consider providing me with as much background as possible.

FOLLOWUP: THE PATIENT IS A 53 YR OLD FEMALE 120 LBS. SHE HAS BEEN TAKING THE LORTAB 7.5MG TWO QID FOR APPROXIMATELY 3 YEARS (OCCASSIONALLY SWITCHING TO OTHER PAIN MEDS THAT DIDN'T HELP) XANAX 2MG - 4MG QID FOR APPROXIMATLEY 4 YEARS, AMBIEN 10 - 20 MG. HS FOR APPROXIMATELY 4 YRS, SOMA QID APPROXIMATELY 2 YEARS, GEODON 40 MG BID, APPROXIMATELY 1 YEAR, RITALIN 20 MG TID TO QID APPROXIMATELY 1 YEAR - FOR THE PAST 2 YEARS SHE HAS BEEN HOSPITALIZED WITH PNUEMONIA TWO - THREE TIMES A YEAR AND WAS DIAGNOSED WITH EMPYSEMA, COPD APPROXIMATELY 5 YEARS AGO. IT SEEMS TO ME THERE SHOULD BE MORE MEDS FOR THE EMPHYSEMA AND COPD - HERE'S WHOLE LIST OF MEDS LORTAB 7.5 MG TWO QID, XANAX 2 - 4MG QID, AMBIEN 10-20 MG QID, SOMA QID, PREMARIN 1.25 MG QD, ADVARI 200/50 BID, BUMEX 2 MG ON PRN BASIS, GEODON 40MG BID, RITALIN 20 MG TID TO QID, NEXIUM 40 MG QD, HAS BEEN TREATED BY THE SAME DOCTOR FOR 5 YEARS - THIS IS MY SISTER AND I AM CONCERNED ABOUT THE POLYPHARMACY THING. I KNOW SHE IS IN PAIN BUT I AM REALLY WORRIED ABOUT HER STARTING THE METHADONE AT 40 MG 4 TIMES A DAY - FROM WHAT I HAVE READ ABOUT THE METHADONE IT COULD BE DEADLY ESPECAILLY WITH THE OTHER MEDS SHE IS TAKING ALONG WITH THE COMPLICATIONS OF EMPHYSEMA, COPD AND PNUEMONIA. I HAVE TRIED TALKING HER INTO GOING TO ANOTHER DOCTOR, BUT IN HER MIND (AFTER TAKING ALL THESE MEDS FOR SO LONG) THIS DOCTOR IS DOING ALL HE CAN. A YEAR AGO SHE WAS ADMITTED TO THE HOSPITAL WITH PNUEMONIA AND XANAX WITHDRAWALS - AS SOON AS SHE WAS RELEASED FROM THE HOSPITAL HER DOCTOR PUT HER RIGHT BACK ON IT. I THINK HE JUST LIKES WRITTING PRESCRIPTIONS. YOUR OPINION AND ANY INFORMATION WILL BE GREATLY APPRECIATED.
THANKS
TERRY

Answer
I agree with you that this case is complicated and a veritable pharmacological stew.     The list includes several agents widely known to be both potent in CNS activity and also prone to dependencies.     Since she has been on many of these drugs for such a long period of time and at healthy dosages she will be very susceptible to withdrawals if she ever hopes to eliminate any of them.    

Your concern for her condition and her health does not appear to be readily accepted by her own opinion.    As long as she is in this co-dependent style relationship with her physician there is little chance of breaking the pattern.     By your report everyone seems to be satisfied with the status quo.   Unless at least one of the two,   patient or physician,   desires the situation to change it will be your solo uphill battle to make a difference.

It is far beyond my position to comment on this with regard to appropriateness of treatment.    Too much lies within the patient-physician relationship over time that I am not aware of therefore cannot speak to it.     It is true that her dosages are high but perhaps they have to be as she has built a huge tolerance.    Treatment of her COPD and emphysema should be a priority,  yes,  but unless her condition is clinically out of control then her regimen is fine.    Her medications indicate more of a DSM-IV battery of diagnoses,  with intense focus on Axis I and maybe Axis II and little interest at all in Axis III.    

My suggestions to you are first to discuss this with your sister.    You must have her approvals before you can involve yourself with her case given the HIPAA environment.   If she concurs with you that she needs more care then you should,   with her approval,   consult with her physician.    Indicating your concerns and asking for some answers to them.    If that path is unable to produce the results you want then it is time for a second opinion.    Encourage her to see a consultant.    To see another clinician for some advice.

Remember though that should she require eventual detox from some of this excessive medication she will need to sincerely want this too in order to succeed.

Don't be afraid of methadone as a drug alone.    Nor the dose.    Although it is a large dose and a potent med it does not represent a serious threat to her health.   Beyond the obvious concerns of addictive potential that is.