Methadone Steps Out of the Shadows to Manage Chronic Pain

Thomas Samuel, MD
Philadelphia, PA
tsamuel@temple.edu


Methadone is an opioid analgesic that has been used for more than 60 years in the treatment of chronic pain and opioid addiction. Methadone has developed a sordid reputation because of its association with opioid abuse. The mere mention of methadone often conjures images of shady back alleys and unkempt heroin abusers staggering in and out of smoky addiction clinics with little hope of recovery. Despite this perception, methadone has been used for many years quite effectively in the management of chronic cancer-related pain. This article will review some of its useful and clinically practical treatment indications, as well as discuss the pharmacologic characteristics of methadone, in the hopes of restoring its much-maligned reputation.

Unlike its cousin, morphine, methadone acts via several processes to induce analgesia. The affinity of methadone to block the mu and kappa pain receptors is similar to morphine; however, methadone has greater affinity than morphine to the delta pain receptor, inducing increased analgesia. Also unlike morphine, methadone blocks the N-methyl-D-aspartate receptor in the central nervous system (CNS) while inhibiting neuronal serotonin and norepinephrine re-uptake at the CNS receptor level. This peculiar action of methadone makes it an effective tool in treating somatic, visceral, and neuropathic pain. These combined actions of methadone to produce pain receptor blockade, NMDA blockade, and the up-regulation of CNS serotoninergic/noradrenergic pathways lead to synergistic pain relief via multiple mechanisms not employed by other opioids.

The pharmacology of methadone is somewhat complicated; yet, for those familiar with its use, its biologic effects can be used advantageously in multiple clinical situations. Methadone has greater oral bioavailability than morphine (80% versus 35%) and greater protein binding in tissues (high lipid solubility), allowing for an extended elimination phase (13–58 hours). Along with its rapid distribution phase (four hours), these pharmacodynamics allow for the use of methadone as both a long- and short-acting analgesic. Methadone is processed extensively in the liver and eliminated primarily fecally, although a small portion of its metabolites is eliminated via the kidneys. Dose adjustments are recommended only for patients with advanced hepatic disease.

The clinical uses of methadone are multiple and varied. It can be administered orally (via tablet or liquid formulation) or parenterally (either intramuscularly, by continuous subcutaneous infusion, or via IV). In opioid-naive patients, a recommended starting dose of 5 mg by mouth every six to eight hours for three days must be adjusted further to longer intervals of administration once peak plasma levels have been achieved. For patients who have been on other opioids, published data on conversions from morphine to methadone have described ratios of anywhere from 2.5:1 to 15:1. Any conversion from an opioid to methadone should be done carefully, with frequent follow-up to avoid side effects such as excess sedation. These conversions often are best conducted by pain specialists with experience in dose adjustments and resources available for close monitoring, especially in patients with high opioid tolerance. Side effects of methadone are similar to those found in other opioid analgesics, including generalized pruritus, sedation, constipation, urinary retention, and respiratory depression.

Why use methadone when an array of other opioids are available for use? Studies have shown that as many as 80% of patients with cancer-related pain may require a change in their opioid regimen because of unacceptable pain control or side effects. Switching opioids or opioid rotation is an effective method of improving pain control, reducing opioid toxicity, avoiding opioid tolerance, and allowing for improved methods of administration (e.g., transdermally versus orally.) Methadone is another opioid that can be used for rotation and has the additional benefits of both long- and short-acting effects as well as greater versatility in dealing with multiple etiologies of pain. Research also indicates that methadone may cause less tolerance and constipation compared to other opioids.

In short, methadone is a drug whose utility far outweighs its reputation and should be considered more often in the treatment of chronic pain. Although its pharmacology is complex, when administered and managed by pain physicians in cooperation with other physicians, it can be an effective tool to reduce cancer-related pain. The time has come to take methadone out of the shadows of heroin addiction clinics and into the light of modern medical clinical settings.

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Warning: Laughter Is Contagious

Elaine McCann-Jones,RN, OCN^®
Philadelphia, PA
mccann-jones@fccc.edu

A chuckle a day keeps the doctor away. Not only can laughter be fun, but it also has proven to be good for us mentally and physically. Norman Cousins, author of Anatomy of an Illness as Perceived by the Patient, raised questions about the mind’s power to heal. He asked, “If negative emotions produce negative chemical changes in the body, wouldn’t the positive emotions produce positive chemical changes?” They certainly can!

Laughter can help reduce stress; like crying, it is a form of catharsis. A steady dose of laughter that helps reduce stress can improve quality of life, thereby giving us a better sense of self-belonging and well-being. Our society places a high value on a good sense of humor and being able to relate to people.

Laughter can increase oxygen and circulation by causing a temporary increase in heart rate and blood pressure, allowing for the delivery of oxygen and nutrients to the entire body to promote healing. The immune system is able to produce new immune cells more quickly, helping the body fight off a variety of illnesses, such as colds, the flu, and cancer.

Most importantly, laughter releases chemicals in your brain called endorphins, the body’s natural pain killers. In addition, laughter is a form of distraction from pain. Humor has been used against pain since the 13th century, when surgeons used laughter as an anesthetic to distract patients from the pain of surgery.

Many hospitals and ambulatory care settings around the country support humor as a complementary therapy. Some have designated areas where humorous materials are available for patient use. Fox Chase Cancer Center in Philadelphia, PA, has a humor cart designed by the staff, a children’s hospital has clowns that visit the children, and a North Carolina hospital has developed a laughmobile that travels all over the institution. Some suggestions for humorous materials are funny movies; television shows such as “The Three Stooges,” “I Love Lucy,” and “Laurel and Hardy”; humorous songs; joke books; funny pages from the daily and Sunday newspapers; puzzles and games for all ages; yoyos; bubbles; play dough; silly string; water pistols; and silly hats, glasses, and socks. Most of these items are inexpensive, so multiple items can be available for several people at the same time. Use your imagination!

Because pain is an unpleasant experience and humor is a pleasant one, they obviously cannot occupy the same psychological space, leading us to accept the saying, “Laughter is the best medicine.” Even though fighting cancer and other serious illnesses is no laughing matter, instilling humor into the daily care plan helps patients laugh, allowing them to put aside their fears and discomforts if only for a short time. That may be all they need to make their day worthwhile.

If any of these signs are observed—eyes watering while laughing uncontrollably, snorting or hyena sounds, thigh slapping, smeared makeup, red face and sore cheeks, uncontrolled hiccups or difficulty catching breath while laughing wildly—don’t call the doctor!

Bibliography
Always Your Choice. (n.d.) Alternative pain relief. Retrieved January 16, 2003, from http://alwaysyourchoice.com/ayc/adult/community/alternative_pain.php

American Cancer Society. (2004). Humor therapy. Retrieved January 20, 2003, from http://www.cancer.org/docroot/ETO/content/ETO_5_3X_Humor_Therapy.asp?sitearea=ETO

Rx Laughter. (2002). The laughing cure. Retrieved January 20, 2003, from http://www.rxlaughter.org/press12.htm

Wild Iris Medical Education. (2003). Pain control at the bedside. Retrieved January 15, 2003, from http://www.nursingceu.com/NCEU/courses/painpb/index.htm  

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Message From the Coordinator
SIG Plans to Launch New Project; Ideas Wanted

Margaret Flood, RN, MS, AOCN^®
Marlborough, MA
floodpeg@verizon.net


Congress is now over. As usual, it was wonderful. I always feel rejuvenated when I return. I work in a small community hospital that has no other clinical specialists. When I go to Congress, I am able to network and give and receive the support I need.

I am happy to tell you that we now have 414 members, and at our SIG planning meeting, we discussed where we would like to go from here. A topic of conversation was the Pain Management SIG embarking on a project. We are looking for ideas. If you have an idea that you have wanted to try but have not been able to, let me know. Send your idea to me at floodpeg@verizon.net. It could be a program to educate the public or healthcare professionals to effectively manage pain. Whatever your idea, we want to hear from you. Let’s work together to help our SIG grow, a SIG that everyone will want to belong to. Working together, we will help our mission to improve the quality of managing pain.

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Take Control of Opioid-Induced Nausea

Monica Domenick, RN, BSN, OCN^®
Philadelphia, PA
monica.domenick@fccc.edu

Ann Pellegrino, MSN, CRNP, OCN^®
Philadelphia, PA
a_pellegrino@fccu.edu


Nausea is a common side effect of narcotic analgesia. It can occur with the initiation of pain medication, an increase in pain medication, or sudden withdrawal of pain medication. The incidence of nausea in patients taking oral morphine ranges from 10%–40% (McGuire, Yarbro, & Ferrell, 1996). Nausea usually subsides in a couple of days; however, a small percentage of patients continue to experience it.

Opioids can cause nausea by stimulating the chemoreceptor trigger zone. Patients can have nausea or vomiting shortly after taking an opioid. Antiemetics such as ondansetron, prochlorperazine, dexamethasone, and haloperidol can be used to control nausea. Some patients may experience vestibular sensitivity. When this occurs, patients will have nausea or vertigo with movement. In this patient population, scopolamine, dimenhydrinate, and meclizine are good choices for control of nausea. Opioids increase gastric tone, which can cause bloating, early satiety, nausea, and vomiting. Medications that increase gastric motility, such as metoclopramide, work well in this group of patients. Benzodiazepines (e.g., lorazepam) are not true antiemetics but may be useful as adjuncts to antiemetic medications. The most common cause of nausea in these patients stems from opioid-induced constipation. Treating constipation aggressively is important.

Management

• Assess and treat other causes of nausea and vomiting, such as elevated digoxin level, uremia, hypercalcemia, and bowel obstruction.
• Provide a prescription for an antiemetic.
• Consider antiemetics with different mechanisms of action.
• Prophylactic use of antiemetics is not recommended secondary to sedating side effects.
• Try adding a coanalgesic, such as a nonsteroidal anti-inflammatory drug or antidepressant, to lower opioid requirement.
• If pain control is achieved, try decreasing the dose of opioid by 25%.
• If nausea persists, try a different opioid or a different route of administration.
  Occasionally, patients may require around-the-clock doses of antiemetics for persistent nausea.

Pain Management SIG Welcomes 87 New Members

The Pain Management SIG is happy to have the following people join its ranks.

Jean Adelhardt, RN, New York, NY
Gisela Aguilo, RN, Amherst, NH
Nancy Allen, RNC, Palmyra, PA
Leona Anderson, RN, BSN, Ellenwood, GA
Elise Beanman, RN, OCN^®, Palo Alto, CA
Katherine Beebie, ASN, RN, Philadelphia, PA
Catherine Bethel, RN, Convington, LA
Rita Bickels, RN, OCN^®, Ormond Beach, FL
Christine Bradish, RN, Toledo, OH
Susan Brennan, RN, MSN, CS, Lansing, MI
Barry Brinegar, RN, Lexington, KY
Margaret Brock, RN, FNP, Millwood, NY
Angela Carchidi, BSN, West Haven, CT
Anne Coleman, RN, Springfield, OR
Carol Creighton-Jones, RN, OCN^®, Orlando, FL
Susan Dodd, RN, McLean, VA
Susan Drossulis, RN, OCN^®, Sparks, NV
Cynthia Duprey, RN, Manchester, CT
Donna Earles, MN, APRN, BC, River Ridge, LA
Sara Eckert, RN, Cynthiana, KY
Alison Edwards, RN, Smithfield, PA
Laura Esposito, RN, Matthews, NC
Teresa Fisher, Billings, MT
Kathi Gardner, RN, Lodi, CA
Stephanie Gilbertson-White, Madison, WI
Leslie Gilley, RN, Big Stone Gap, VA
Kathleen Gilliam, RN, MSN, CNS, Melbourne Beach, FL
Sherry Goode-Barry, RN, MS, ANP, Munds Park, AZ
Jennifer Graff, RN, OCN^®, CHPN, Midlothian, VA
Kathleen Haley, MSN, CRNP, AOCN^®, San Diego, CA
Pamela Hanks, RN, BSN, OCN^®, Las Vegas, NV
Marlina Hein, RN, Poulsbo, WA
Nancy Hesch, RN, BSN, Cranberry Township, PA
Susheela Hutchinson, RN, Chicago, IL
Julie Isaacson, MSN, NP, OCN^®, Denver, CO
Esther Jacobs, MSN, PhD, Skokie, IL
Karen Jones, RN, BSN, Garland, TX
Catherine Kelly, RN, OCN^®, Jamestown, CA
Kathleen Kelly, RN, BSN, OCN^®, Reston, VA
Mary Kern, Pittsburgh, PA
Linda Kisby, RN, Egg Harbor Township, NJ
Julie Krieger, RN, BSN, MHA, C, San Ramon, CA
Susan Lake, RN, OCN^®, West Grove, PA
Rose Leblanc, RN, Fallson, MD
Paula L’Heureux, Dracut, MA
Sonja Loadholt, Rialto, CA
Kelly Long, RN, Billings, MT
Natalie Mandolfo, MSN, APRN, AOCN^®, Grand Island, NE
Sue Marcotte, RN, Chicago, IL
Donna Marsden, RN, OCN^®, Westport, MA
Loretta Matters, RN, C, MSN, ANP, Durham, NC
Judy McDonald, RN, Mesa, AZ
Ruth Messer, RN, BSN, OCN^®, Lowell, MA
Minty Mihdawi, RN, OCN^®, Gainesville, GA
Carol Miller, RN, BSN, OCN^®, Germantown, WI
Kathleen Murphy-Ende, RN, PhD, AOCN^®, Verona, WI
Anne Myles, RN, Hollywood, FL
Susan Nelson, RN, Sioux Fall, SD
Melanie Nittinger, RN, BSN, OCN^®, Gillett, PA
Rachel Ona, RN, MA, OCN^®, ASN, South Plainfield, NJ
Diane Ono, Santa Rosa, CA
Sharon Overath, RN, Hurst, TX
Aurora Pajarillo, RN, Syracuse, NY
Alicia Palma, RN, Dallas, TX
Patricia Perry, RN, BSN, OCN^®, Pasadena, CA
Constance Phipps, RN, OCN^®, Shawnee, KS
Vicky Probasco, RN, III, Buhl, ID
Emmanuel Punzalan, RN, Carson, CA
Bridget Rae, RN, BSN, ONC, Chicago, IL
Marilyn Riley, RN, OCN^®, Philadelphia, PA
Debra Rogers, RN, Santa Barbara, CA
Maria Rosenfield, RN, Largo, FL
Elizabeth Ryan, Staten Island, NY
Jeannine Schneider, RN, BSN, OCN^®, Las Cruces, NM
Lori Shockey, Forest Grove, OR
Kathy Sokola, RN, MS, Newark, DE
Christine Strackbein, RN, OCN^®, Sussex, WI
Consuelo Viana, RN, OCN^®, Los Angeles, CA
Maxine Waits, RN, Lena, LA
Lynn Walker, RN, Orlando, FL
Carol Wallace, RN, Centerville, VA
Lina Wen, RN, New Orleans, LA
Elizabeth Wineland, RN, Washington, IL
Emma Wittstein, RN, MSN, Fairfield, CT
Elisabeth Wolfe, PhD, RN, AOCN^®, Toledo, OH
Ann Woodworth, RN, BSN, Corpus Christi, TX
Carolyn Wulf, Boca Raton, FL

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Help Your Patients Beat Their Pain With Preoperative Education

Elaine Sein, RN, BSN, OCN^®
Cheltenham, PA
Elaine.Sein@fccc.edu 

Kathy Groh, RN, OCN^®
Medford, NJ
k_groh@fccc.edu


Caring for patients in surgical oncology requires a broad knowledge base, clinical expertise, and compassion. Patients and families often struggle with a new diagnosis and the need for major surgery. Nurses caring for these patients must assess their understanding of the diagnosis and proposed surgery. One major component of preoperative education is postoperative pain management. Physicians and nurses in the outpatient department introduce this concept. Nurses in preadmission testing follow through with full assessment of patients’ understanding of proposed surgical procedures and their perceptions of postoperative pain. This discussion sets the stage for preoperative teaching.

Surgical procedures can be as simple as an excisional breast biopsy or as major as a Whipple procedure for pancreatic cancer. Therefore, instructions should be tailored to meet the needs of each patient. During preadmission testing visits, nurses give patients and families an avenue to discuss concerns. Patients are encouraged strongly to bring a family member to the preadmission testing visit. Family members help to reinforce information given to the patients and often provide feedback needed to enhance the educational session. Nurses review the type of discomfort the patients may experience following procedures, as well as the methods and medications available to provide adequate relief. This can range from acetaminophen and positioning techniques to the use of an epidural catheter for continuous pain relief. Patients need to know that they have a right to good pain control. They also need to know that they must be active participants in their care and keep their caregivers aware of discomfort or pain. This enhances postoperative outcomes as far as comfort and leads to patient satisfaction.

All individuals have different pain tolerance levels; nurses need to be sensitive to each patient’s individual needs. Patients should be taught that no one should suffer with unnecessary pain. Many people are fearful of taking drugs, especially opioids, and delay asking for medication until their pain is severe. This results from the many myths associated with opioids. Addiction is one myth. Patients need to be reassured that they will not become addicted with short-term use of pain medication.

Another issue that comes up often in conversation with patients is allergy versus sensitivity to drugs. Patients need to understand that some symptoms they experience with pain medications will disappear after a few doses. A concern also exists about why morphine is the drug used most often after major surgery. Many people still associate morphine with end-of-life care. Nurses must explain the need to use morphine or related opioids for the short term to facilitate recovery. Morphine is the opioid used first line because of the ease in titration and conversion it offers. Nurses doing preoperative teaching also should reinforce the importance of asking for pain medicine as soon as pain begins so that it does not get a grip on patients. If patients wait until pain is severe, they will need more medicine for longer periods of time.

Many surgical oncology procedures such as major abdominal, thoracic, and head and neck procedures require more advanced methods of pain control. Patient-controlled analgesia (PCA) and patient-controlled epidural analgesia (PCEA) pumps for postoperative pain control are in the mainstream. If patients have PCA or a PCEA pump, they need an explanation for the rationale for using these methods. Many people are fearful of having a catheter threaded into their spine. The attending physician, nurse, and anesthesiologist must allay these fears with concrete explanations and time for questions. Patients with cancer are overwhelmed with new information and cannot assimilate all verbal information. Therefore, postoperative pain management educational material should be available to patients to take home for review and reinforcement. Patient education also should include information on the use of laxatives to prevent constipation.

Medication is not the only method of providing comfort postoperatively. Patients can get pain relief from changing position, as well as from splinting incisions when getting in and out of bed. Other modalities include stress reducers such as deep breathing, music therapy, humor therapy, and just having someone take the time to sit with them and talk about their feelings.

Oncology nursing is a specialty in which nurses are up to the task of supporting and educating patients to make their surgical experiences and outcomes as therapeutic as possible.

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Message From the Editor
SIG Searchers for Coeditor

Jerome Koss, RN, OCN^®
Philadelphia, PA
j_koss@fccc.edu


I have to announce three things.

I have become the Web administrator of the Pain Management SIG’s Virtual Community page. I hope that I do a good job. Your comments are welcome. Please, please send them.

In consideration of this new role, I am looking for a coeditor. Serving as an editor is a great experience. Not to exclude anyone from the Philadelphia area, but having a member from another part of the country would be interesting. I know that this SIG has members in Alaska and Hawaii. I also do not want to forget our members in Japan, Brazil, Israel, Ontario, Manitoba, the United Kingdom, and the military. I apologize if I missed any place. If you are not interested in serving as coeditor, I still always look for interesting articles. I hope that what you find in the newsletter is interesting to you. I need your ideas to make it the best it can be.

Lastly, I want to mention that Jeannine Brant, RN, MS, AOCN^®, Kyle-Anne Hoyer, RN, BSN, MSN, AOCN^®, and I will be talking about pain management side effects at this year’s Institutes of Learning. Don’t miss it. If anyone has a similar announcement, please let me know. Our membership is interested.

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Pain Management SIG Officers

Coordinator Margaret Flood, RN, MS, AOCN® 48 Robinhood Rd. Marlborough, MA 01752-2722 508-485-7774 (H) 208-460-5054 (fax) floodpeg@verizon.net Coordinator-Elect Josephine Hawkins, RN, MSN, AOCN® 10139 Saffron Dr. Saint Louis, MO 63136-2011 314-869-1758 (H) 314-454-8934 (O) 314-454-7151 (fax) jeh9309@bjc.org

Editor Jerome Koss, RN, OCN® 527 S. 17th St. Philadelphia, PA 19146-1557 215-546-1623 (H) 215-728-7411 (O) 215-728-4766 (fax) j_koss@fccc.edu ONS Publishing Division Staff Keightley Amen, BA Copy Editor 412-859-6258 kamen@ons.org

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