Medications that induce (speed up or increase) or inhibit (slow down or decrease) metabolism of methadone do so by affecting one of these enzymes. Specific enzymes are responsible for methadone metabolism and can be affected by a number of medications.Short-acting opioids such as morphine, oxycodone or hydromorphone are beneficial when initiating methadone until a patient is on a stable dose. Methadone may cause excess accumulation if a patient is taking many breakthrough doses in addition to a scheduled regimen. Methadone is often not recommended as the breakthrough medication to complement a scheduled methadone regimen.CT is experiencing somatic pain (muscle aches and pain) and neuropathic pain (shooting). These actions make methadone ideal for patients experiencing different types of pain concomitantly. Methadone is active at mu-opioid and NMDA receptors and inhibits reuptake of serotonin and norepinephrine.Note: more frequent dose increases may result in adverse effects/overdose.Ĭase-specific recommendation of Methadone therapy and Nystatin suspension Assess, and Titrate dose if needed, after 5-7 days.Monitor for therapeutic effectiveness (pain severity rating, breakthrough doses used) and toxicity (increased sedation or confusion, difficulty arousing patient).Oral thrush therapy: Nystatin suspension Swish and swallow 5ml PO Q.I.D.Maintain current breakthrough regimen with Morphine concentrate with increased dose of 3ml (60mg) PO Q4H PRN Place order for Methadone 10mg tablet 1 tablet PO Q8H. New Dose and Interval: Using standard conversion table (provided below), 500mg/day of Morphine is equivalent to 33mg/day of Methadone, using a 15:1 conversion ratio.New Opioid Requested: Methadone tablets.Total Daily Usage of Current Opioids: Morphine PO 500mg/day that, until recently, controlled her pain well.Assessment: Uncontrolled pain, somatic and neuropathic in nature Oral thrush due to steroid use.Morphine 20mg/mL 1.5ml (30mg) PO Q4H PRN (~6 doses per day pain decreases from 8 to 5 rating on VAS after each breakthrough dose).What is your starting dose of methadone? Which antifungal do you recommend? Current pain medications: You decide to recommend methadone to better manage her pain and an antifungal course. You note that she was treated with fluconazole 2 months ago for a prior case of oral thrush. She has a history of asthma, exacerbated by her breast cancer and recently completed a 6-day steroid taper. She also has oral thrush that developed a few days ago. CT is a 72-year-old woman with metastatic breast cancer experiencing aching pain in her chest with shooting pains down her arm that have become increasingly uncontrolled over the past 2 weeks.
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