posted 10-09-2003 08:42 PM            

There is a big difference between the two meds. Oxycodone by nature is a short acting narc. It has a half life of 3-4 hrs at the most. Methadone on the other hand has a half life of up to 70hrs. It does take awhile to build up in the system. I'm attempting to reply to both of your posts. It does take time to start to work. Say you took a total of 10 mgs yesterday. Even tho the pain relieveing effects have some what lessoned you still have that amount of med in your blood stream. So you take 10 mgs today and now you have 20 mgs in the system. There are some side effects with this drug in the beginning. However those should subside with in the first couple of weeks. Do take this med slowly. You are on a very low dose but an apropriate dose at that. To help with the side effects. i always tell peolpe to devide the doses in to 4 threu out the day. So try breraking the 5mgs in half and try that. Methadone has been a life saver for me and others on this board. I am kind of surprised that your doc didn't try other long acting preps first but each Doc is different. I hope that you have great pain relief from it. Take good care and if I can be of further assistance just ask...

posted 10-10-2003 08:34 AM            

Alot of Docs like to try the Oxy meds and morphine meds first is all. Methadone is a considered a second line med because of the long acting nature of this med. It can be hard to titrate properly and it seems to have more side effects than the others in the begtinning is all. I do hope that it helps you like it has me. If I can help futher please let me know.....

posted 10-11-2003 09:37 PM            

Even though there is some market amongst opiate users who need it to help with withdrawl, you don't get high on methadone.

posted 10-11-2003 09:51 PM            

Its true that with methadone there is less of the euphoric feelings than with other meds. However there has been alot of concern about diversion with this med. You can still abuse methadone and the results are most often deadly because of methadones long acting nature. Those that are opiate niave especialy. Because of addicts that chase the high methadone still has alot of sedating propertys. Unfortunately because those effects kick in later it most always is to late because of the addict taking more of the meds to get the euphoric feeling. And methadone taken IV route which I'm sure some addicts have done acts very much like all the other opiates in all ways including the euphoric effect. Don't be fooled about this med. Most docs still don't understand the potency and strength of this med. IV methadone also only lasts about 3-4 hours like the others. Only in the oral route does methadone get stored in the liver and builds up for later use. Again the scheduling of this med as class 2 is very appropriate.....

posted 10-11-2003 10:01 PM            

I just got back from a primary care conference where they were pushing methadone big time due to its advantages over what's out there now -- lower abuse potential, lower cost, and "more informed" abuser. IE, those likely to be responsible for diversion are more likely to know how what the h*ll they are doing. (I know this is an offly weird way of looking at it). I am not at all arguing that it should be schedule II.

posted 10-11-2003 10:18 PM            

Please forgive me. I'm diffenately not trying to argue at all. I believe that this med is underpersrcibed. And I find it great that it has finally been more accepted as the great pain med that it is. That is what it was made for pain that is. Being that it is a true longacting med and all. And because it has less euphoric effects than other meds. The main reason I believe it should be Rxed more is for its multiple recptors that it attachs to and all. And that it is the only opiate that has any effect on nerve pain. I do agree with you on alot of pionts. My warnings are valid because in this little community of IdahoFalls that I live "only 50,000. people" that last year alone 11 people accidently died of methadone overdose. To me that is alarming. Anyhow take good care and it's good to have you here and welcome if I haven't said it to you earlier rubinj. Just alittle curious as to the meaning of your name. Oh well....

posted 10-11-2003 11:37 PM            

"I'm not at all arguing that it SHOULDN'T be schedule II" IMHO methadone should be S II.

posted 10-12-2003 12:04 AM            

Nice to make your aquantance Daniel. I have a brother that is a doctor. I hope that you make it thru residency. According to my brother is was a real B@@$@#. If you know what I mean. Again nice to have you here. I'm looking forward to learning and sharing as much as possible. Take good care....

posted 10-13-2003 02:02 AM            

The drug will take 1-2 weeks to adjust too, just give it a little time and try to hang in there. As for your Vicoden, the Methadone is taking up some of your morphine receptors so there are fewer for it to attach too.

I know this is a tough drug to get adjusted too, and doesn't give the instant relief that other's do, but it is one of the few chronic drugs out there that provides very powerful pain relief once your stable.

posted 10-13-2003 01:59 PM            

Hey Rosebud, It doesn't continuously build up in your system, After 4-6 days you will reach steady serum levels and at that point you can determine your need for an increase.

I think you just misunderstood what Matt and others have described as build up. Meth will reach a steady level given a steady dose in about a week. It does not continue to build up higher and higher the longer you use it. Some docs are more conservative about meth increases but the determining factor is partly based of your previous exposure to potent opiates and your reaction to the medication and allowing enough time to reach a steady serum level before increasing the dose.

Meds with short half life's can be very unforgiving, If you miss a dose of OxyC by more than a few hours the initial phases of withdrawal will begin. But you can also escalate a dose of oxy much quicker because you don't have that residual amount of oxy staying with you for days after your last dose.

With meth because it takes so long to be eliminated you won't even begin to feel nasty until half your serum level has depleted. This could take anywhere from 20-72 hours, making it a much more forgiving medication as far as missing a dose or being late for a dose.

It also acts on receptors that others opiates don't. The NMDA receptor is not a true opiate receptor but has a link to tolerance and perceived pain. Meth blocks this receptor from other meds binding to and stimulating it. Meds that bind to this receptor are believed to cause hyperalgesia=increased pain and rapid tolerance. Blocking the receptor increases ones tolerance to pain and slows tolerance to the medication.

Many new meds are being formulated with NMDA blocking drugs to give meds like morphine some of the beneficial properties of methadone.

Normal short half life drugs can be increased much more rapidly than methadone and the answer to a slow titration process would be to have BT meds available until you have titrated methadone completely.

Meth may prevent the euphoric effects of other opiates but it does not prevent the analgesic effects of these other BT meds.

It's just the folks that relate euphoria to pain relief or their BT meds is grossly disproportionate to their base dose of meth that think their BT med no longer works while taking methadone.

I've read about the rapid increase in methadone overdoses in the last few years and I think it's due to a misconception that no amount of meth will create euphoria. That's just not true. If you take enough "more than your used too" and continue to escalate your dose you will receive some euphoric effects, It's the rapid increases self medicating patients do to find that same euphoric feeling that causes overdoses.

This theory can be applied to any drug or alcohol. Say someone's first time use of crack gives them the most tremendous euphoria from a relatively small piece of crack, At the end of a 3 day binge those pieces are 5 times the size and still don't replicate the euphoria that the initial dose gave.

This is what happens with meth. They are on a stable dose that helps their pain but gives them no warm fuzzy feeling so they increase their daily dose to find that feeling again. The first day they aren't adversely effected leading them to believe that it can be rapidly increased safely.

So the next day they double their dose again and it's not quite as great as the day before, so they increase it even more. Now someone has tripled what they were used to in 3 days and have the residual half-life in their system. The next dose, even if no larger then the previous dose, when combined with the residual from the previous days is what pushes them over the edge.

Accommodation to euphoria occurs long before accommodation to the respiratory suppressive action of opiates setting them up for an OD. A single dose of Narcan will not reverse all the methadone in their system, It may bring them around enough to leave the ER AMA.

When the narcotic antagonist wears off in 2-3 hours the level of methadone escalates right back to wear it was. Overdoses of methadone require monitoring beyond a single dose of narcan. They would most likely need several repeated doses or a drip of an opiate antagonist.The same holds true to the 24 hour meds or patch. After removing a patch you continue to absorb Fentanyl transdermally for up to 17 hours.

However people that OD often don't tell the truth about their daily use or the amount that turned them blue and brought them to the ER. The addict can sign himself out AMA once he appears normal. When the Narcan wears off 2-3 hours later the meth kicks back in and starts building back up to where it was prior to that one dose of an opiate antagonist. Respiratory suppression kicks back in and they are in the same position as they were when they were first admitted to the ER.

Because of the myth that Methadone can't be abused, docs think a patient that abuses oxy won't abuse meth. IMO, If they are abusing oxy, meth is an extremely dangerous drug to give a months supply to a patient with a history of non compliance. If they couldn't comply with med instructions on the Oxy why would a doc believe they would comply with methadone instructions which are even more important to follow?

This is why meth maint. clinics don't provide their patients with the same supply a CP patient would receive.

I'm sorry, I just don't agree with Rubin that you can't get high on meth. If you double your standard dose you are acomadated to you will sweat and become warm and fuzzy and nod out just like on Heroin.

This misinformation is why the death rate has climbed drastically in the last few years. Someone new to meth for PM wants info and goes to an addiction forum to get the scoop and hear how patients on MM don't get high and it just deminishes their withdrawal symptoms.

When MM is done properly this is true but they don't have the freedom to not comply with the instruction and can't double their dose to obtain a buzz, It doesn't mean it's not possible though.

Using Methadone to treat addiction is very different from using meth to treat pain. Doses are monitored and limited where pain patients have acces to a months supply at a time and dose much more frequently.

A MM patient may tell you it lasts 24 hours and using it more often doesn't make sense. He's actually telling you that dosing for meth maint every 24 hours is enough to prevent withdrawal but that has nothing to do with anelgesia.

On a cancer ward meth is dosed every 3-4 hours and for CP every 6-8 hours. I still feel a decrease in pain relief after 4 hours.

Hey Rubin, WE don't have to agree on everything. Perhaps telling people that no matter how much meth they take they won't get high is actually a good thing. Perhaps the knowledge that this isn't true and spreading that knowledge may lead someone looking to abuse meth right down that path.

However I have faith in the true CPer and know the statistics and odds of a true pain patient continuing to use opiates for addictive reasons rather than out of desperation for pain relief.

MM patients use it out of desperation to return to a normal life free from having to ingest something every 4-8 hours to prevent withdrawal.
I have an ample amount of fear and respect for both types of patient and the medication.
Take care, Shore

PS. To answer the initial question , what's the difference. Well.. they are both synthetic opiates, they both have the same side effect profile, OxyC is about 10X more expensive and methadone binds to the NMDA receptor and Oxy doesn't. Meth is much more forgiving if you are late for a dose. It works better on nerve pain but is more sedating than oxy. Those are the main differences that come to mind.

posted 10-13-2003 08:03 PM            

Thanks for your great response.

I promise you that I have a lot to learn, and will continue to do so. My knowledge in this area (or lack thereof), comes realitively recently, and has not been tempered with much personal experience. Please continue to provide responses!

posted 10-14-2003 02:40 PM            

I know you can't believe everything you read on the net but the info about medical schools and pain management training in general is that med students receive less than 3 credit hours in their entire education regarding the use of opiates. Obviously the professor's or Chief resident's are going to pass their beliefs on to the students they train and encounter.

I guess my question is, have they changed the medical curriculum to give pain management training the time that is truly needed or is the old school thought of opiates still pervasive? If your thnking of PM as a specialty, Anesthesiology would likely make you a more rounded specialist in the pain management field.

Some people respond well to ESI's, trigger point injections, RFA nerve ablation and with a fellowshp in general surgery you would have the ability to implant and manage IT pumps for the folks that don't respond to other forms of treatmnent.IMO I guess I'm just impressed with the multiple specialties my PM docs hold and put to use, making their opractice a full service practice where people aren't turned away because a patient has already had a negative experience with the one or two methods of pain management a doc on his own may offer.

I would trust an anesthesiologist a whole lot more with a needle in my spine than I would a DO or physiatrist. Basically because of the experience they likely already have in the OB field and knowledge of pharmacology.

After my 3rd failed lumbar fusion I waited 8 weeks to see the Physical medicine/PM professor at our local medical school. I spent about a half hour with a resident and then the professor came in and looked at my chart and the first thing out of her mouth was "we don't treat chronic pain with opiates here" She told me that she didn't believe there was a modality she could offer that I hadn't already pursued and that I would just have to learn to live with it.

More like die with it but there is no doubt in my mind that every physical medicine/pain management doc that comes through her program will have the exact same views as their mentor. That's scary.

If you decide to go into another specialty which I understand there are plenty of reasons for deciding which specialty you wish to practice. I hope things have changed in school with the latest regulations regarding treating pain.

posted 10-15-2003 12:18 AM            

I have become interested in the last few weeks in this area as I have just finished serving my first rotation in a rural area with a family physician, with one PM doc total in the area, and he has a 15 month waiting list. In addition, I recently attended the National Covention of the American Academay of Family Physicians, where I attended a fair amout of continuing education on the subject of PM. I am fortunate to not yet suffer from some of the maladies that ya'll have, but I do have some friends on other boards, and we do have some medications in common (Topomax). FYI: The AAFP is where most of my Methadone info came from.

posted 10-15-2003 08:29 AM            

It was my understanding that DO's are trained to treat the patient from the whole body perspective instead of just the one area that is the problem. Correct me if I am wrong. I have been to DO's in the past and your right they do treat patients in about the same way as regular mds. I was a little interested in that we at Idaho State University are getting a DO program here in the next few years. Any how just thought I would ask to clarify the difference in the training..

posted 10-15-2003 12:34 PM            

There is a right way and a wrong way to move from meth to other meds. Although you did not receive the relief that you hoped from meth it still has properties that have proven to enhance it's effectiveness in treating neuro pain. But of course not everyone responds the same especially if the side effects of the medication become unbearable.

As far as DO's, I also understand they are just as qualified as any MD or GP although my understanding is that they approach things in the way Matt described, as a whole body problem incorporating homeopathic methods for treating any illness whether it concentrates on nutrition, mechanical adjustments much like a chiropractor, or herbal medicines or mental health.

The needle guy at my PM practice is a DO/anesthesiologist that did a fellowship in general surgery and was trained by Medtronic's to do the IT pump implants and management of the pumps. My medication management doc is Board certified as a psychiatrist and Neurologist. Docs with multiple specialties just have more to bring to the table.

IF my needle doc was a DO alone I doubt I would have the confidence in his needle work that I would with an anesthesiologist. Just as some people will respond to a specific medication better than others some people may respond well to homeopathic treatment.

The key to obtaining better pain management is really having more than one method of pain management to rely on. I've been taught so many different methods of rellaxation, yoga, hypnosis, biofeedback, stretching ... just about every non opiate method they could think of and I save the stuff that works for me and toss out the rest. But this does leave me with more than medication to handle daily pain and flares.

I kind of look at docs with multiple specialties as having a few more tricks "in there little black bag" should one specific modality not be effective. IF a DO came through a residency and his mentor was hog bent on nutrition being the cause of all illness then He really can't offer a patient anymore than say a nutritionist could although he would have the training and ability to prescribe or treat pain just as any GP or anesthesiologist would. So it goes back to what were the views of his mentors and what was he taught in school. Any doc can go into the pain management arena and claim to be a PM doc.

What actually makes them a PM doc is the real question and what do they have to offer patients that don't respond to relaxation and antidepressants.

Any specialty or even family medicine has the ability to treat pain, it's just a matter of are they comfortable and trained well enough to handle the harder cases to manage and can they offer more than simple medication maint.

Every doc has the power to ease suffering, it's just a matter of their beliefs and willingness to cross into a specialty that may bring more scrutiny upon their prescribing practices.

A doc that never prescribes opiates will never be visited by the DEA or get that call from the pharmacist about their patient or be called upon by the board of pharmacy. Many have a philosophy of better safe than sorry as far as covering their own butt.

I've seen docs that claim to be advanced pain interventionists that wouldn't prescribe a T3. However they know which doctors in the area will treat pain aggressively and will refer patients they believe have no other choice than opiates. Simply because they don't want to be the one under scrutiny for treating pain aggressively with meds that draw attention to their practice.

So a DO does have the ability to treat the toughest cases and may even be able to offer adjunctive therapies to help manage their pain. It comes down to however hard you try you can't slam every square peg into a round whole regardless of how hard you hammer. I spent almost 18 months with the advanced pain management group and all their intervention. The only thing I took away from that experience was the ability to relax which helps with BT pain.

Teaching relaxation techniques may be useful but nobody can live out their life in an altered state of mind in a deeply relaxed state. You don't get much done sitting in a yoga position humming.LOL

I think we have all seen examples of mind body control on the TV where someone can pierce their skin with large gage needles and not shed a drop of blood or compact their body into an 18"x18"' box, but even people with this great ability can't function in the real world such as a workplace when in that deep state of relaxation and mind/body control.
I can see it now, John, get out of that box and stop humming and get some work done and take those needles out your face before you see your next apt.LOL

It's a neat trick and an amazing ability but just because it can be done doesn't mean it's the answer for all pain issues. Opiate phobic docs rely on these methods to control pain and it's just not practical unless you want to live out your life in a floatation tank and doesn't work on every patient.

Good luck with whatever specialty you decide on and for Jiggy, don't worry that the med that was supposed to work better on neuro pain didn't for you.

There are other meds on the horizon and other modalities to try. Morphine can be given the same NMDA blocking ability simply by adding OTC dextromathorphan. There is a new gel cap on the market called Dexalone which is a pure dextro capsule and adds the same site blocking ability that meth has. Neuro pain is the hardest pain to treat and just doesn't respond as well to opiates as say mechanical pain.

I'm not suggesting that opiates shouldn't be used on Neuro pain but you have to be open to other modalities or other meds that are being used for off label purposes such as the anti seizure meds.

If Neurontin doesn't help, then you try Toppamax, if that doesn't work there is Dilantin, Lamictyl, Klonopin, and the whole class of meds used for seizures that seem to help with burning nerve pain. Finding the right anti seizure med that helps with neuro pain is as much trial and error as finding the right opiate or modality to use in conjunction to treat pain.

posted 10-15-2003 02:34 PM            

Shoreline I agree with you 100 percent. I do alot of different things to help alieveate my pain. Stretching 3-4 times a day. I also use a RS medical stimulator. Its like a tens unit except better. It has two cycles. One for nerve pain the other for muscle pain. It takes a 45 minutes to complete both cycles and I use it 2-3 times a day. i also have trigger piont injevtions done 3 times a week. And I take MSM and Condrotin and glucosimine and elavil,soma,bextra, besides the pain meds methadone,oxyir and dilaudid. I still have ESI's done 2-3 times a year. I never had nothing but bad side effects with the anti siezure meds so they are out. Like Shoreline side everyone is different and responds different to all the pain relieving methods out there and there is nothing but more coming into the market. Jiggy it's unfortunate that you had such a bad experience with methadone. I ask did your doctor do a taper at all or did you come off of methadone cold turkey. If cold turkey shame on the Doc for making you endure such an event. I do hope that you find the relief that you deserve. And welcome to the boards by the way. Take good care .....

posted 10-15-2003 04:10 PM            

A quick background:

Bachelor Degree - (can be in anything, mine is in Managerial Finance; however, you do have to have certain science and math requirements.

Medical Degree - (can be either a MD or DO). Traditionally, MD's learned science and how to treat a disease or system. DOs learned how to treat a "case" or person. Many MD programs (like mine) have moved toward the DO model in the last 20 years, while DO programs have adopted DO many of the first 2 years of the MD programs. DO's also learn osteopathic manipulation (which some use, many don't)

Internship - Often integrated as part of the residency now, but still can be done separately. 1 year period. You MUST complete internship before you can be licsensed as a doctor. After completing this year, you can put out a shingle and be a General Pratitioner.

Residency - This is 2-4 years of training AFTER internship where you become a specialist. The major specialists are: Family Practice, Internal Medicine, Pediatrics, General Surgury, Opthamology, Radiology, Psychiatry, Neurology, Allergy, Dermatology, Pathology, OG/GYN, Ear/Nose/Throat, Orthapedic, Urology, Plastic Surgury, Neurosurgury, Thoracic Surgury, Colon/Rectal Surgury, and Physical/Rehab Medicine ( I may have forgot one or two).

Please note that quite a few were not on this list.

Fellowship -- After you complete your Residency, you then complete further training in such areas as Cardiology, Pain Management, Endicrinology, Pediatric Whatever, Oncology, and the like.