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General Operational Topics

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Post Heroin users
Author: rnielsen
Date: Jun 4, 2009 2:20 pm
I have a heroin user who is in for 6 weeks of antibiotics for a mycotic femoral aneurysm. He is on Methadone 143 mg (73 ml)/d, Memantine 10 mg bid; Fentanyl patch 100 mcg /day and dilaudid 72 mg / day by PCA. A few days ago the dilaudid was working, but it isn't now. I think we should stop the fentanyl and dilaudid and increase the methadone and maybe rotate to morphine for breakthrough. He wants to double the dilaudid. How high do you go? When and how do you draw the line in patients who don't have a life limiting illness?
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+ Re:Heroin users (by SharolHerr on 06/04/2009)
Addiction and chronic pain syndromes most often require treatment guidelines and responses that are very different from the Palliative patient population. It sounds like your patient is an acutely ill patient and not a patient with an end stage disease process. It would need to be established if the patient's increasing pain syndrome is related to a worsening clinical situation or complication of the disease and therefore the pain has increased or if the pain syndrome is secondary to the addiction history. These patients are often best served by a pain specialist. It would also need to be determined if the patient is on the methadone for opioid maintenance due to the addiction or whether this was started for the acute pain problem. If the methadone is for the addiction then the dose would not be escalated. It would seem this case is outside the scope of a palliative practice. When that is the case, many programs make referral to pain specialists/services and collaborate with the physician who has initiated the methadone therapy. The palliative service can outline equianalgesic dosing but if the syndrome is secondary to the addiciton caution should be taken with escalating opioids, including the methadone. If there is an advanced or terminal disease process that is worsening, the rules are different for increasing opioid doses. Clinical cases are often difficult to consult on with the forum model but a pain specialist would be a great resource for you to tap into.
Sharol Herr, RN, MSEd; Nurse Clinician/Education Coordinator; Mount Carmel Health Palliative Care Leadership Center; Columbus, Ohio.

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