Can We Talk About Methadone?

[IsraelEMS]

I just treated my first Methadone overdose and want to know more about it (it's very uncommon here and in 20 years this was my first such case). We were called by a bystander who saw a man he judged to be about 90 who seemed very confussed and was struggling to get into his house. We arrived to find the pt responsive to verbal but sometime only to pain (it went up and down). His puils where very small but not quite pinpoint. At this point his breathing was fine. We found about 40 empty bottles of methadone next to the pt and more on his person. We do not know how many of those he actually took. We did find identification for the man and he was ony 60 much to everyone's suprise. We assessed the sceen based on the area and objects found nearby as not safe and evacuated as quickly as possible. We requested ALS but none was available.

In ambulance the pt maintained a steady respitory rate but dropped his sats to 65%. BP was 110/70. We administered 10L of O2 and his sats came up to 92%. Heart rate was about 90. Blood sugar was 133. When we parked at the hospital his heartrate was down to 60, breathing unchanged (about 16 breaths per minute). By the time we got him into a bed (only took about 2 minutes), he dropped his resp rate to 8 (!) but maintained his saturations with O2, heart rate was steadily dropping.

So here are my questions. Does methadone effect the body in the same was a herroin or other opiates (it seemed to from what we were seeing)? If so, why wasn't his bp lower(although to be fair we didn't know his base and did not have a medical history on him so maybe that is partially the answer)? What was going on with his breathing (in the absence of a lung disease the disadince between his rr and O2 sat was a little confussing)? What else could we have done or should we have looked out for?

 

[FiremanMike]

Methadone is a long acting opiate, so anything you’d see with other opiates would apply.

Good on you for not slamming the narcan. He’s still breathing and satting fine on oxygen, absolutely zero reason to toss him into withdrawal.

 

[IsraelEMS]

Methadone is a long acting opiate, so anything you’d see with other opiates would apply.

Good on you for not slamming the narcan. He’s still breathing and satting fine on oxygen, absolutely zero reason to toss him into withdrawal.

So how does it help with Opiate addiction?

 

[Raptor]

satting fine on oxygen

92% is considering 'fine'?

 

[IsraelEMS]

92% is considering 'fine'?

Yes, If his rr is normal, he is not showing signs of respitory distress and his color is normal 92% is fine. No reason to treat what is not broken.

 

[johnrsemt]

Remember don't treat the monitor,
What Israel said; if he looks good and is mentating the same as he was 92% is great. Better than my normal

 

[FiremanMike]

So how does it help with Opiate addiction?

Ehhhhhh, now you’re moving to a different topic. The theory is that methadone is pharmaceutical grade, so a controlled purity, and can be tapered by a physician.

The truth of the matter, and most in recovery will attest to this, is that it’s just trading one addiction for another and they’re merely prolonging the withdrawal process

We don’t see much methadone in my area, mostly soboxone and occasionally vivitrol. I have heard soboxone has its own issues and withdrawal process and the issue with vivitrol is that you have to be clean for so many days before you can take the first shot, it also comes with access issues because it’s a monthly injection and getting folks in recovery to come in once a month can create problems.

 

[FiremanMike]

92% is considering 'fine'?

Yes.

I’ll take 92% over a patient in withdrawal any day of the week and twice on Sunday.

 

[silver]

Ehhhhhh, now you’re moving to a different topic. The theory is that methadone is pharmaceutical grade, so a controlled purity, and can be tapered by a physician.

The truth of the matter, and most in recovery will attest to this, is that it’s just trading one addiction for another and they’re merely prolonging the withdrawal process

It also has very favorable pharmacokinetics. Relatively slow time to peak effect and long half life with a clinical effect of ~24hrs. MMT centers can distribute a dose daily.

Unfortunately, in this scenario that means he probably hasn't experienced the peak respiratory depression yet, and if he needs naloxone it would likely need to be a continuous drip.

 

[IsraelEMS]

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It also has very favorable pharmacokinetics. Relatively slow time to peak effect and long half life with a clinical effect of ~24hrs. MMT centers can distribute a dose daily.

Unfortunately, in this scenario that means he probably hasn't experienced the peak respiratory depression yet, and if he needs naloxone it would likely need to be a continuous drip.

Ok, so that could in part explain the breathing. I have seen other od pts go from fine to sudden respiratory arrest. His was more like a massive drop that then stabilized, although, even with O2 I still don't understand how he maintained 92% at only 8 breaths per minute. My protocol has me getting the ambu ready at that point.

 

[Carlos Danger]

Ok, so that could in part explain the breathing. I have seen other od pts go from fine to sudden respiratory arrest. His was more like a massive drop that then stabilized, although, even with O2 I still don't understand how he maintained 92% at only 8 breaths per minute. My protocol has me getting the ambu ready at that point.

With oxygen supplementation a person can easily maintain an adequate Sp02 while breathing 8 times per minute. In fact, respiratory rates in that range are common during sleep for many people, who survive the night just fine without supplemental oxygen.

Passive airway obstruction is likely a more common cause of respiratory arrest due to opioid OD than is actual respiratory depression.

Google "apnea test for brain death" and learn how apneic oxygenation works.

 

[IsraelEMS]

They were not normal breaths though. It was clearly distress as each breath was coming from his intercostal muscals and required a lot of work. He clearly couldn't keep that up for long before tiring out. Does that make a difference?

@FiremanMike How do the two drugs you mentioned differ from Methadon? I am not familure with them at all.

 

[FiremanMike]

They were not normal breaths though. It was clearly distress as each breath was coming from his intercostal muscals and required a lot of work. He clearly couldn't keep that up for long before tiring out. Does that make a difference?

@FiremanMike How do the two drugs you mentioned differ from Methadon? I am not familure with them at all.

They’re both opioid receptor blockers, they just work differently..

 

[Carlos Danger]

They were not normal breaths though. It was clearly distress as each breath was coming from his intercostal muscals and required a lot of work. He clearly couldn't keep that up for long before tiring out. Does that make a difference?

@FiremanMike How do the two drugs you mentioned differ from Methadon? I am not familure with them at all.

Again, you technically don't need any breaths to maintain a decent Sp02, especially when a high Fio2 is being delivered. As long as oxygen is flowing to the lungs (i.e. you have an open airway and 10 lpm of oxygen being administered), it will diffuse across the alveocappilary membranes into the plasma and bind to hemoglobin. I'm not saying this guy wasn't going to crump before long; I'm just saying you shouldn't be surprised when a person's Sp02 improves dramatically on a high Fi02, even when they are in severe respiratory distress.

Methadone basically works by binding to the opioid receptor subtypes most responsible for mediating withdrawal symptoms, but it differs from other opioids in that it binds more weakly to the receptor subtypes (mu2, IIRC) which contribute the most to euphoria and respiratory depression. The net effect is a drug that satisfies the physiological need that an opioid dependent person has developed, while having a much smaller risk of respiratory depression. As you witnessed, life-threatening respiratory depression is still possible when very large doses are ingested, or when it is combined with other respiratory depressants.