RSD Puzzle #068

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE #68
Methadone is no different than other types of Morphine agonists in regard to tendency for physical dependence.

I have been treated with Methadone for chronic pain. Because of the problems of fatigue, depression, and the fact that there are reports of deaths due to Methadone, I would like to get off this medicine. Can I just stop it cold turkey or should I replace it with other medications?

I appreciate your concern. It is easy to start on Methadone but it is not as easy to discontinue it. You should discuss with your pain specialist in detail regarding how you want to be detoxified and to come off medication. Methadone is no different than other types of Morphine agonists in regard to tendency for physical dependence. The only difference is that Methadone has a long half-life, and can last in the system for a few days. In that regard, the rebound phenomenon (withdrawal) is not noticeable when multiple doses of the medicine are prescribed such as in the dose of 2 or 3 times a day. By the time the previous day's is practically all out of the system, the second dose replaces it. In this regard, it is very similar to medications such as MS Contin or other long duration skin patches of the opiate agonist medications. Clinically, the fact that withdrawal is accelerated (rebound phenomenon) is camouflaged by overlapping dosages of the medications, the adverse affect on the brain is accelerated. This adverse effect consists of practically complete arrest of formation of cerebral endorphins and secondary side effects of reduction of Estrogen and other types of hormones related to the hypothalamus of the brain. As a result the patient becomes fatigued, has tendency to gain weight, has tendency to be inactive, and especially during the night while sleeping the extremities do not have the normal tossing and turning so the inactivity can aggravate the RSD and can aggravate the edema and inflammation of the RSD. Also such patients show a significant suppression of the brain endobenzodiazepines (endoBZs) and natural cerebral antidepressants.

1. Recently the Harvard researchers have discovered a medication, Buprenorphine (Buprenex)[1]. Buprenex has been found by the Harvard researchers to be promising for the treatment of "polydrug" abuse. This analgesic medication has been tried on patients dependent on both opiates and Cocaine. Buprenex is mu opiate receptor agonist and antagonist. In addition, it has been found to have some advantages over Methadone in terms of relative safety in the treatment of Heroin addiction. Surprisingly, it is also effective in reducing the side effects of Cocaine withdrawal as well.

2.The second form of detoxification from Methadone and other opiate agonists dependence is switching the patient to Stadol and Ultram in a cold turkey fashion as long as the patient also takes Klonopin to reduce any chances of potential for seizure disorder from Ultram.

1. Ling E, Wesson DR, Charuvastra C, et al: A controlled trial comparing buprenorphine and methadone, maintenance in opioid dependence. Arch Gen Psychiatry 1996; 53:401-7.

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