How to manage muscle aches and joint pains in a patient undergoing methadone (Dolophine) taper?

From the Guidelines

To manage muscle aches and joint pains during methadone tapering, use non-opioid analgesics like acetaminophen (500-1000mg every 6 hours, maximum 4g daily) or NSAIDs such as ibuprofen (400-600mg every 6-8 hours with food) if not contraindicated, as recommended by the most recent guidelines 1. When managing muscle aches and joint pains in a patient undergoing methadone taper, it is essential to consider the patient's overall well-being and the potential risks and benefits of continuing opioid therapy versus tapering.

Key Considerations

• The patient's agreement and interest in tapering is crucial for a successful taper, and clinicians should work closely with patients to establish goals and maximize pain treatment with nonpharmacologic and nonopioid pharmacologic treatments 1.
• A slow taper, such as a reduction of 10% per month or slower, is likely to be better tolerated than faster tapers, especially for patients who have taken opioids long-term 1.
• Non-pharmacological approaches, including warm baths, gentle stretching, massage, and adequate hydration, can provide additional relief and should be considered as part of a comprehensive treatment plan.
• Psychological support is also important, as anxiety about withdrawal can amplify pain perception, and clinicians should remain alert to signs of and screen for anxiety, depression, and opioid misuse or opioid use disorder 1.

Medication Management

• Adjunctive medications like clonidine (0.1-0.2mg every 6 hours) or low-dose gabapentin (300mg three times daily) may be considered to reduce withdrawal symptoms or manage neuropathic pain, but their use should be individualized and monitored closely.
• Clinicians should be cautious when tapering opioids and should carefully assess and discuss with the patient the benefits and risks of increasing opioid dosage if necessary 1.

Monitoring and Follow-up

• Clinicians should follow up frequently (at least monthly) with patients engaging in opioid tapering and should collaborate with the patient on the tapering plan, including decisions about the tapering schedule and when pauses in the taper might be warranted 1.
• Team members, such as nurses, pharmacists, and behavioral health professionals, can support the clinician and patient during the ongoing taper process through telephone contact, telehealth visits, or face-to-face visits 1.

From the FDA Drug Label

The opioid abstinence or withdrawal syndrome is characterized by some or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis Other symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate.

Management of muscle aches and joint pains in a patient undergoing methadone (Dolophine) taper may involve:

• Recognizing that joint pain and muscle aches are symptoms of opioid withdrawal syndrome
• Considering non-opioid analgesics for pain management
• Being aware that patients on methadone maintenance may require higher and/or more frequent doses of analgesics due to opioid tolerance
• Monitoring patients closely for signs of withdrawal and adjusting treatment as needed 2, 2, 2

From the Research

Managing Muscle Aches and Joint Pains in Methadone Taper

• Muscle aches and joint pains are common symptoms experienced by patients undergoing methadone taper 3
• A multidisciplinary approach to pain management is recommended, including patient education and counseling, physical interventions, and nonopioid medications 3
• The use of methadone for chronic neuropathic pain is controversial, and its efficacy and safety profile may differ from other opioids 4
• When tapering methadone, it is essential to consider the patient's individual needs and medical history, as well as the potential for opioid withdrawal and pain relapses 3, 5

Considerations for Methadone Taper

• Methadone has a complex pharmacology, with a high inter-individual variability and potential for interaction with other medications 6
• Patients on methadone maintenance therapy may be 'opioid-tolerant' but 'pain-intolerant', making postoperative pain management challenging 6
• A management algorithm for the perioperative care of methadone patients should consider the type of surgery, fasting status, and gastrointestinal function 6
• Supplemental analgesic medication may be employed to relieve pain in methadone-maintained patients, except for opiate antagonists which should be avoided 7

Pain Management Strategies

• Nonopioid medications and physical interventions can be used to manage muscle aches and joint pains in patients undergoing methadone taper 3
• Short-acting narcotics may be administered at higher doses and more frequently to relieve pain in methadone-maintained patients 7
• Patient education and counseling are crucial in managing pain and preventing opioid withdrawal and pain relapses during methadone taper 3