Should the patient continue their regular methadone regimen on the day of surgery, holding the morning dose if undergoing general anesthesia?

Should Patients Continue Methadone on the Day of Surgery?

Yes, patients should continue their regular methadone dose on the morning of surgery, including the day-of-surgery dose, regardless of whether they are undergoing general anesthesia. 1

Primary Recommendation

• The Society for Perioperative Assessment and Quality Improvement (SPAQI) explicitly recommends that opioid agonists, including methadone, should be continued on the morning of operation. 1

• Patients receiving methadone maintenance therapy must take their usual morning dose on the day of surgery to prevent withdrawal symptoms and maintain therapeutic stability. 1

Critical Rationale: Why Continuation is Essential

Prevention of Withdrawal and Relapse

• Abrupt discontinuation of methadone precipitates opioid withdrawal symptoms and dramatically increases the risk of relapse to illicit drug use, which carries significant morbidity and mortality. 2

• Physical dependence is expected during opioid agonist therapy, and withdrawal syndrome includes restlessness, lacrimation, rhinorrhea, perspiration, myalgia, anxiety, tachycardia, and hypertension—all of which complicate perioperative management. 2

Methadone Does Not Provide Surgical Analgesia

• The FDA label explicitly states that maintenance patients on a stable methadone dose who experience surgical or postoperative pain cannot be expected to derive analgesia from their ongoing methadone dose. 2

• The maintenance dose of methadone controls only narcotic withdrawal symptoms and is ineffective for relief of acute surgical pain. 2

• Separate analgesics, including additional opioids, must be administered in doses that would be indicated for non-methadone-treated patients with similar painful conditions. 1, 2

Perioperative Management Algorithm

Step 1: Verify and Continue Maintenance Dose

• Contact the patient's methadone maintenance clinic or prescribing physician to verify the current daily dose and confirm the time and amount of the last dose. 1

• Administer the patient's usual methadone maintenance dose on the morning of surgery as scheduled. 1

Step 2: Plan for Higher Analgesic Requirements

• Due to opioid tolerance induced by methadone, patients will require somewhat higher and/or more frequent doses of additional opioid analgesics than non-tolerant patients to achieve adequate pain control. 2

• Patients receiving long-term opioid therapy will likely need higher than usual opioid dosing to achieve pain control or will need adjunctive nonopioid analgesia perioperatively. 1

• Write continuous scheduled dosing orders for postoperative analgesics rather than as-needed orders to maintain consistent pain control. 1

Step 3: Use Short-Acting Opioids for Breakthrough Pain

• Continue the methadone maintenance dose unchanged throughout the perioperative period and add short-acting opioid analgesics (such as hydromorphone, oxycodone, or fentanyl) to treat surgical pain. 1

• Avoid using mixed agonist-antagonist opioids (such as nalbuphine, butorphanol, or pentazocine) because they may precipitate acute withdrawal syndrome in methadone-maintained patients. 1

Step 4: Implement Multimodal Analgesia

• Aggressively employ non-opioid analgesics including acetaminophen, NSAIDs, regional anesthesia techniques, and adjuvant medications to reduce total opioid requirements. 1

Important Drug Interactions and Safety Considerations

Serotonergic Medications

• Methadone may increase the likelihood of serotonin syndrome when combined with other medications that increase serotonergic activity, including certain opioids (meperidine, fentanyl, sufentanil, tramadol, tapentadol), ondansetron, and SSRIs. 1

• Monitor for signs of serotonin syndrome (agitation, confusion, tachycardia, hypertension, hyperthermia, hyperreflexia, myoclonus) when combining methadone with serotonergic agents perioperatively. 2

QT Prolongation Risk

• Extreme caution is necessary when any drug known to prolong the QT interval is prescribed in conjunction with methadone, including class I and III antiarrhythmics, some neuroleptics, tricyclic antidepressants, and certain anesthetic agents. 2

• Avoid concomitant use of medications that induce electrolyte disturbances (hypomagnesemia, hypokalemia), including diuretics and laxatives, as these may further prolong the QT interval. 2

CNS Depression

• Methadone has additive effects when used with alcohol, other opioids, benzodiazepines, or CNS depressants; deaths have been reported when methadone has been abused in conjunction with benzodiazepines. 2

• Exercise heightened vigilance for respiratory depression when administering additional opioid analgesics on top of methadone maintenance therapy, particularly in the immediate postoperative period. 2

Special Considerations for Methadone Administration

Pharmacokinetic Complexity

• Methadone should be administered only by clinicians experienced in its use because of the risk of accumulation due to its long and variable elimination half-life (8 to 59 hours). 1, 2

• Methadone's peak respiratory depressant effects typically occur later and persist longer than its peak analgesic effects, and steady-state plasma concentrations are usually not attained until 3 to 5 days of dosing. 2

Renal Function

• Opioids with no active metabolites, including methadone, are preferred for patients with renal insufficiency or end-stage renal disease. 1

Care Coordination

• Notify the addiction treatment program or prescribing physician regarding the patient's admission and discharge from the hospital. 1

• Inform the methadone maintenance program of any medications given during hospitalization (including opioids and benzodiazepines) because they may appear on routine urine drug screening. 1

• Reassure the patient in a nonjudgmental manner that their addiction history will not prevent adequate pain management and discuss the specific plan for perioperative pain control. 1

Common Pitfalls to Avoid

• Do not withhold the morning methadone dose on the day of surgery based on NPO status or concerns about anesthesia; this will precipitate withdrawal without providing any benefit. 1

• Do not assume that the methadone maintenance dose will provide surgical analgesia; it will not, and separate analgesics must be prescribed. 2

• Do not underdose postoperative opioid analgesics out of concern for respiratory depression; methadone-tolerant patients require higher doses, and inadequate pain control leads to worse outcomes. 1, 2

• Do not confuse anxiety or pain-related distress with narcotic withdrawal symptoms and inappropriately increase the methadone maintenance dose; methadone does not act as a tranquilizer or treat acute pain. 2