Methadone: the surprising (and controversial) drug used in anesthesia 

Wow that's ashame. It's amazing the amount of Drs who are still ignorant about addiction and MAT. I've been on Suboxone for 16 years so I've been there with doctors who are ignorant. BTW congrats on your clean time.

That doctors opinion doesn't matter, you're health and wellness are ALL THAT MATTERS. ❤Cheers on your sobriety! 🎉

MAT is a great thing for people who WANT it. Sounds like you do. Don’t let anyone ever talk down to you because of your issues. EVERYONE and I mean EVERYONE has issues. Keep on doing your thing and continuing your sobriety journey. That’s all that matters. You stay with it. And TBH, you will probably be on it the rest of your life. But, it’s better than spending all your money, losing all your friends and family because of an addiction. Good for you!

That's why I'd seriously risk waking up in the middle of surgery before I would admit to anyone, ever, that I'm dependent on opiates. The stigma is too much. The doc better give me more juice if I wake up screaming and suspect whatever he wants, but I ain't talking about it.

It’s not intended that we have such a short period of time to get to know and talk to our patients. Unfortunately it’s a setback of our specialty that we can overcome with much less frequency than we would like to. To compensate that, or at least minimize, we generally develop the ability of quickly establishing a deep linkage with the patients, in many cases recurring to humor, which may be the main reason why we are generally seen as the most easygoing doctors in the surgical environment.

@@henriquelaydner4080 Thanks for your response! Clearly you are the next anesthesiologist I hope to have!

Thats very important there are more drugs that i can think of that are dangerous with an maoi

Max has a sharp sense of responsibility and he knows exactly where to draw the line between giving educational instruction and providing clinical advise. Nevertheless, I can say that a particular type of surgery that I consider suitable for administering methadone is vertebral arthrodesis, which can elicit a lot of long lasting pain. I’d rather go with methadone instead of oxycodone, that is not as potent and I judge as having a greater risk of developing addiction because it has more euphoria-inducing effects. Proof of that is the opioid abuse crisis in the United States.

Yes, my father too.

I use both, I always have excellent BP and Pulse Ox levels. There is so much misinfo out there, DEA, CDC, FDA needs to let Dr'.s treat their patients properly and with dignity.

@@mallardtheduck406totally agree!! ❤

@@mallardtheduck406also all my EKGs are always fine I get them every 6mos.

​@@mallardtheduck406I agree. If you regularly take benzodiazepines and need opiates your body is going to be used to the benzos and not effect your heart rate much. They did go a little overboard with that benzos/opiate warning. Th

The patient would technically still be "observation". This is indicated by medical necessity and also has an impact on how the insurance is billed (U.S. only). If patient is admitted for >2 midnights, then the surgery is considered inpatient surgery.

I can relate... I was in an accident resulting in broken back and other injuries. It required me to have 6 back surgeries over extended period fusing 12 levels of my spine. Another accident required fusing 3 levels in my neck. I belong to the 1 meter club; over 1 meter of incisions. I was on the Oxy Family both fast and slow, switched to generic MSContin and MSCodone. I have a high tolerance so doses have to be high to get barely get any pain relief. Had Fentanyl, Methadone, Morphine, and just about any pain meds pain meds out there. Each change of new meds always started at too low dose, then ramped up. I quit taking meds and have dealt with pain using Tylenol and Ibuprofen. for almost 3 years. Recently I had a surgical procedure that required General Anesthesia. I was joking with my Anesthesiologist just before 'Lights Out". I told him about my high tolerance and he said he has that covered. I also told him Propofol, Fentanyl, Ativan, etc need to be high dose. Again he said he has that covered. He starts Propofol in my 20 gauge IV, count down from 100, after hitting 72, I said 'see I told you so'. He laughed and said we have that covered. He hit me with another dose of Propofol, more Fentanyl, turns on the Nitrous, and said try counting now. Made it to 50 and next thing I know I am in different part of hospital. Good luck and hope your surgeries bring pain relief.

I have been suffering for 35+ year's post chronic cancer pain, and the most they will give me now is a .25mcg Fentanyl/Duragesic patch which does next to nothing, but better than nothing. I hate Methadone, I will remember to tell them not to give me Methadone during surgery.

​@@mallardtheduck406 They tried a Transdermal Fentanyl Patch (didn't work), Methadone (didn't work). What did work in prior pain management was Oxycodone 20mg 4x day, Oxycontin 30mg 2x day, Valium 5mg 4x day. This worked and was lowest dose for any pain relief. Would have glad they prescribed 2x more in later surgeries recoveries.

@@mallardtheduck406 that’s funny I hated fentanyl. Gave me a weird feeling unlike any other pain medications and I’ve been on them all. Hope you’re getting some relief anyways!

@@SJR_Media_Group lol yeah every anesthesia doc I’ve had was funny as hell for general surgery. When I had my ACL replacement I woke up crying the pain was so bad. The nurse had to call the doctor in and I’m begging him for pain meds. I said can’t you give me the machine thing?!!? He said yeah, but it can’t give you what I’m going too now and I can’t give you anymore than this. I believe it was either 18.5mg or 28.5mg every 45min. They’d give me the dose through my IV and I’d be knocked out immediately and wake up half an hour later crying in pain for 15min until the process repeated. That was before my tolerance got really high. Hopefully they give me a pain management doctor for my recovery. I’ve got another decade before they’ll think about my knee replacements and was told by two neurologists not to have back surgery until I either couldn’t control my bowls or had constant sciatica. Said it’s 50/50 any time for better pain and mobility. Either get better pain relief and worse mobility or vice versa rairly both. I said yessir. They both told me not to let ortho do my back and don’t let anyone convince me. I’ve yet to meet anyone that had back surgery and was glad they did 100%. Some had benefits in areas but worse in others, but wouldn’t have done it over again if they had the chance. Hope that you’re finally getting some relief! God bless~

This is a good one. Love Max's videos too. Remifentanil has a context-sensitive half-life of 3 mins which is independent of the duration of infusion. This is very different with Fentanyl where an infusion lasting roughly 2 hours would have a context-sensitive half-life of roughly 50 minutes, whilst an infusion with a duration of 8 hours would have a context-sensitive half-life as long as 5+ hours. As Remifentanil has a small central volume and rapid clearance, it's rapidly cleared no matter the size of the peripheral compartment or infusion duration. It accumulates in the periphery but speed of recovery almost is meaningless to the speed of recovery because it's clearance is so fast (non-specific plasma esterases). Fentanyl has a much higher volume of distribution (Vd), higher central volume and increased lipid solubility where accumulation can occur and elimination is slower. Remifentanil is almost the pharmacokinetically ideal continuous infusion intraoperative opioid for these reasons, particularly when you're using a TCI syringe pump that has the Minto PK model, where you can make precise changes to the target plasma concentration and time to equilibration is extremely fast. Otherwise, many just do intermittent Fentanyl boluses depending on the level of surgical stress or changes in haemodynamics which is more phasic and imprecise but simple. Otherwise, the only problem is that given Remi's extremely short duration, if you're using high doses for long cases there's the potential for Remifentanil-induced hyperalgesia requiring extra consideration when administering pre-emergence analgesia.

@@pseudoMIMS, congratulations for the technically perfect response, but I wonder if it is the best in case who’s asking is not at least a medical student. I’d simplify it by saying that remifentanil is as potent as fentanyl, but it lasts just as long as it’s being administered, whereas fentanyl lasts longer even if given as a single dose. Choosing between them has to take into account many factors, from the nature of the procedure and the patient’s general health to even the economic impact, since fentanyl is cheaper than remifentanil (at least here in Brazil).

@@henriquelaydner4080 Haha I am actually a medical student (and a pharmacology researcher too). Yes, more or less. However, I felt the need for people to have the rationale as to why there's a major difference in duration given the nuances of context-sensitive half-life. Otherwise, for the purposes of a TIVA-TCI anaesthetic then Remifentanil is central. But, yes, it costs significantly more than Fentanyl.

Yes!

Yes methadone is pretty inexpensive!

@@MaxFeinsteinMDwould you administer methadone in a patient you plan on also administering ketamine to, considering they are both NMDA antagonists?

@@MaxFeinsteinMD Not for me, I pay an annual $100 a year. The perks of Canadian healthcare. 😀

Yeah no wonder I’ve never heard of anyone on that much methadone. They never should’ve let you even reach that dose.

if your arm was blown off or you had a terminal illness, such as anaplastic thyroid cancer, you would be on your ass screaming for fentanyl, methadone, or morphine. I saw both of my grandmothers die of this type of cancer.

@@rochelle-xz8gl I’m sorry for your loss, but I fail to see what your comment has to do with my question or statements.

I think they do, I'm taking Bupernorphine and scheduled next week for gallbladder removal, was told not to stop Bupernorphine use, my doctor has a plan, but was told would still have fentanyl given during my surgery, that's if I'm in pain, but they also said Bupernorphine would also be administered.

Most surgeons do localize the incision site, this alone does not provide adequate analgesia in the vast majority of patients

There are risks of nerve damage

It would take an extremely long time to wake patients up from an entirely ketamine based anesthetic. It also causes hallucinations which can be unpleasant. There are untoward physiologic effects as well including significant increase in secretions from the mouth.

Sufentanil. As is a stronger compound analogue than fentanyl if you get your leg blown off in combat that is what you would be given for the excruciating pain.

@@PeterBornAgainok and what is the risk of respiratory depression using that?

Learn how to spell it first

I am in an MAT program and went under anesthesia 4x this summer. I was at a high dose like yourself when I started but I’ve tapered down to 10mg. The first 3 times the anesthesiologists were like “okay that’s no big deal! Good job by the way” they were the only ones that had any understanding of the dosage & how those programs work. The fourth time the anesthesiologist was a total dick, it was awful. He basically asked why I was on methadone so long and then said something like “maybe it’s not working for you”. I got pretty defensive because I have almost 6 years sober and I’ve done some amazing things during that time. My advice is if you have to go in for surgery is to bring your MAT doctors direct information and be ready to educate. I wasn’t ready for all the ignorance about MAT but I will say the anesthesia residents were way more knowledgeable.

@killmewhileimahead awesome..thank you for sharing your experience