Morphine V Methadone V Fentanyl analgesia in dogs and cats

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Rob Loxley — Wed, 12 Oct 2011 14:46:49 GMT

[quote user="RAJAT MUKHERJEE"]and seeing as we don't use generic methadone anyways (physeptone?) doesn't really make a difference... [/quote]

Um, Physeptone isn't animal-licensed so Comfortan would come higher up the cascade??

Also good to know about the generic fentanyl patches

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Mark Holmes — Wed, 12 Oct 2011 13:28:47 GMT

[quote user="Sarah Keir"]

We charge £65 for a 100 Durogesic patch and about £66-68 for CRI (including fluids and the drugs).

[/quote]

There is now a generic fentanyl patch available at the FRACTION of the cost of durogesic. (I have just charged a 0.025microg patch out at less that £10), just look up fentanyl on Dunlops

The cat fracture I stuck it to is looking great but it has taken 24hrs to be fully effective.

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Stephen Courtney — Sun, 11 Sep 2011 00:32:21 GMT

I've just had the Alstoe rep in - they sell vetergesic, now including the new multidose vial.

He tole me that it is impossible to give so much buprenorphine that you inhibit respiration, that in cats you can repeat the full dose hourly, that in dogs you can do so every 3-4 hours.

In other words, you can top up the vetergesic more or less as needed to improve analgesia, and that results are not far off using full agonists

Any comments? I'm a little sceptical. Shame on me!

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Anonymous — Sat, 10 Sep 2011 22:30:40 GMT

[quote user="robloxley"]

[quote user="David Beattie"]Boss's reason is that doesn't want more paperwork and regulations[/quote]

I was in the same position and ended up sorting the protocols myself... PM me if you need some pointers

[/quote]

Thanks, Rob, you've inspired me to go ahead and take the plunge into requesting a schedule 2 (I have already been dropping hints...). Have decided to go with methadone - you're quite right, if I really miss morphine for CRI's that much, it wouldn't be a big step to get small amount of that too once had methadone register set-up and working for couple of months.

Thanks for offer of advice - will let you know if run into bureaucratic confusion

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

bob lehner — Sat, 10 Sep 2011 21:02:02 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="bob lehner"] or a denturing kit[/quote]

Yeah!!

[/quote]

Ha ha , very good - 'What a difference an 'A' makes' - as Dinah Washington nearly sang.....

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Rajat — Sat, 10 Sep 2011 20:56:15 GMT

Thank you for that Bob/Mark/Evelyn, I was not looking fwd to the situation of potentially having to swap drugs here, didn't really think it through but makes sense, they're all mu opioids but like y'all say they are different drugs, and seeing as we don't use generic methadone anyways (physeptone?) doesn't really make a difference... it did when we had to get rid of spironolactone and metoclopramide when the licensed versions of those came out!

[quote user="Anthony Todd"]My impression used to be that there was absolutely none, and the problem was stopping the animals racing about and damaging the wound??[/quote]

Lol

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Anthony Todd — Sat, 10 Sep 2011 20:48:36 GMT

[quote user="robloxley"]like you probably use for more 'routine' ops - neuters, dentals[/quote]

Is there now pain after routine neutering?

My impression used to be that there was absolutely none, and the problem was stopping the animals racing about and damaging the wound??

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Evelyn Barbour-Hill — Sat, 10 Sep 2011 16:31:44 GMT

[quote user="bob lehner"] or a denturing kit[/quote]

Yeah!!

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Evelyn Barbour-Hill — Sat, 10 Sep 2011 16:27:56 GMT

[quote user="bob lehner"]

[quote user="Evelyn Barbour-Hill"]Indeed and arguably............. you could continue to use ampoules of Physeptone if you can make a case that there is no veterinary-licensed preparation of methadone in ampoules and a multidose vial is not suitable for your purpose; as long as it is not solely on the grounds of cost. [/quote]-

Hmm - if you exclude cost, what other reason could there be for not using the licensed product ?

[/quote]

Ooo, I'm sure I could think of something. Not wanting a preservative in it? Not trusting quality of rubber-stoppered solutions? You only have to make case, you don't have to prove it.

Just stirring here

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Rob Loxley — Sat, 10 Sep 2011 15:44:13 GMT

[quote user="bob lehner"]I have also had it on high authority that it is OK to dispose of small remnants of vials of Sch 2 CDs in the sharps container or a denturing kit so long as the whole vial is accounted for in the CD Register. [/quote]

I.e. you treat it as 'patient-returned drugs' rather than 'stock', which is what we do with the remnants in a vial. The changes you highlight in the VMD notes do seem to make life easier for disposal of unwanted/OOD stock (must be a first ).

I can also see the advantage of a multidose vial being more economical when just needing small amounts rather than having to use or chuck the waste from a whole vial. From my maths it also works out a bit cheaper than buprenorphine multidose (depending on your exact dose) and I get the impression their anticipated market is as much expanding our use of CD2s (e.g. bitch spays, major dentals) than just replacing human methadone usage for, say, fractures and RTAs.

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Mark Holmes — Sat, 10 Sep 2011 12:09:30 GMT

[quote user="bob lehner"]Hmm - if you exclude cost, what other reason could there be for not using the licensed product ? The manufacturers of the newly licensed methadone, 'Comfortan' ( not to be confused with 'Comfortis' - the new flea killer) say they do a range of vials from 5 -50 mls (although they also say that not all package sizes will be marketed) - so, hopefully if they do market the 5 ml size, this should be reasonably appropriate for the smaller practice with a lower useage.[/quote]

There may well not be a reason not to use the licensed product, but thats not the point. The point is if you have one, then you shouldn't feel compelled by licensing to use what you consider to be an inferior drug given the circumstances.

In an ideal world our drug choice would be based upon a clinically controlled trial comparing all drug choices in the identical circumstances to which you wish to use them. Clearly that is a practical impossiblity most of the time. we have to consider which drug choice we consider most appropriate in the circumstances gievn a variety of influences. Experience, other drug trials, KOLs, and a degree of anecdote. Having considered conciously or subconciously all the alternatives we arrive at an educated decision on what is best for our patient. Thats how it should be.

When company decides to license or not license a product, they largely consider if they can make a product profitable. If they can make it profitable the timing of the licensing research and application will be dependant on factors such as company cash flow etc. Non of which has any relevance to patient care.

You could fore see the circumstances arising where drug A is unlicensed but acknowledged to be the most effective at treating a particular condition (call it X). It is however not economial to license drug A given the quantity being used. Drug B however has some benefit in treating condition X, is also currently licensed for another condition the safey data has been produced and therefore extending the license to cover condition X would be profitable.

The use of Drug B over Drug A would be against the patients interests even if licensed.

It may be the case that the licensed drug is the most appropriate, to be fair it usually is but it should be of little significance in what drug we chose to use. This discusssion if largely hypothetical but it makes the point.

Licensing should have no more influence than the brand of drug we select.

We have recently had a veterinary licensed metoclopramide, the drug is no more effective or appropriate because it now has a fancy label and a stupid name.

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

bob lehner — Sat, 10 Sep 2011 11:07:07 GMT

[quote user="Sarah Keir"]With the disposal problem of out of date/excess opiods is a real factor. Some how we have ended up with a few vials of out of date opiods and we have been waiting over a year for the police to come and watch the disposal[/quote]

It doesn't have to be a policeman in to witness destruction of Sch 2 CDs any longer - from VMD Guidance Note on Controlled Drugs.:

'DESTRUCTION
34. Schedule 2 controlled drugs may not be destroyed except in the presence of an
Animal Medicines Inspectorate (AMI) or RCVS Practice Standards Scheme
Inspector, a witnessing veterinary surgeon who is independent of the practice
concerned (this excludes locums who have or are acting in the practice, family
members or any relationship that may pose a risk of collusion), or another person
authorised to witness the destruction of controlled drugs under the Misuse of Drugs
Regulations 2001 or the Misuse of Drugs Regulations (Northern Ireland) 2002 such
as a Police contact.'

I have also had it on high authority that it is OK to dispose of small remnants of vials of Sch 2 CDs in the sharps container or a denaturing kit so long as the whole vial is accounted for in the CD Register. You only need to get a witness in if you are disposing of larger volumes of OOD Sch 2s.

Hmm - if you exclude cost, what other reason could there be for not using the licensed product ? The manufacturers of the newly licensed methadone, 'Comfortan' ( not to be confused with 'Comfortis' - the new flea killer) say they do a range of vials from 5 -50 mls (although they also say that not all package sizes will be marketed) - so, hopefully if they do market the 5 ml size, this should be reasonably appropriate for the smaller practice with a lower useage.

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Evelyn Barbour-Hill — Sat, 10 Sep 2011 01:54:20 GMT

[quote user="Mark Holmes"][quote user="RAJAT MUKHERJEE"]

So now that methadone is licensed, does this mean we have to use this first line instead of morphine because of the cascade? If so thats a real PAIN!

[/quote] NO IT ABSOLUTELY DOES NOT it means that should it be appropriate to use methadone you need to use the licensed methadone. Just because a drug is licensed it does not make it the most appropriate drug to use. That way our medicine is based on nothing more than the marketing policies of the various drug companies. Licensing should apply to one brand over another, not one drug over another. The whole of veterinary anaesthesia would otherwise be royally buggered!

[/quote]

Indeed and arguably............. you could continue to use ampoules of Physeptone if you can make a case that there is no veterinary-licensed preparation of methadone in ampoules and a multidose vial is not suitable for your purpose; as long as it is not solely on the grounds of cost.

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Mark Holmes — Fri, 09 Sep 2011 20:31:42 GMT

[quote user="RAJAT MUKHERJEE"]

So now that methadone is licensed, does this mean we have to use this first line instead of morphine because of the cascade? If so thats a real PAIN!

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Rajat — Fri, 09 Sep 2011 18:55:41 GMT

Not an expert, no letters after my name but...

I share many people's concerns here about the often variable and somewhat random efficacy of fentanyl patches, and frequently find that they are poorly stuck on hours sometimes 1-2 days after application especially if they go home with it. I don't have a problem sending patients home with them as long as I have warned the owner but more and more I try not to use them. When used, I like the ventral aspect of the hock especially in cats as it is relatively flat and can be bandaged firmly to keep the patch in contact with the skin.

I like to treat moderate to severe (anticipated or current) pain with intravenous drugs, usually combinations of Morphine or Fentanyl with Lidocaine and Ketamine. Lidocaine can be used in cats but I tend to avoid great analgesia for a castration!Fentanyl is a fantastic drug, it gets me through the week when I have 20 yo cats to do 1 hour long GAs on and maintain BP and use minimal Iso, it really does the trick!

I havent found cats resenting transmucosal buprenorphine and have found it provides significant analgesia so do send cats home with this when needed. Patients who need ongoing high doses mu opioids usually recieve them parenterally in the hospital.

I totally agree NSAIDs provide a different kind of analgesia to opioids and are invaluable in the haemodynamically stable patient..

So now that methadone is licensed, does this mean we have to use this first line instead of morphine because of the cascade? If so thats a real PAIN!

Raj

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Sarah Keir — Fri, 09 Sep 2011 15:23:59 GMT

Moderately painful ops (eg neuterings) get buprenorphine in premed and a NSAID if appropriate. Very painful ops get methadone. We currently use the methadone in single dose vials and I can't see us changing to the multi-dose vials. Used to use morphine which also got on well with. I think we only changed for the vomiting issue.

With the disposal problem of out of date/excess opiods is a real factor. Some how we have ended up with a few vials of out of date opiods and we have been waiting over a year for the police to come and watch the disposal! They don't have the same problem with human drugs. The mother of one of the vets here was on massive doses of opiods at home before she died - no-one cared about the left over drugs once she didn't need them, no-one collected them, no-one to dispose of them, hospital didn't want them, GP didn't want them!

We charge £65 for a 100 Durogesic patch and about £66-68 for CRI (including fluids and the drugs).

Sarah

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Rob Loxley — Fri, 09 Sep 2011 13:07:12 GMT

[quote user="David Beattie"]Boss's reason is that doesn't want more paperwork and regulations[/quote]

I was in the same position and ended up sorting the protocols myself... PM me if you need some pointers

[quote user="David Beattie"]Trying to get two Sch2 opioids with separate registers isn't going to happen[/quote]

I's just one register with different pages for different drugs.

I do like the ease of keeping check on whole single-use vials of methadone, and equally we have the same issue of the informal ketamine register not adding up. Moving to a multidose methadone will inevitably involve some fudge to balance stocks every time a new bottle is opened, and to make sure we don't end up with out-of-date stock drug (like you probably use for more 'routine' ops - neuters, dentals etc.)

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Anonymous — Fri, 09 Sep 2011 08:39:52 GMT

[quote user="Sarah Keir"]I am a little worried there is a practice out there that has no profound analgesia (i.e. full opiods) for severe pain. May be you don't get RTAs?[/quote]

Thanks you for your concern. We do surprisingly get RTAs, not to mention other painful conditions!

Boss's reason is that doesn't want more paperwork and regulations (the ketamine register fails to add up every time and Tier2 PSS inspectors apparently have a field-day with this every time - perhaps if they stopped having a field day with an informal register that will probably only add up properly if fudged, and instead commented on the lack of a full opioid agonist, then the standard of the practice would actually be improved.)

Trying to get two Sch2 opioids with separate registers isn't going to happen, which is why I'm trying to decide which to go for before pluggin my case.

As I see it, methadone has the following failings:

clinically: cannot be used in CRI
practically: whole multi-use vial must be used in 28days otherwise chaos ensues with home office inspector present to witness destruction etc. (unlikely to go down well with boss!)

Otherwise, it seems to be best choice.

I've used both morphine and methadone in previous jobs, but mainly morphine which I'm therefore much more familiar with.

Probably leaning towards methadone. Don't think should be a problem using it up in 28days (can give to routine neuters etc which currently get buprenorphine if needs used up faster). Not able to use in CRI is bigger problem as in-patients do not get injections after 10pm unless transferred to expensive OOH provider - currently I would leave the likes of a fracture repair on a ketamine-infusion overnight post-op, and would have liked to be able to leave on morphine also, otherwise keeping to buprenorphine overnight as at least longer-duration of action and less likely analgesia will 'run-out' in middle of night than with single methadone inj.

NB: Having now worked with no full-agonists for 3 months, I have found has not been as disastrous as one might have expected. Buprenorphine might take 30-40mins to take effect, but does seem reasonably effective and certainly seems to be able to be titrated up to effective dose like full-agonists can (I tend to give 0.02mg/kg initially, but further doses subjectively seem to have a beneficial effect to me and not noted any problems with 'overdose' as yet). Also medetomidine (appreciate would be concerns in systemically unwell patients) is a great analgesic I think - with a buprenorphine/medetomidine premed, ketamine CRI and judicious use of LA's, I find most fracture repairs can be done under about 1.5% isoflurane GA and recover well and appear comfortable afterwards.

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Sarah Keir — Thu, 08 Sep 2011 19:30:36 GMT

I used to use fentanyl patches for seriously painful things that need analgesia over the next few days but I've gone off them in favour of CRI (morphine or morphine/ketamine). Bad about Durogesic patches - nearly always have problems with them staying on, I will only send home on animals if 'sensible' owners who I know will call if problems/actually come back, very variable affect, still have to give other injectables for first 24h. On the theme of hair growth, if you check cat spay clips after a week there is impressive amount of hair growth! So hair growth over a few days must have some affect. Bad about CRI - can make them zonked or at very least off food, but can control amount.

I am a little worried there is a practice out there that has no profound analgesia (i.e. full opiods) for severe pain. May be you don't get RTAs?

We mustn't forget the greatest form of pain relief - euthanasia.

Sarah

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Andrew Kent — Wed, 07 Sep 2011 17:47:16 GMT

I have played around with fentanyl patches in the past but never found them particularly effective, anecdotally they seem to work better in cats (kick in quicker) but have found them fairly useless in dogs where they can take 24 hours to be therapeutic.

I do however like fentanyl CRI especially during anaesthetics.

Andy

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Hannah Wynne Richards — Wed, 07 Sep 2011 17:41:14 GMT

I spoke to John Hird about fentanyl patches,as I was worried about the legalimplications of sending dogs home with them, and he said they didn't work very well

Wynne

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

An On MRCVS — Wed, 07 Sep 2011 15:46:52 GMT

I,m a bit puzzled by these fentanyl patches. According to the BSAVA formulary we need a 100mcg one for a 25kg dog. OK but as far as i can see from the wholesaler prices we would have to charge 50 pounds or nearly just for one patch. Is that what you guys charge?

Also, looking at the formulary it's a bit vague about the efficacy: stuff about concentrations can be very variable, some animals may not develop adequate plasma concentrations. And then heat sources will increase the uptake which is worrying.

Are you sure they are so good? Enough to be worth the big cost?

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Amanda Nicholls — Wed, 07 Sep 2011 14:32:34 GMT

[quote user="robloxley"]

Not sure whether however moving from single use to multidose vials will make it easier to keep accurate track of stock levels...

[/quote]

The multidose vial is going to be a complete PITA for me as I only use tiny amounts for cat premeds, certainly won't use 10mls every month. I've not yet had to get anyone in to witness me disposing of any Sch 2's as I manage to use up what I've ordered in!

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Rob Loxley — Wed, 07 Sep 2011 13:41:51 GMT

[quote user="David Beattie"]The practice I currently work in has only buprenorphine, I'd been looking to get a full agonist, but before asking was trying to decide which?? This discussion has been helpful, but I'm still struggling to decide![/quote]

We went for methadone first, but once you've got all the procedures/protocols in place for dealing with schedule 2 CDs then getting another type e.g. morphine or fentanyl is no real bother (as long as you don't let them go out of date...).

Not sure whether however moving from single use to multidose vials will make it easier to keep accurate track of stock levels...

Re: Morphine V Methadone V Fentanyl analgesia in dogs and cats

Andrew Kent — Wed, 07 Sep 2011 09:33:23 GMT

Methadone is not suitable for use as a CRI due to it's pharmacokinetics as you get cumulative build over a period of time (so anaesthetists leas me to believe) but it is fine to give IV at a slightly lower dose range. I always administer it this way. Andy