Protocols - Hemorio

- Its great indications are: neurotoxicity with morphine and neupathic pain
(where it is up to 3 times more potent than morphine), and pains that barely
respond to the other usual regimes.
- Its higher indication is for subjects that may not use Morphine (if there is any
proper indication for such, as the case of subjects in disintoxication or psychic
dependence in treatment).
- The chosen opioid at the algic crisis is Morphine, mainly in the acute crisis of
Falciform Disease because the origin is ischemic, which is an indication for
Morphine. After the control of the pain, Morphine may be changed to other
opioid or to its oral presentation, making use of the conversion scale even for
the oral methadone, if the case may be.
- It may be used as the first choice or in rotation to another opioid:
A – If you start as the first choice, i.e., the first opioid: The ideal is the
subject to know how to write and read and be capable to complete the
outpatient clinic form about pain, bring it at the next appointment, which must
be done at most 10 days thereafter.
1. Start with methadone 5-10mg every 12h, with a rescue drug of 5 mg (up to
every 3 h);
2. If the pain has a minimum relieve, consider an increase for 10mg (if you
started with 5mg) every 12h and 5mg of rescue;
3. In case of any relieve of the pain until the value 2 of EAV, instruct the
subject just to take a new similar dose of 5 mg, 4 hours or more, as soon as
the pain starts to increase and to write down the interval in the form;
4. Try to keep the same dose and interval for 4-6 days until reaching the
steady state. The intervals must be written down as well;
5. After the first week, the notes will be analyzed. As methadone accumulates,
the time of analgesia increases and the daily dose will be calculated based on
the notes of the last 2 or 3 days and divided by 12;
6. The night dose can be a little higher in order to assure a night with no pain;
7. Sedation or nauseas and/or vomits are overdose signs. Then, the next dose
must be decreased in 50% and reevaluated;
8. If the pain presents a minimum relieve, consider increase to 10mg of
methadone;
9. The dose may be increased from 1/3 to 1/4 once a week, in accordance to
the rescue number;
10. Try to keep the same dose and interval for 4 - 7 days until reaching the
steady state. On day 5 or 6, calculate the dose taken by day on the last 48 h,
added the rescues. Divide the total dose for interval every 12 h up to every 6 h,
in accordance to the interval of each subject;
11. The equivalent dose of Methadone changes in accordance to the dose
previously used. I.e., the dose of Methadone will be calculated from the dose of
the previous opioid;
12. Methadone must be used carefully in the elderly, at the cachexia or in
subjects with a clearance changed;
B – If you make a rotation with Morphine: The rotation of other opioid for
methadone directly is not recommended, in case of parenteral methadone.
If it is necessary, convert the opioid for oral methadone, the total found will be
divided by two in order to reach the SC dose.
E.g., oral methadone dose on the 24h = 40mg. The SC dose is 20mg on the
24h. Se below the table for conversion.
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