My guests today are Abigail Lee and Johanna Bennett, two Doctor of Nursing Practice graduate students at the University of New England who focused their DNP project on perioperative use of IV methadone.
Abigail Lee attended Southern Maine Community College and transferred to the University of Southern Maine to study nursing. She worked at Maine Medical Center in the Cardiothoracic Intensive Care Unit. She intends to head down to North Carolina to work as a CRNA.
Johanna Bennett went to Saint Anselm College. She started her career in healthcare in the Medical/COVID ICU as a new graduate nurse and worked there for three years before starting CRNA school at the University of New England. Jo will be joining our team at Maine Medical Center to work as a CRNA.
This episode is on the longer side, so here’s your TL:DL, too-long; didn’t listen summary of perioperative IV methadone – the opioid-spairing opioid.
Standard short-acting pure mu-agonists—like fentanyl, hydromorphone, and morphine—often leave our patients trapped in a roller coaster of ‘peaks and valleys,’ leading to oversedation, unexpected pain spikes, and high total opioid consumption in the PACU.
In this episode, we explore why methadone is uniquely positioned as the ‘opioid-sparing opioid.’ Beyond its strong 
-receptor agonism, methadone boasts NMDA receptor antagonism and serotonin/norepinephrine reuptake inhibition, targeting pain at multiple pathways to blunt central sensitization and wind-up phenomenon.
Key Clinical Takeaways from the Literature:
- The Effective Dose: An ideal single dose on induction is 0.2 to 0.25 mg/kg ideal body weight (or roughly 10-20 mgIV). Underdosing (<0.1 mg/kg) eliminates the long-term benefit, while dosing over 0.3 mg/kg slightly increases transient PACU sedation without adding extra analgesia.
- Where it Shines: Greatest reductions in PACU pain scores and overall post-op opioid consumption occur in high-nociceptive surgeries—like multi-level spinal fusions, cardiac, thoracic, and major reconstructive procedures.
- Safety Profile: A single intraoperative dose displays a safety profile comparable to short-acting opioids—with no increased incidence of delayed respiratory depression, PONV, or QT prolongation in acute, single-dose settings.
I want to share one particular guideline that I’m familiar where the hospital developed a clinical guideline to help their team incorporate IV methadone as a perioperative analgesic.
The key points in this guideline include:
1. Consider using methadone in surgeries lasting greater than an hour which are at high risk of significant postoperative pain, especially when patients are not candidates for epidurals or regional blocks.
2. Avoid the use of methadone in patients who have a baseline prolonged QTc or with those patients who are on buprenorphine or in surgeries less than one hour since the peak respiratory depression is about 45 minutes after administration.
3. The typical dose proposed in the guideline is 0.2 mg/kg of ideal body weight IV with consideration to reduce the dose to 1.5 mg/kg for surgeries that have a same day discharge plan. Rescue doses of 3 to 5 mg are used instead of hydromorphone after the end of the procedure if needed for post-operative analgesia.
4. This center continues to use standard PACU orders for IV and PO analgesia following the use of methadone
5. On the buprenorphine point: Methadone has a significantly lower binding affinity for mu-receptors than buprenorphine so in patients who are actively taking buprenorphine, single dose perioperative methadone is relatively ineffective without alternative strategies like weaning the buprenorphine or interventions tailored for patients with chronic pain or opioid use disorder – which are both beyond the scope of this podcast.
If you want to hear a little more about the challenges around pain management with patients on buprenorphine in particular, please go listen to episode 13 of Anesthesia Guidebook with Aurora Quaye, MD, one of the leading researchers in this space and a pain management specialist at Maine Medical Center in Portland. We recorded that show way back in March of 2020, so it probably is time to check back in and get the latest on all the research and amazing work her and her team have been doing in the last several years.
So, that’s a little primer on where we’re headed today. I want to thank Johanna and Abigail for their incredible walk through of methadone in this conversation, as all as for the tips they share on navigating the DNP project process.
If you’re looking to eliminate PACU pain spikes, optimize your patient’s chance for enhanced recovery, or rethink your perioperative analgesic strategy, this deep dive is for you.
And with that, let’s get to the show.
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