Methadone: Starting Dosing Information
Authors: Frank Ferris MD and Charles F.Von Gunten MD
life greater than an oozing, odorous, painful, and bleeding
malignant skin wound. The pathology of a primary or
metastatic cancer to the skin leading to an open wound
is a combination of neovascularization, necrosis, and
inflammation, leading to pain, bleeding, odor, and exudate.
As with other chronic wounds, a fundamental decision needs
to be made about whether the wound can eventually heal
or not. The choice of dressing is generally the same as with
pressure ulcers. However, malignant wound management
raises additional issues that deserve comment. Note: For any
complex wound, it is recommended you seek professional
consultation from a wound care expert.
wounds. The overall goal is to prevent exudate macerating
other normal tissues or dripping off the patient into clothes
and bedclothes. This serves both infection control as well as
cosmetic goals. One can use absorbent foams to minimize
the frequency of dressing changes and maximize absorption.
Typically a gauze pad (such as an ABD pad) is placed on
top of the foam. Alginate dressings have a role in wounds
that have exudates and/or are bleeding. They are absorptive,
hemostatic, and help to control infection. They do not have to
be pulled off and can simply be washed off in shower.
infection, especially with anaerobic or fungal species. Odor
is frequently the first sign of anaerobic infection along
with a purulent exudate. If the infection is only superficial,
topical treatment (metronidazole, silver sulfadiazine) may be
sufficient. However, if there is evidence of a deeper tissue
infection, then systematic metronidazole should be used.
If the wound is determined to be non-healing, then topical
agents like povidone can be used; however, some patients
find it irritating and painful. Povidone is cytotoxic to bacteria
and will keep the wound clean. Povidone should not be used
for wounds that are expected to heal because it is cytotoxic
to normal granulation tissue.
absorbers; kitty litter or activated charcoal can be placed
on a cookie tray underneath the bed. In addition there are
charcoal dressings that can be used to cover a particularly
malodorous wound. Additional approaches include a candle
in the room in an attempt to combust the chemicals causing
odor. One can also introduce a competing odor; bowls of
vinegar, vanilla, or coffee. Fragrances and perfumes are
often poorly tolerated by patients and should be avoided.
may be friable and predispose to bleeding. It may either
present as oozing (micro vascular fragmentation) or vascular
disruption from necrosis or sloughing leading to “a bleeder.”
Any dressing that comes into contact with the surface may
adhere and tear the surface when it is pulled off (e.g. saline,
wet-dry dressings). Tis can be prevented by using a mesh
synthetic polymer, non-stick, non-absorptive dressing (e.g.
Mepitel). Other options to control bleeding are alginate
dressings, topical low dose (100 U/ml) thromboplastin, silver
nitrate, or cautery. In addition to systematic treatments for
pain (e.g. oral or parenteral opioids), local anesthetics can
also be helpful.
assessment and management. In: Krasner DL, Rodeheaver GT,
Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for
Authors: Lynn Hallarman MD and Clare Kearns MSW
Background: 54,000 American Veterans die each month
and account for one quarter of all US deaths. Inquiring
about military service has both practical and therapeutic
benefits. Hospice care is now a covered benefit for all
enrolled Veterans and the Veteran Administration will
purchase hospice services from local communities it serves.
Military service can be a core experience in defining the way
Veterans live and die. Knowing the components of a military
history can be a useful tool in bridging the silence that often
surrounds the war experience and can act as a catalyst
for discussions about end of life preferences. Establishing
an environment of trust is critical when speaking with war
Veterans about end of life care. A polite inquiry about military
service is a good way to create an atmosphere of respect,
keeping in mind that not all Veterans will want to speak with
you about the details of their war experience. Because a
discussion of combat experiences can reactivate deeply
buried issues, it is important to make this known to the
Veteran and ask if he/she wants to proceed.
Listed below are phases to help get started in taking a
• Are you a Veteran?
• Tell me about your military experience.
• What did you do in the military?
• When and where did you serve?
• What branch of the military were you in?
• How has it affected you?
• What was your highest rank?
• Did you see combat or were you in a combat area?
• Did you see enemy fire or casualties?
• Were you ever a prisoner of war?
• Were you wounded or hospitalized?
• Do you currently receive care at a VA?
• Do you have a service connected condition?
Deepening the Military History
• Do you think you were changed as a result of being
in the military? Please describe the changes.
• Do you think your experiences in the military are
affecting you today?
• Is there anything about your experiences that are
still troubling you?
• Do you have nightmares about the war?
• What was your homecoming like? Is there anything
about your homecoming that is still troubling you today?
• Do you think your experiences in the military and your
• Do you keep in touch with your war buddies?
• Do you think your military experiences are
influencing the way you are now coping with your illness?
If the Veteran experiences significant anxiety and needs
psychological assistance, or if you would like guidance, you
can contact your local VA Medical Center to access their
mental health clinics, trauma recovery clinics, or Vet Centers.
2. Beresford L. VA Transforms End of Life Care.
3. Patient resources can be found at: http://www.va.gov.
Search for “Veterans Fact Sheet.”
We’re here when you need us.
Medical Director: Dr. Jeff Lewis
Nursing Director: Lynda Anderson
Executive Director: Joe Muench
Methadone: Starting Dosing Information