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Methadone is familiar to most laypersons as a treatment for heroin addiction, dispensed at special clinics. Methadone is also a powerful, inexpensive, and effective analgesic, but it has many unique and potentially lethal aspects that have to be well understood before using it for pain relief. Addiction treatment with methadone requires a special license, but any provider who can prescribe Schedule II medications can write for methadone for pain. Unfortunately, because no special training is required to prescribe methadone and because poor insurance coverage is leading to the increased use of inexpensive methadone, there has been a tragic dramatic increase in opioid deaths attributed to methadone. This chapter reviews the indications, contraindications, drug interactions, metabolism, genetic issues, ethics, and initial evaluation and treatment for methadone.
This chapter presents a case study of a healthy 15-year-old girl for elective diagnostic ankle arthroscopy for ankle pain and swelling. Using the study as a reference, it focuses on the ethical issues related to common, routine preoperative tests. The chapter examines two preoperative tests with special social implications: HIV and pregnancy testing. The informed consent process requires respect for informed refusal, and with rare exceptions, patients should not be coerced into undergoing screening pregnancy testing by threatening to cancel the case if they refuse. Good medical practice, both from ethical and medical standpoints, includes applying evidence-based guidelines in determining if a preoperative test should be done. Pregnancy testing and HIV testing are examples of tests with significant social implications, but little proven medical benefit as screening tests. Policies requiring such tests should be reconsidered in light of the ethical principles respecting patient autonomy and striving for beneficence and nonmaleficence.