Few topics in hospital-based pain management generate such diverse viewpoints as the use of methadone as an analgesic. Increasingly ordered by hospice physicians and some hospitalists as a tool for managing difficult pain cases, it is also coming under scrutiny for risks related to cardiac complications, respiratory depression, and the challenges of determining appropriate doses.
For some, the risks are grave enough to contraindicate methadone prescription for use in routine hospital practice, unless the hospitalist is well-versed in its use and has access to a pharmacist or other pain expert to review medication orders. Hospitalists should also be aware of the Food and Drug Administration’s strongly worded November 2006 Public Health Advisory, “Methadone Use for Pain Control May Result in Death and Life-Threatening Changes in Breathing and Heart Beat.”1
The FDA stopped short of recommending against the use of methadone as an analgesic, but it admonished physicians to use caution when prescribing it for patients unused to the drug—particularly during drug initiation, conversion from another opioid, or titration upward. Patients should be cautioned to take the drug exactly as prescribed. The advisory also recommended a new maximum initial dose of 30 mg per day (typically prescribed 10 mg tid), when initiating methadone for pain management.
Jean Youngwerth, MD, associate program director of the University of Colorado at Denver and Health Sciences Center, is well aware of the benefits and risks of prescribing methadone in her dual roles as hospitalist and palliative care consultant. “It is a great analgesic, becoming a lot more popular in recent years,” Dr. Youngwerth says. “It’s also ridiculously cheap [often under a dollar a day], which is an important consideration for some of our patients returning home with chronic pain. For other patients, it’s an extra analgesic tool, giving good pain relief, especially for refractory somatic or neuropathic pain.”
But methadone also has downsides. “Its pharmaco-kinetics are so complex and poorly understood that people unfamiliar with prescribing it can get in trouble in a hurry,” Dr. Youngwerth says. “You can kill people with oversedation. I do not prescribe it in my hospitalist practice and I discourage other hospitalists from prescribing it for their patients without consulting a pain or palliative care specialist. You don’t see its maximal effects until at least three to four days out, and that’s usually too long for the hospitalist. When I start palliative care patients on methadone, I normally keep them in the hospital for three or four days so that I can monitor the effects.”
Dr. Youngwerth believes her experience in pain management justifies prescribing methadone for palliative care patients. Even so, she always calls one of the local physician pain experts she works with or a hospital pharmacist to make sure she is ordering it safely and correctly. “I don’t think doctors should be scared off by all the bad publicity about methadone, but they need to realize these are valid concerns,” she says. “People run into problems when they assume that it is just another opioid.”
Hospitalists must recognize the stark realities of using the drug.
“Methadone is the easiest opioid to kill someone with,” says Gail Gazelle, MD, palliative care physician with MD Can Help and Harvard Medical School in Boston. “At the same time, its unique properties can give analgesic effects you can get from no other drug.”
For hospitalists, these issues are complicated by their short involvement with hospitalized patients, who are quickly prepped for discharge back to various community settings and living situations.
Dr. Gazelle wonders, “Is a short hospital stay the right place to initiate methadone treatment, given all of the complications?” If the answer is yes, communicating with the attending and agreeing on a plan for its continued use after discharge from the hospital are essential.