Methadone’s Merits
Why would a hospitalist want to prescribe a drug that comes with so many caveats?
Carol Jessop, MD, a hospitalist and palliative care consultant at Alta Bates Summit Medical Center in Berkeley, Calif., uses methadone—often in combination with the anti-depressant desipramine or the anticonvulsant gabapentin—to treat complex regional pain syndromes and neuropathic pain.
Dr. Jessop carefully assesses patients for neuropathic pain, listening for descriptors such as burning, stinging, or numbing. These are the patients for whom she most often receives palliative care consultations, often following years of out-of-control pain or lack of response to high doses of other opioids. “My job is much easier now that I understand the difference between nocioceptive and neuropathic pain,” she notes.
“I think methadone is magic, perhaps due to its effect on the NMDA (n-methyl, d-asparte) receptors,” Dr. Jessop says. “I’m also convinced from my clinical experience that there can be nerve healing going on when these pain syndromes are effectively treated. I had a patient with horrible phantom pain following multiple hip surgeries and amputation of his leg. He was referred by a family practitioner, who said, ‘I cannot get this man’s pain under control.’ ” The patient’s pain is now controlled with methadone, 30 mg three times a day. He rarely needs to take his hydromorphone (Dilaudid) for breakthrough pain, and he is able to use his prosthetic leg—which would have been unthinkable before.
Dr. Jessop believes low doses of methadone—even lower than the conversion charts recommend—can have a big effect. “I don’t have problems with methadone because I’m so careful in prescribing it,” she says. “I also work closely with the attending physician and give patients my cell phone number when they return home. It is important to get the family involved and to be clear about the risks and benefits.”
Brad Stuart, MD, senior medical director of Sutter VNA and Hospice in Northern California, also believes methadone can be a wonderful pain management tool. “There is no substitute, in my estimation, to adding a little methadone to the opioid regimen—even just 5 mg of liquid three times a day—for difficult neuropathic pain cases,” Dr. Stuart says. “It’s true that you don’t want to raise the dose too quickly. But I find that it’s unusual not to see benefit in these kinds of patients. I disagree with those who would advise hospitalists to stay away from methadone for treating refractory neuropathic pain. If you start slow and go slow, the risks are small relative to the gain.”
Eduardo Bruera, MD, a palliative care physician at M.D. Anderson Cancer Center in Houston, is another believer in methadone for difficult pain cases, although he emphasizes that his experience is limited to the pain associated with cancer. Dr. Bruera does not use methadone as a first-line analgesic, but he finds it effective when other opioids have not been. “Patients who continue to have a lot of pain after multiple escalating opioid doses or signs of opioid toxicity may be signaling that the opioid you’re using is not working,” he says. “If we make three or four dose changes without response, it’s time to change the opioid.”
Dr. Bruera acknowledges that persuasive research studies to establish methadone’s purported efficacy in treating neuropathic pain have not been conducted. “Unfortunately, methadone is an orphan drug, so we don’t know who would pay for those studies. Should we consider it as a first-line opioid for cancer pain? Again, that is an unanswered question.”