Dr. Bruera has been involved in a number of the few published studies and reviews of methadone’s analgesic efficacy, and he is engaged in ongoing orphan drug status research.12, 13
Methadone as Analgesic
Stephen Bekanich, MD, hospitalist and palliative care consultant at the University of Utah Medical Center in Salt Lake City, falls in the middle range of opinions on methadone.
“From the hospitalist’s standpoint, there are downsides,” Dr. Bekanich says. “People who don’t understand how to titrate it may change doses on a daily basis or more often, which is dangerous. They may not understand the dosing equivalents or pay enough attention to drug interactions.
“Of all the opioids, careful assessment and follow-up may be the most important with methadone. Always make sure you have concrete post-discharge plans. If I didn’t have a pharmacist to collaborate with, as a hospitalist I’d probably stay away from it. But it’s different when I put on my palliative care hat.”
Rachelle Bernacki, MD, a hospitalist, palliative care physician and geriatrician at the University of California-San Francisco Medical Center, agrees methadone can be a useful analgesic—particularly when other opioids have failed to relieve the pain. “But I don’t start with it; I may add a small dose of methadone to the existing regimen for complex pain,” she says.
“I caution my residents not to try methadone without consulting with someone familiar with the drug,” explains Dr. Bernacki, who adds that she is fortunate to work with a pharmacist at UCSF who is an expert in pain management and palliative medicine. “Having taught residents, I can confirm that there is a lot of confusion about its use. But I have also used methadone in my outpatient geriatric practice—with fantastic results.”
Paresh Patel, MD, a hospitalist at VCU Medical Center, says he and his colleagues use methadone as a second-line analgesic when pain is not well managed with morphine. He always keeps an eye out for the risks, including potential interactions with psychiatric medications and the need to look at EKGs.
Dr. Patel says conversion from other opioids is one of the biggest challenges in using methadone. He is not satisfied with the various published opioid conversion charts and relies on experience and trial and error. “I always wait 48 hours before titrating up,” he says.
More research is needed in this area, Dr. Patel says, and he is thinking of getting involved in a methadone research project. TH
Larry Beresford is a frequent contributor to The Hospitalist.
References
- Food and Drug Administration. FDA Public Health Advisory: Methadone use for pain control may result in death and life-threatening changes in breathing and heart beat. Available at: www.fda.gov/cder/drug/advisory/methadone.htm. Last accessed June 4, 2007.
- Moulin DE, Palma D, Watling C, et al. Methadone in the management of intractable neuropathic noncancer pain. Can J Neurol Sci. 2005 Aug: 32(3); 340-343.
- Altier N, Dion D, Boulanger A, et al. Management of chronic neuropathic pain with methadone: A review of 13 cases. Clin J Pain. 2005 Jul-Aug;21(4):364-369.
- Morley JS, Bridson J, Nash TP, et al. Low-dose methadone has an analgesic effect in neuropathic pain: A double-blind randomized controlled crossover trial. Palliat Med. 2003 Oct;17(7):576-587.
- Lawlor PG, Turner KS, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: A retrospective study. Cancer. 1998 Mar;82(6):1167-1173.
- Ripamonti C, De Conno F, Groff L, et al. Equianal-gesic dose/ratio between methadone and other opioid agonists in cancer pain: Comparison of two clinical experiences. Ann Oncol. 1998 Jan;9(1):79-83.
- Gazelle G, Fine PG. Fast Fact and Concept #75: Methadone for the treatment of pain. End-of-Life/Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee, www.eperc.mcw.edu/ff_index.htm
- American Methadone Treatment Association. 1998 Methadone Maintenance Program and Patient Census in the U.S., New York, NY, April 1999.
- Office of National Drug Control Policy. Fact sheet. Available at: www.whitehousedrugpolicy.gov. Last accessed June 4, 2007.
- Finn S, Tuckwiller T. The Killer Cure. The Charlotte (W. Va.) Gazette. Available at: www.wvgazette.com. Last accessed June 29, 2007.
- Weaver MF, Schnoll SH. Opioid treatment of chronic pain in patients with addiction. J Pain Palliat Care Pharmacother. 2002:16(3);5-26.
- Bruera E, Sweeney C. Methadone use in cancer patients with pain: A review. J Palliat Med. 2002 Feb;5(1):127-137.
- Bruera E, Palmer JL, Bosnjak S, et al. Methadone versus morphine as a first-line strong opioid for cancer pain: A randomized, double-blind study. J Clin Oncol. 2004 Jan 1;22(1):185-192.