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Ding H, Song Y, Xin W, Sun J, Zhong L, Zhou Q, He C, Gong L, Fang L. Methadone switching for refractory cancer pain. Palliat Care 2022; 21:191. [PMID: 36324113 PMCID: PMC9628261 DOI: 10.1186/s12904-022-01076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Methadone is commonly considered an alternative opioid treatment for refractory cancer pain. This study aims to investigate the efficacy, safety, and cost of methadone in the treatment of refractory cancer pain. METHODS A retrospective study was conducted in patients who used methadone for refractory cancer pain from April 2016 to December 2020 at a cancer specialized hospital. Pain control, evaluated via pain score and breakthrough pain frequency, and adverse events of methadone were compared with analgesic regimens prior to methadone administration. The factors potentially affecting the switching outcome were analyzed via multivariate analysis. Moreover, the cost of pain control was estimated. RESULTS Ninety patients received methadone for poor pain control (74.4%), intolerable adverse events (10.0%), or both (15.6%) after prior opioid treatments. Sixty-four patients (71.1%) were successfully switched to methadone with median pain score significantly decreased from 4.0 to 2.0 (p < 0.001) and median daily frequency of breakthrough pain from 3.0 to 0.0 (p < 0.001) at a maintained median conversion ratio of 6.3 [interquartile range (IQR): 4.0-10.0] to prior opioid treatment. Similar adverse event profiles of constipation, nausea, vomiting, and dizziness were observed between methadone and prior opioid regimens. The median daily cost of analgesic regimens was significantly reduced from $19.5 (IQR: 12.3-46.2) to $10.8 (IQR: 7.1-18.7) (p < 0.01) after switching to methadone. The 3-day switch method significantly improved the rate of successful switching compared with the stop and go method (odds ratio = 3.37, 95% CI: 1.30-8.76, p = 0.013). CONCLUSION Methadone is an effective, safe, and cost-saving treatment for patients with refractory cancer pain.
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Affiliation(s)
- Haiying Ding
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Yu Song
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Wenxiu Xin
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Jiao Sun
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China ,grid.417397.f0000 0004 1808 0985Zhejiang Key Laboratory of Prevention, Diagnosis and Therapy of Upper Gastrointestinal Cancer, Zhejiang Cancer Hospital, 310022 Hangzhou, China
| | - Like Zhong
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China ,grid.417397.f0000 0004 1808 0985Zhejiang Key Laboratory of Prevention, Diagnosis and Therapy of Upper Gastrointestinal Cancer, Zhejiang Cancer Hospital, 310022 Hangzhou, China
| | - Qinfei Zhou
- grid.410726.60000 0004 1797 8419Department of Rare Cancer & Head and Neck Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Chaoneng He
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Liyan Gong
- grid.410726.60000 0004 1797 8419Department of Rare Cancer & Head and Neck Medical Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Luo Fang
- grid.410726.60000 0004 1797 8419Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) , Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China ,grid.417397.f0000 0004 1808 0985Zhejiang Key Laboratory of Prevention, Diagnosis and Therapy of Upper Gastrointestinal Cancer, Zhejiang Cancer Hospital, 310022 Hangzhou, China
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2
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Treillet E, Giet O, Picard S, Laurent S, Seresse L. Methadone Switching for Cancer Pain: A New Classification of Initiation Protocols, Based on a Critical Literature Review. J Palliat Med 2021; 24:1884-1894. [PMID: 34851186 DOI: 10.1089/jpm.2021.0309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The initiation of methadone, a known effective analgesic for cancer pain, is complex. The existing protocols are often inadequately described; therefore, a classification of literature is needed. We reviewed and classified the recent literature on methadone initiation protocols in cancer patients experiencing severe pain. Objective: To provide a new classification of initiation protocols, based on a critical literature review. Data Sources: The MEDLINE database was searched for articles published until March 25, 2021, using the terms "cancer pain," "methadone," "methadone introduction," or "methadone initiation." The search was limited to human studies, randomized controlled trials (RCTs), other clinical trials, meta-analyses, and case reports. Selected articles were assessed for initiation details (rapid or progressive), administered dose (fixed rescue dose or ad libitum), and dose calculation (fixed or progressive ratios using morphine equivalent daily dose [MEDD] for daily or unitary dose). Results: Twenty-four publications that met our inclusion criteria were analyzed. No large-scale prospective double-blind RCTs with robust design were identified. Most studies assessed relatively small numbers of patients. Eight initiation types were identified, of which three involved seven "high quality" studies: "rapid switch-fixed doses and rescue dose-progressive daily ratio," "progressive switch-fixed dose and rescue dose-progressive daily ratio," and "rapid switch-ad libitum-fixed ratio for unitary dose" protocols. This classification provides the latest information on methadone initiation protocols. The total daily dose of methadone varied largely across protocols. Conclusion: We recommend a maximal daily methadone dose of 100 mg (3 doses of 30 mg or 5 doses of 20 mg) for MEDD <500 mg, when the two "ad libitum" protocols are used. Further clinical research on this topic is warranted.
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Affiliation(s)
- Erwan Treillet
- Pain Unit, Colmar Civil Hospital, Colmar, France.,Palliative Care Mobile Unit, Santé Centre Alsace, Colmar, France.,Pain Unit, APHP Lariboisiere Hospital, Paris, France
| | - Olivier Giet
- Palliative Care Unit, Colmar Civil Hospital, Colmar, France
| | - Stéphane Picard
- Palliative Care Unit, Hopital Diaconnesse Croix Saint Simon, Paris, France
| | | | - Laure Seresse
- Palliative Care Mobile Unit, APHP Pitie Salpetriere Hospital, Paris, France
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3
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Paul AK, Smith CM, Rahmatullah M, Nissapatorn V, Wilairatana P, Spetea M, Gueven N, Dietis N. Opioid Analgesia and Opioid-Induced Adverse Effects: A Review. Pharmaceuticals (Basel) 2021; 14:1091. [PMID: 34832873 PMCID: PMC8620360 DOI: 10.3390/ph14111091] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 01/08/2023] Open
Abstract
Opioids are widely used as therapeutic agents against moderate to severe acute and chronic pain. Still, these classes of analgesic drugs have many potential limitations as they induce analgesic tolerance, addiction and numerous behavioural adverse effects that often result in patient non-compliance. As opium and opioids have been traditionally used as painkillers, the exact mechanisms of their adverse reactions over repeated use are multifactorial and not fully understood. Older adults suffer from cancer and non-cancer chronic pain more than younger adults, due to the physiological changes related to ageing and their reduced metabolic capabilities and thus show an increased number of adverse reactions to opioid drugs. All clinically used opioids are μ-opioid receptor agonists, and the major adverse effects are directly or potentially connected to this receptor. Multifunctional opioid ligands or peripherally restricted opioids may elicit fewer adverse effects, as shown in preclinical studies, but these results need reproducibility from further extensive clinical trials. The current review aims to overview various mechanisms involved in the adverse effects induced by opioids, to provide a better understanding of the underlying pathophysiology and, ultimately, to help develop an effective therapeutic strategy to better manage pain.
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Affiliation(s)
- Alok K. Paul
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia;
| | - Craig M. Smith
- School of Medicine, Institute for Mental and Physical Health and Clinical Translation, Deakin University, Geelong, VIC 3216, Australia;
| | - Mohammed Rahmatullah
- Department of Biotechnology & Genetic Engineering, University of Development Alternative, Dhanmondi, Dhaka 1207, Bangladesh;
| | - Veeranoot Nissapatorn
- School of Allied Health Sciences, World Union for Herbal Drug Discovery (WUHeDD) and Research Excellence Center for Innovation and Health Products (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand;
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Mariana Spetea
- Department of Pharmaceutical Chemistry, Institute of Pharmacy and Center for Molecular Biosciences (CMBI), University of Innsbruck, Innrain 80–82, 6020 Innsbruck, Austria;
| | - Nuri Gueven
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia;
| | - Nikolas Dietis
- Medical School, University of Cyprus, Nicosia 1678, Cyprus;
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4
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Abstract
Methadone is increasingly being used for its analgesic properties. Despite the increasing popularity, many healthcare providers are not familiar with methadone's complex pharmacology and best practices surrounding its use. The purpose of this narrative review article is to discuss the pharmacology of methadone, the evidence surrounding methadone's use in acute pain management and both chronic cancer and non-cancer pain settings, as well as highlight pertinent safety, monitoring, and opioid rotation considerations. Methadone has a unique mechanism of action when compared with all other opioids and for this reason methadone has come to hold a niche role in the management of opioid-induced hyperalgesia and central sensitization. Understanding of the mechanisms of variability in methadone disposition and drug interactions has evolved over the years, with the latest evidence revealing that CYP 2B6 is the major determinant of methadone elimination and plays a key role in methadone-related drug interactions. From an acute pain perspective, most studies evaluating the use of intraoperative intravenous methadone have reported lower pain scores and post-operative opioid requirements. Oral methadone is predominantly used as a second-line opioid treatment for select chronic pain conditions. As a result, several oral morphine to oral methadone conversion ratios have been proposed, as have methods in which to rotate to methadone. From an efficacy standpoint, limited literature exists regarding the effectiveness of methadone in the chronic pain setting with most of the available efficacy data pertaining to methadone's use in the treatment of cancer pain. Many of the prospective studies that exist feature low participant numbers. Few clinical trials investigating the role of methadone as an analgesic treatment are currently underway. The complicated pharmacokinetic properties of methadone and risks of harm associated with this drug highlight how critically important it is that healthcare providers understand these features before prescribing/dispensing methadone. Particular caution is required when converting patients from other opioids to methadone and for this reason only experienced healthcare providers should undertake such a task. Further randomized trials with larger sample sizes are needed to better define the effective and safe use of methadone for pain management.
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Affiliation(s)
- Denise Kreutzwiser
- Pain Management Program, St. Joseph's Hospital, St. Joseph's Health Care London, London, ON, Canada.
| | - Qutaiba A Tawfic
- Department of Anesthesia and Perioperative Medicine, Western University, London Health Sciences Centre, and St. Joseph's Health Care London, London, ON, Canada
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5
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Sulistio M, Wojnar R, Key S, Kwok J, Al-Rubaie Z, Michael N. The role of methadone in cancer-induced bone pain: a retrospective cohort study. Support Care Cancer 2020; 29:1327-1335. [PMID: 32627056 DOI: 10.1007/s00520-020-05606-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/26/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Cancer-induced bone pain (CIBP) can be challenging to manage in advanced cancer. The unique properties of methadone may have a role in refractory CIBP. We aimed to evaluate the analgesic effects of methadone for CIBP when other opioids are ineffective or intolerable. METHODS A retrospective study of palliative care inpatients rotated to methadone from another opioid for CIBP over a 4-year period. Primary outcome was ≥ 30% reduction in pain intensity (11-point numeric rating scale) from baseline to completion of methadone rotation (MR). Secondary outcomes were ≥ 50% reduction in pain intensity and changes in long-acting and breakthrough opioid requirements. RESULTS Ninety-four eligible patients completed MR for the following reasons: poor pain control (72.3%), opioid toxicities (4.3%) or both (23.4%). On completion of MR, 70.2% and 53.2% achieved a ≥ 30% and ≥ 50% reduction in pain respectively, with mean pain intensity score reduced from 5.6 (SD = 2.1) at baseline to 2.6 (SD = 2.5) (p < 0.001). Mean calculated daily methadone dose pre-MR was 25.7 mg (SD = 10.9), with 72.3% of patients requiring a lower dose on completion of MR (mean 17.0 mg, SD = 8.5). The mean number of breakthrough opioid analgesia used a day reduced from 3.4 (SD = 2.3) to 1.8 (SD = 1.7) (p < 0.001). CONCLUSIONS MR for CIBP may result in reduction in pain intensity, when other opioids are ineffective or intolerable, with patients requiring reduced overall dosing of their long-acting opioid and frequency of breakthrough opioid use.
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Affiliation(s)
- Merlina Sulistio
- Palliative and Supportive Care Research Department, Cabrini Health, 646 High St, Prahran, Melbourne, VIC, 3181, Australia.
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
| | - Robert Wojnar
- Palliative and Supportive Care Research Department, Cabrini Health, 646 High St, Prahran, Melbourne, VIC, 3181, Australia
| | - Seraphina Key
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Justin Kwok
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ziad Al-Rubaie
- School of Medicine, University of Notre Dame Australia Sydney, Sydney, NSW, Australia
| | - Natasha Michael
- Palliative and Supportive Care Research Department, Cabrini Health, 646 High St, Prahran, Melbourne, VIC, 3181, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- School of Medicine, University of Notre Dame Australia Sydney, Sydney, NSW, Australia
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6
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Abstract
OPINION STATEMENT The opioid epidemic is one of the most important public health crises as opioid-related deaths have become a leading cause of accidental death in the USA. Various efforts have been made to understand how to safely and appropriately prescribe opioids for patients with chronic pain, including those with cancer-related pain. We find the guidelines proposed by the Expert Consensus White Paper on the use of methadone to be current, comprehensive, and practical. While methadone is a complex medication with unique pharmacokinetics and pharmacodynamics, it remains a superior choice for many patients with cancer pain given its cost and applicability in a variety of situations. Methadone should be prescribed in the context of experienced clinicians as well as an interdisciplinary team. At a critical time when preventing opioid-related deaths is a priority, we recommend implementing additional precautions for monitoring including universal screening for risk of non-medical opioid use, education on proper storage and disposal, as well as discussing a plan with patients and caregivers in the case of serious complications such as opioid overdose.
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Affiliation(s)
- Yvonne Heung
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1414, Houston, TX, 77030, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1414, Houston, TX, 77030, USA.
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7
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Borius PY, Garnier SR, Baumstarck K, Castinetti F, Donnet A, Guedj E, Cornu P, Blond S, Salas S, Régis J. An Open-Label, Analgesic Efficacy and Safety of Pituitary Radiosurgery for Patients With Opioid-Refractory Pain: Study Protocol for a Randomized Controlled Trial. Neurosurgery 2019; 83:146-153. [PMID: 28973682 DOI: 10.1093/neuros/nyx363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/05/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypophysectomy performed by craniotomy or percutaneous techniques leads to complete pain relief in more than 70% to 80% of cases for opioid refractory cancer pain. Radiosurgery could be an interesting alternative approach to reduce complications. OBJECTIVE To assess the analgesic efficacy compared with standard of care is the primary goal. The secondary objectives are to assess ophthalmic and endocrine tolerance, drug consumption, quality of life, and mechanisms of analgesic action. METHODS The trial is multicenter, randomized, prospective, and open-label with 2 parallel groups. This concerns patients in palliative care suffering from nociceptive or mixed cancer pain, refractory to standard opioid therapy. Participants will be randomly assigned to the control group receiving standards of care for pain according to recommendations, or to the experimental group receiving a pituitary GammaKnife (Elekta, Stockholm, Sweden) radiosurgery (160 Gy delivered in pituitary gland) associated with standards of care. Evaluation assessments will be taken at baseline, day0, day4, day7, day14, day28, day45, month3, and month6. EXPECTED OUTCOMES We could expect pain improvement in 70% to 90% of cases at day4. In addition we will assess the safety of pituitary radiosurgery in a vulnerable population. The secondary endpoints could show decay of opioid consumption, good patient satisfaction, and improvement of the quality of life. DISCUSSION The design of this study is potentially the most appropriate to demonstrate the efficacy and safety of radiosurgery for this new indication. New recommendations could be obtained in order to improve pain relief and quality of life.
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Affiliation(s)
- Pierre-Yves Borius
- Functional and Stereotaxic Neurosurgery Department, Hopital La Timone, Marseille University Hospital, Marseille, France.,Neurosurgery Department, Hopital Pitié Salpêtrière, Paris University Hospital, Paris, France
| | | | - Karine Baumstarck
- Methodological support Platform, Marseille University Hospital, Marseille, France
| | - Frédéric Castinetti
- Endocrinology Department, Hopital La Timone, Marseille University Hospital, Marseille, France
| | - Anne Donnet
- Pain center, Hopital La Timone, Marseille University Hospital, Marseille, France
| | - Eric Guedj
- Nuclear Medicine Department, Hopital La Timone, Marseille University Hospital, Marseille, France
| | - Philippe Cornu
- Neurosurgery Department, Hopital Pitié Salpêtrière, Paris University Hospital, Paris, France
| | - Serge Blond
- Functional Neurosurgery Department, Lille University Hospital, Lille, France
| | - Sébastien Salas
- Palliative Care Department, Hopital La Timone, Marseille University Hospital, Marseille, France
| | - Jean Régis
- Functional and Stereotaxic Neurosurgery Department, Hopital La Timone, Marseille University Hospital, Marseille, France
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8
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Lukin B, Greenslade J, Kearney AM, Douglas C, Howell T, Barras M, Good P. Conversion of other opioids to methadone: a retrospective comparison of two methods. BMJ Support Palliat Care 2019; 10:201-204. [PMID: 30772842 DOI: 10.1136/bmjspcare-2018-001645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/02/2018] [Accepted: 01/23/2019] [Indexed: 11/04/2022]
Abstract
CONTEXT A rapid method of methadone conversion known as the Perth Protocol is commonly used in Australian palliative care units. There has been no follow-up or validation of this method and no comparison between different methods of conversion. OBJECTIVES The primary objective of this study was to test the hypothesis that the achieved doses of methadone are independent of the conversion method (rapid vs slower). The secondary objectives included examining the relationship between calculated target doses, actual achieved doses and duration of conversions. METHODS This is a retrospective chart audit conducted at two hospital sites in the Brisbane metropolitan area of Australia which used different methadone conversion methods. RESULTS Methadone conversion ratios depended on previous opioid exposure and on the method of conversion used. The method most commonly used in Australia for calculating target doses for methadone when converting from strong opioids is a poor predictor of actual dose achieved. More appropriate conversion ratios are suggested. CONCLUSION Further research is needed to refine the ratios used in practice when converting patients from strong opioids to methadone. Caution and clinical expertise are required. A palliative methadone registry may provide useful insights.
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Affiliation(s)
- Bill Lukin
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Australian Centre for Health Services Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Alison Mary Kearney
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Queensland Emergency Medicine Foundation, Milton, Queensland, Australia
| | - Carol Douglas
- Department of Palliative and Supportive Care, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Tegwen Howell
- Queensland Emergency Medicine Foundation, Milton, Queensland, Australia
| | - Michael Barras
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Phillip Good
- Department of Supportive and Palliative Care, Mater Health Services, Brisbane, Queensland, Australia .,Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Queensland, Australia.,Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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9
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McPherson ML, Costantino RC, McPherson AL. Methadone: Maximizing Safety and Efficacy for Pain Control in Patients with Cancer. Hematol Oncol Clin North Am 2018; 32:405-415. [PMID: 29729777 DOI: 10.1016/j.hoc.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Methadone is a valuable opioid in the management of patients who have cancer with pain. Methadone is a mu-, kappa-, and delta-opioid agonist, and an N-methyl-D-aspartate receptor antagonist. These mechanisms of action make methadone an attractive option for complex pain syndromes. It is critically important that providers consider a patient's risk status before beginning methadone. Careful consideration must be given to dosing methadone in both opioid-naïve and opioid-tolerant patients, with vigilant monitoring for therapeutic effectiveness and potential toxicity until the patient achieves steady state.
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Affiliation(s)
- Mary Lynn McPherson
- Advanced Post-Graduate Education in Palliative Care, Online Master of Science and Graduate Certificates in Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, S405, Baltimore, MD 21201, USA.
| | - Ryan C Costantino
- Pain Management/Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD 21201, USA
| | - Alexandra L McPherson
- Pain Management/Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD 21201, USA
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10
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Schuster M, Bayer O, Heid F, Laufenberg-Feldmann R. Opioid Rotation in Cancer Pain Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:135-142. [PMID: 29563006 PMCID: PMC5876542 DOI: 10.3238/arztebl.2018.0135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 07/11/2016] [Accepted: 11/14/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Rotating several different WHO level III opioid drugs is a therapeutic option for patients with chronic cancer-related pain who suffer from inadequate analgesia and/or intolerable side effects. The evidence favoring opioid rotation is controversial, and the current guidelines in Germany and other countries contain only weak recommendations for it. METHODS This review is based on pertinent publications retrieved by a systematic review of the literature on opioid rotation for adult patients with chronic cancerrelated pain who are regularly taking WHO level III opioids by the oral or trans - dermal route. RESULTS 9 individual studies involving a total of 725 patients were included in the analysis, and 3 previous systematic reviews of studies involving a total of 2296 patients were also analyzed. Morphine, oxycodone, fentanyl, hydromorphone, and buprenorphine were used as first-line opioid drugs, and hydromorphone, bupre - norphine, tapentadol, fentanyl, morphine, oxymorphone, and methadone were used as second-line opioid drugs. In all of the studies, pain control was achieved for 14 days after each rotation. In most of them, the dose of the new drug introduced in each rotation needed to be increased above the dose initially calculated from a rotation ratio, with the exception of rotations to methadone. The frequency of side effects was only rarely lessened, but patients largely considered the result of opioid rotation to be positive. No particular opioid drug was found to be best. CONCLUSION Opioid rotation can improve analgesia and patient satisfaction. The success of opioid rotation appears to depend on the magnitude of the initial dose, among other factors. Tables of equianalgesic doses should be considered no more than a rough guide for determining the dose of the new drug. Rotations to methadone should be carried out under clinical supervision in experienced hands.
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Affiliation(s)
| | - Oliver Bayer
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Hospital Mainz
| | - Florian Heid
- Department of Anesthesiology, University Hospital Mainz
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11
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Reddy A, Schuler US, de la Cruz M, Yennurajalingam S, Wu J, Liu D, Bruera E. Overall Survival among Cancer Patients Undergoing Opioid Rotation to Methadone Compared to Other Opioids. J Palliat Med 2016; 20:656-661. [PMID: 27997283 DOI: 10.1089/jpm.2016.0316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Methadone has been associated with lower overall survival (OS) in patients with chronic pain. There are no data available on the association of methadone with OS in cancer patients. OBJECTIVE Our aim was to compare the OS in cancer outpatients undergoing opioid rotation (OR) to methadone and other strong opioids. DESIGN Demographics, symptoms, and morphine equivalent daily dose (MEDD) were collected in patients who underwent OR from strong opioids to either methadone or other strong opioids and returned for a follow-up within six weeks. SETTING/SUBJECTS Nine hundred thirty-eight consecutive outpatients to the supportive care center of a tertiary cancer center were reviewed. MEASUREMENTS Kaplan-Meier curves were used to evaluate survival. RESULTS Of a total of 164 eligible patients, 54/76 patients who underwent OR to methadone and 48/88 patients who underwent OR to other opioids returned for a follow-up visit. The median age was 56 years, 54% were male, and 87% had advanced cancer. There were no significant differences between the two groups in patient characteristics, performance status, MEDD, and pain scores. The Kaplan-Meier curves revealed no significant difference in median OS between all patients undergoing OR to methadone and other opioids [3.75 months (95% confidence interval, CI, 2.30-6.46) vs. 2.62 months (95% CI 1.74-4.33); p = 0.35] and also among those who returned for a follow-up following an OR to methadone and other opioids [5.15 months (95% CI 3.64-7.41) vs. 5.90 months (95% CI 2.62-9.28); p = 0.89]. CONCLUSIONS We observed no significant difference in OS in cancer patients in methadone group compared to other opioids.
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Affiliation(s)
- Akhila Reddy
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Ulrich S Schuler
- 2 Universitätsklinikum Carl Gustav Carus , PalliativCentrum & Medizinische Klinik, Dresden, Germany
| | - Maxine de la Cruz
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Sriram Yennurajalingam
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Jimin Wu
- 3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Diane Liu
- 3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
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Haumann J, Geurts J, van Kuijk S, Kremer B, Joosten E, van den Beuken-van Everdingen M. Methadone is superior to fentanyl in treating neuropathic pain in patients with head-and-neck cancer. Eur J Cancer 2016; 65:121-9. [DOI: 10.1016/j.ejca.2016.06.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/20/2016] [Accepted: 06/30/2016] [Indexed: 10/21/2022]
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Porta-Sales J, Garzón-Rodríguez C, Villavicencio-Chávez C, Llorens-Torromé S, González-Barboteo J. Efficacy and Safety of Methadone as a Second-Line Opioid for Cancer Pain in an Outpatient Clinic: A Prospective Open-Label Study. Oncologist 2016; 21:981-7. [PMID: 27306912 DOI: 10.1634/theoncologist.2015-0503] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/09/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Most clinical reports on methadone rotation describe outcomes in hospitalized patients. The few studies that have included outpatients are retrospective. The aim of this study was to assess the efficacy and safety of methadone as a second-line opioid in adult patients with advanced cancer after rotation in routine clinical practice at a palliative care outpatient clinic. PATIENTS AND METHODS This was a prospective, open-label study of 145 patients whose treatment was rotated from other opioids to methadone. Informed consent was obtained in all cases. The main outcome measure was change in the variable "worst pain" at day 28. Pain and pain interference were assessed with the Brief Pain Inventory, with side effects evaluated according to the Common Terminology Criteria for Adverse Events version 3.0. Pain levels were evaluated at study entry and at days 3, 7, 9, 14, 21, and 28. RESULTS Rotation to methadone was performed for the following reasons: poor pain control (77.9%), opioid side effects (2.1%), or both (20%). The mean daily oral morphine equivalent dose before rotation was 193.7 mg. The median worst and average pain scores decreased significantly (p < .0001) from baseline to day 28: The median worst pain score decreased from 9 (interquartile range [IQR]: 8-10) to 6 (IQR: 3-8), and the median average pain score decreased from 6 (IQR: 5-7) to 4 (IQR: 2-5). The proportions of patients with moderate to severe worst and average pain decreased by 30.3% and 47.5%, respectively, by day 28. No increase in opioid toxicity was observed during the study. CONCLUSION In outpatients with advanced cancer, rotation to methadone as a second-line opioid was efficacious and safe when using a tiered scheme with close follow-up by experienced health professionals. IMPLICATIONS FOR PRACTICE The results of this study, conducted prospectively under real clinical conditions, support the efficacy and safety of oral methadone as a second-line opioid in ambulatory patients with cancer. Moreover, these findings corroborate previously reported outcomes in retrospective outpatient studies and prospective studies that evaluated inpatient populations. Although more research into methadone rotation strategies is still needed, this study describes a successful tiered scheme of oral methadone rotation that was proven safe and effective during follow-up.
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Affiliation(s)
- Josep Porta-Sales
- Palliative Care Service, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute, Barcelona, Spain Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Cristina Garzón-Rodríguez
- Palliative Care Service, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute, Barcelona, Spain
| | | | - Silvia Llorens-Torromé
- Palliative Care Service, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute, Barcelona, Spain
| | - Jesús González-Barboteo
- Palliative Care Service, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute, Barcelona, Spain Center for Health and Social Studies, University of Vic, Barcelona, Spain
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Lusetti M, Licata M, Silingardi E, Reggiani Bonetti L, Palmiere C. Therapeutic and recreational methadone cardiotoxicity. J Forensic Leg Med 2016; 39:80-4. [PMID: 26859696 DOI: 10.1016/j.jflm.2016.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/07/2015] [Accepted: 01/18/2016] [Indexed: 11/30/2022]
Abstract
Several classes of drugs have been associated with an increased risk of cardiovascular disease and occurrence of arrhythmias potentially involved in sudden deaths in chronic users even at therapeutic doses. The study presented herein focuses on pathological changes involving the heart possibly due to methadone use. 60 cases were included in the study in total and were divided into three groups (therapeutic methadone users: 20 cases, recreational methadone users: 20 cases, and sudden death group in subjects who had never taken methadone: 20 cases). Autopsies, histology, biochemistry and toxicology were performed in all cases. Macroscopic and microscopic investigation results in therapeutic methadone users were similar to those observed in sudden, unexpected deaths in non-methadone users. In recreational methadone consumers, macroscopic and microscopic examination of the heart failed to provide results consistent with acute or chronic myocardial or coronary damage, thereby corroborating the hypothesis of death most likely following respiratory depression.
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Affiliation(s)
- Monia Lusetti
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Manuela Licata
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Enrico Silingardi
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Luca Reggiani Bonetti
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Clinical Pathology, Modena, Italy
| | - Cristian Palmiere
- University Center of Legal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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Abstract
This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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McLean S, Twomey F. Methods of Rotation From Another Strong Opioid to Methadone for the Management of Cancer Pain: A Systematic Review of the Available Evidence. J Pain Symptom Manage 2015; 50:248-59.e1. [PMID: 25896106 DOI: 10.1016/j.jpainsymman.2015.02.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/10/2015] [Accepted: 02/18/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Up to 44% of patients with cancer-related pain require opioid rotation (OR) because of inadequate analgesia or side effects. No consensus exists regarding the most efficacious method for rotation to methadone. OBJECTIVES To define the available evidence regarding methods of rotation to methadone and to determine if sufficient evidence exists regarding the superiority of one method. METHODS A predefined search strategy, using Medical Subject Headings (MeSH) search terms and keywords combined using Boolean operators, was performed. Study selection was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Data were extracted, quality of studies assessed, and narrative synthesis undertaken. RESULTS A total of 3214 potentially relevant studies were identified. Twenty-five studies were included: 15 retrospective and 10 prospective (n = 1229). One trial compared three-day switch (3DS) and rapid conversion (RC) methods; two, 3DS; 10, RC; nine, ad libitum (AL). Success rates were as follows: 3DS-93%, RC-71.7%, and AL-92.8%. The single clinical trial and retrospective studies demonstrated poorer analgesia and an excess of adverse events (AEs) in the RC group (five dropouts because of AEs) compared with the 3DS group (no severe AEs). Time to stable analgesia was as follows: RC <4.3 days and AL <6 days. CONCLUSION Evidence identified was mainly from uncontrolled observational studies, making causality difficult to establish. Studies were heterogeneous in methodology and outcome measures. There was a trend toward excess AEs using the RC method, in comparison to the AL and 3DS methods. The methodological quality of the AL studies was low. A direct comparison of AL and 3DS methods would be informative.
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Affiliation(s)
- Sarah McLean
- Our Lady's Hospice and Care Services, Blackrock Hospice, Dublin, Ireland.
| | - Feargal Twomey
- Milford Hospice and University Hospital Limerick, Limerick, Ireland
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Salpeter SR, Buckley JS, Buckley NS, Bruera E. The Use of Very-Low-Dose Methadone and Haloperidol for Pain Control in the Hospital Setting: A Preliminary Report. J Palliat Med 2015; 18:114-9. [DOI: 10.1089/jpm.2014.0266] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - Eduardo Bruera
- University of Texas M. D. Anderson Cancer Center, Houston, Texas
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