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Fürst P. The Use of Low-Dose Methadone as Add-On to Ongoing Opioid Treatment in Palliative Cancer Care—An Underrated Treatment? Life (Basel) 2022; 12:life12050679. [PMID: 35629347 PMCID: PMC9143404 DOI: 10.3390/life12050679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this review is to summarize the current knowledge of low-dose methadone treatment in palliative cancer care. In Sweden, methadone is quite common in specialized palliative care, where almost a tenth of patients are prescribed this drug. Negative attitudes towards methadone do not seem to prevent it from being used for pain management, and by starting with low doses and then increasing slowly and gradually, methadone can apparently be introduced safely. It is still uncertain whether methadone has a better analgesic effect than other opioids. However, for pain relief in cancer patients with severe and complex cancer-related pain, NMDA receptor inhibition with methadone may, in selected cases, be an attractive alternative, especially in the form of low-dose supplements to other ongoing opioids. Due to long half-life and complex metabolism, the use of methadone requires an experienced physician and solid follow-up. Continuous administration of opioids, including low-dose methadone, has been proven effective and safe in reducing pain in dying patients without increasing the risk of confusion, regardless of age.
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Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden;
- Palliative Medicine, Stockholms Sjukhem Foundation, SE-112 19 Stockholm, Sweden
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Bertin C, Delage N, Rolland B, Pennel L, Fatseas M, Trouvin AP, Delorme J, Chenaf C, Authier N. Analgesic opioid use disorders in patients with chronic non-cancer pain: A holistic approach for tailored management. Neurosci Biobehav Rev 2020; 121:160-174. [PMID: 33358994 DOI: 10.1016/j.neubiorev.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022]
Abstract
Chronic pain is a major public health issue that frequently leads to analgesic opioid prescriptions. These prescriptions could cause addiction issues in high-risk patients with associated comorbidities, especially those of a psychiatric, addictive, and social nature. Pain management in dependent patients is complex and is yet to be established. By combining the views of professionals from various specialties, we conducted an integrative review on this scope. This methodology synthesizes knowledge and results of significant practical studies to provide a narrative overview of the literature. The main results consisted in first proposing definitions that could allow shared vocabulary among health professionals regardless of their specialties. Next, a discussion was conducted around the main strategies for managing prescription opioid dependence, as well as pain in the context of opioid dependence and associated comorbidities. As a conclusion, we proposed to define the contours of holistic management by outlining the main guidelines for creating a multidisciplinary care framework for multi-comorbid patients with chronic pathologies.
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Affiliation(s)
- Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France; Fondation Institut Analgesia, Faculté de Médecine, F-63001, Clermont-Ferrand, France.
| | - Noémie Delage
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), CH Le Vinatier, Université de Lyon, UCBL1, INSERM U1028, CNRS UMR 5292, Bron, France
| | - Lucie Pennel
- Service Universitaire de Pharmaco-Addictologie - CSAPA, CHU Grenoble Alpes, UFR de médecine, Université Grenoble-Alpes, 38043 Grenoble, France
| | - Mélina Fatseas
- University of Bordeaux, 33076 Bordeaux Cedex, France; CNRS-UMR 5287- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA), Bordeaux, France; CHU de Bordeaux, France
| | - Anne-Priscille Trouvin
- Centre d'Evaluation et Traitement de la Douleur, Université Paris Descartes, Hôpital Cochin, Paris, France; U987, INSERM, Boulogne Billancourt, France
| | - Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm 1107, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, F-63003, Clermont-Ferrand, France; Observatoire Français des Médicaments Antalgiques (OFMA) / French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France; Fondation Institut Analgesia, Faculté de Médecine, F-63001, Clermont-Ferrand, France
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Fürst P, Lundström S, Klepstad P, Strang P. The Use of Low-Dose Methadone as Add-On to Regular Opioid Therapy in Cancer-Related Pain at End of Life: A National Swedish Survey in Specialized Palliative Care. J Palliat Med 2020; 23:226-232. [DOI: 10.1089/jpm.2019.0253] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Staffan Lundström
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- European Palliative Research Centre, Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anesthesiology and Intensive Care medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Abstract
Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced cancer and neuropathic pain syndromes in which conventional opioids were no longer effective. The challenge is in accepting methadone as a main stream first line opioid, from being considered as a second line replacement/substitution drug all these years. Methadone has a significant role as opioid rotation in refractory cancer pain, especially when started early leading to successful conversion. Advantages of methadone in paediatric patients with advanced cancer were its safety and efficacy as a first-choice opioid, availability as a liquid formulation and its infrequent dose requirements. Methadone is neither recommended nor justified to be used as an anti-cancer drug and its role as an anti-cancer agent is a misconception. Many guidelines were proposed after 2008 to address methadone safety. Most of them emphasized on prevention of cardiac arrhythmia and association of methadone with QTc prolongation rather than address the real issue. Methadone has been established to be safe when used in opioid naïve patients with careful titration instituted in an ambulatory setting and has equal success in opioid rotation in outpatient setup. Methadone prescription should be carried out by experienced pain and palliative care providers with careful dose titration and clinical monitoring.
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Affiliation(s)
- S Ramkiran
- Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Vishakapatnam, Andhra Pradesh, India
| | - Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Santos Suárez J, Del Valle Arnáez G. Morphine infusor pump switch to oral methadone. BMJ Support Palliat Care 2019; 10:1-3. [PMID: 30944123 DOI: 10.1136/bmjspcare-2018-001760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/06/2019] [Indexed: 11/04/2022]
Abstract
Between 2014 and 2017, four patients with widespread cancer were referred to a home palliative care team from a hospital in Oviedo (Spain) with subcutaneous elastomeric infusion pump containing 180-260 mg/day of morphine for previously uncontrolled pain. 3-4 rotations were performed over 5-11 days, gradually substituting morphine for oral methadone (three times a day) to minimise the risks of rapid conversion, with a highly variable final subcutaneous morphine:oral methadone ratio (5:1 to 17:1), guided by the absence of pain, and to enhance the patient's functional capacity avoiding device dependence. The final methadone dose varied between 15 and 39 mg/day. There was daily telephone supervision and visits every 2-4 days. Patient demise occurred 56, 111, 168 and 350 days following the opioid conversion, and methadone was maintained until then. In all cases and prior to concluding the rotation, pain was controlled and sleepiness had subsided.
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Affiliation(s)
- Juan Santos Suárez
- Palliative Care, Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain
| | - Gema Del Valle Arnáez
- Palliative Care, Servicio de Salud del Principado de Asturias (SESPA), Oviedo, Spain
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Mercadante S, Bruera E. Methadone as a First-Line Opioid in Cancer Pain Management: A Systematic Review. J Pain Symptom Manage 2018; 55:998-1003. [PMID: 29101087 DOI: 10.1016/j.jpainsymman.2017.10.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/24/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
AIM The objective of this review was to assess the existent evidence for the use of methadone as a first-line therapy in cancer pain management. METHODS A systematic literature search on MEDLINE and Embase databases was carried out from each database, setting up the date to August 30, 2017. Studies were included if methadone was a first-line drug as a Step 3 of World Health Organization analgesic ladder, or at low doses (Step 2), if they were conducted in adult patients with cancer pain, and if they contained outcomes on pain- and opioid-related adverse effects. RESULTS The initial search yielded 219 records. Ten articles were considered after the initial screening according to inclusion and exclusion criteria. They included three longitudinal open-label studies. In two studies methadone was initiated at low doses (≤10 mg/day). These studies suggested that methadone was effective in providing analgesia and well tolerated as first opioid at different starting doses and in different conditions and settings. Five additional studies were randomized controlled studies with morphine in patients who had received opioids for moderate pain. Methadone, compared with oral morphine, or transdermal fentanyl, either at low (Step 2 level) or relatively higher doses (Step 3 level), provided similar analgesia with similar adverse effects profile with limited dose escalation in time. CONCLUSION Available data are not sufficient to draw net conclusion. However, open-label and controlled studies have shown that methadone may be effective as first-line drug in the management of cancer pain, providing analgesia and adverse effect profiles similar to those produced by other opioids. The finding that methadone doses tend to remain stable suggests that metabolic characteristics and extraopioid analgesic effects, as its well antihyperalgesic properties may be interesting potential advantages. Further studies should provide information regarding the long-term use of methadone or the need to switch from methadone to other opioids when a loss of analgesic response occurs.
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Affiliation(s)
- Sebastiano Mercadante
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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