Use of methadone as an alternative to morphine for chronic pain management: a noninferiority retrospective observational study

Methadone administration for outpatient was noninferior to morphine as analgesic on chronic pain. In addition, it was associated with lesser side effects.

Introduction:

Chronic pain causes disability and is prevalent in the general population. Opioids are a part of a multimodal strategy for pain management. Methadone, a cheap and long-acting synthetic opioid, may represent an option for those who have limited access to the aforementioned class of analgesics. We aimed to provide a real-world evidence for the analgesic use of methadone, compared with morphine.

Methods:

We conducted a noninferiority, retrospective observational single center study of patients with chronic pain, managed with either methadone or morphine at an outpatient specialized clinic. We extracted data from the electronic health records of patients who underwent an active treatment between August 2012 and January 2020 and were examined for at least 2 consecutive medical visits, after the administration of one of the aforementioned drugs. Data were analyzed using a generalized additive model with random-effects mixed linear method to account for the individual-related, time-related, and drug-related variations. The numeric verbal scale (0–10) was used to assess the pain severity.

Results:

From the database of 3373 patients, we included 262 patients (175 methadone and 87 morphine). In an unadjusted analysis, methadone was superior to morphine, and the mean worst pain was 0.86 points lower (95% confidence interval, −1.29 to −0.43). Moreover, methadone was superior to morphine in the adjusted analysis, with the worst pain mean being 1.24 points lower. This provided evidence for the noninferiority of methadone than morphine.

Conclusion:

Methadone was superior to morphine in a 20% noninferiority margin for reducing worst pain.

[Use of methadone in the elderly with cancer pain: a systematic review]

OBJECTIVE

To identify the clinical use of methadone as an analgesic in the management of cancer pain in elderly patients.

MATERIAL AND METHODS

We performed a systemic review of the literature on the specific use of methadone in elderly with cancer pain in MEDLINE, COCHRANE DATABASE and SCOPUS. A second search was conducted in MEDLINE to look for clinical trials and systematic review of the use of methadone in cancer pain, selecting only those in which the mean age of patients was ≥ 65 years old.

RESULTS

Four articles were obtained in the first search, and from the second 7 clinical trials, none of them specific to methadone use in elderly patients with cancer.

CONCLUSIONS

There are insufficient data on the use of methadone as an analgesic in the elderly with cancer. Given its pharmacological characteristics it must be used by trained personnel. Several recommendations are proposed for its use as an analgesic in the treatment of cancer pain in the elderly.

Intravenous Methadone for Severe Cancer Pain: A Presentation of 10 Cases

Purpose. Methadone, a synthetic opioid agonist, is an effective alternative to strong opioids (morphine, hydromorphone, oxycodone, and buprenorphine) and is widely available as an oral formulation. Few data have been published so far on the use of intravenous (i.v.) methadone for the management of severe or refractory cancer pain. Methods. We followed 10 consecutives cancer patients with severe pain, treated with IV methadone. All had advanced disease and had already received strong opioids, some in association with ketamine. Pain was assessed at T0, T24 hours, and at the end of the treatment. Results. All patients benefited from the switch to IV methadone with a reduction of pain on VAS after 24 hours (median: 4/10; range 0-5) until the end of the treatment (all cases <3/10). The median starting dose was 100 mg/day (range 20-400) and the final dose remained stable with a median of 100 mg/day (range 27-700). The median duration of IV methadone was 11 days (range 2-59). No cardiac toxicity had been observed. Conclusions. IV methadone is an effective pain relieving alternative for the treatment of severe cancer pain, especially in refractory pain syndrome. Moreover, we did not observe any toxicity (neurological or cardiac) or any other major side effects and the treatment was overall well tolerated. More extensive comparative studies should be planned.

Opioid-free perioperative analgesia for hemicolectomy in a patient with opioid-induced delirium: a case report and review of the analgesic efficacy of the alpha-2 agonist agents

Surgical pain in patients with documented opioid-induced delirium can be difficult to treat. We present a case of a patient undergoing laparoscopic hemicolectomy effectively treated with an opioid-free, alpha-2 adrenoreceptor agonist analgesic regimen.

CASE REPORT

A 21-year-old woman with persistent abdominal pain presented to the operating room for laparoscopic hemicolectomy for redundant right colon. Her medical history included a recently diagnosed postoperative opioid-induced delirium. Epidural infusion with local anesthetic offered partial pain relief with sensory levels of T9-L2. With the addition of dexmedetomidine infusion in the immediate postoperative period, the patient was comfortable with pain scores of 1 to 2/10 on Numerical Rating Scale (NRS). On postoperative day 1, the infusion was discontinued and the clonidine, 12 μg/hours was added to the epidural bupivacaine. With increased sedation 48 hours later, neuraxial clonidine was discontinued in favor to transdermal clonidine 0.1 mg/week, which was maintained until hospital discharge. Pain scores were maintained at 2 to 3/10 on NRS for the next 3 days when increased abdominal distention because of abscess formation rendered a new surgical intervention. The analgesia for the exploratory laparoscopy was maintained using epidural clonidine and bupivacaine infusion as well as intravenous dexmedetomidine, which were maintained another 2 days. Pain scores remained minimal until discharged home 3 day later.

DISCUSSION

Nonopioid analgesic regimens are beneficial in patients at risk of postoperative cognitive dysfunction attributable to opioids. Successful postoperative analgesia was achieved in our patient by alternating various routes of administration of alpha-2 adrenoreceptor agonists.

Is there a color line in death? An examination of end-of-life care in the African American community

Although the goals of end-of-life care and hospice are to mitigate suffering and improve quality of life for patients with terminal illnesses, they remain underutilized by a significant number of African Americans. While sociocultural issues play a role in the underutilization of these resources among African Americans, other confounding factors affect the ability of African Americans to adequately access quality care at the end of life. Here, the authors examine the various barriers preventing increased use of hospice care and palliative therapy among African Americans. A particular focus of this examination will revolve around suggestions for increasing the use of end-of-life care among African Americans in the future.

Practical approaches to pharmacologic management of pain in older adults with cancer

PURPOSE/OBJECTIVES

To identify appropriate strategies for pharmacotherapeutic agents in the management of pain in older adults with cancer.

DATA SOURCES

PubMed literature searches, personal reference collection, and clinical experience.

DATA SYNTHESIS

To make good decisions about pain management when developing treatment plans for older adults, healthcare providers should focus on the pharmacokinetic and pharmacodynamic properties of drugs in the context of the physiologic changes that occur with aging.

CONCLUSIONS

Unrelieved pain can have a detrimental effect on older adults; conversely, overmedicating can lead to an increased risk of adverse events. With advancing age, physiologic changes alter the pharmacokinetic and pharmacodynamic properties of drugs by reducing their absorption, changing their distribution, and modifying their metabolism and elimination. Also, common comorbidities increase the risk of pharmacologic toxicity and narrow the therapeutic window. In addition, polypharmacy-an issue more common in older adults-increases the complexity of prescribing and risk of adverse events. Consequently, older adults require individualization of their pharmacotherapies. Healthcare providers should consider carefully the risks and benefits of nonsteroidal anti-inflammatory drugs, opioids, and adjuvants before initiating an analgesic trial. The 2009 guidelines published by the American Geriatrics Society described several key principles for prescribing analgesics to older adults and offered specific recommendations and caveats for each drug class.

IMPLICATIONS FOR NURSING

Current guidelines support appropriate management of cancer pain in older adults with specific recommendations for each class of analgesics as well as general prescribing principles.

Management of chronic pain in cancer survivors

Chronic pain is a frequent complication of cancer and its treatments and is often underreported, underdiagnosed, and undertreated. Pain in cancer survivors is caused by residual tissue damage from the cancer and/or the cancer therapy. This pain can be divided into 3 pathophysiologic categories: somatic, visceral, and neuropathic. The most common treatment-induced chronic pain syndromes are neuropathies secondary to surgery, radiation therapy, and chemotherapy. Comfort and function are optimized in cancer survivors by a multidisciplinary approach using an individually tailored combination of opioids, coanalgesics, physical therapy, interventional procedures, psychosocial interventions, and complementary and alternative modalities. Management of chronic pain must be integrated into comprehensive cancer care so that cancer patients can fully enjoy their survival.

The management of opioid-related sedation

There are many side effects of opioids used for cancer and non-cancer pain, which can limit their use and vastly undermine the quality of life for patients. Sedation is a frequent and serious side effect of opioid analgesics, sometimes reported as fatigue or tiredness from patients. There are a number of specific therapies to control or manage these adverse effects, making it feasible to dose opioids to adequate analgesia with tolerable side effects. The balance between effect and side effects is the goal of chronic opioid pharmacotherapy. In particular, sedation commonly can be problematic in a patient who is taking opioids, to the extent that one may want to discontinue the medication and suffer with the pain rather than experience debilitating fatigue or sedation. When sedation clinically becomes excessive, measures should be taken to make it possible to continue treatment with analgesics with acceptable sedation management. There are many techniques to oppose sedation including simple antidotes, such as rest, exercise, and timing of opioid medications, and more complex solutions, such as opioid rotation and the use of psychostimulants or other classes of medications to counteract sedation. The treatment of opioid-induced sedation can be very effective and should be part of a skill set that the clinician can easily employ to enhance the quality of life of patients.