Open Access Open Access  Restricted Access Subscription or Fee Access

Discussion on methadone initiation protocols: A case report

Matthieu Delaye, MD, Sophie Laurent, MD, Mélanie Try, MD, Erwan Treillet, MD

Abstract


Through a concrete case, we discuss the main published protocols to initiate methadone and illustrate the advantages and disadvantages of rapid or gradual initiation and on-demand or fixed doses with rescue doses. Daily doses can vary widely depending on the protocol chosen. An on-demand administration could lead to an overdose as illustrated in our case. A better understanding of particularities and limitations of these protocols could lead to safer methadone initiation. Systematic comparison of different protocols and calculation of the daily dose should be a standard in clinical practice.


Keywords


methadone, opioid rotation, cancer pain, methadone initiation

Full Text:

PDF

References


van den Beuken-van MH, Hochstenbach LM, Joosten EA, et al.: Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. J Pain Symptom Manage. 2016; 51(6): 1070-1090.

Treillet E, Laurent S, Hadjiat Y: Practical management of opioid rotation and equianalgesia. J Pain Res. 2018; 11: 2587-2601.

Fine PG, Portenoy RK: Establishing “best practices” for opioid rotation: Conclusions of an expert panel. J Pain Symptom Manag. 2009; 38(3): 418-425.

Nicholson AB, Watson GR, Derry S, et al.: Methadone for cancer pain. Cochrane Database Syst Rev. 2017; 08: CD003971. 5. Smith HS: Opioid metabolism. Mayo Clinic Proc. 2009; 84(7): 613-624.

Mercadante S, Bruera E: Methadone as a first-line opioid in cancer pain management: A systematic review. J Pain Symptom Manage. 2018; 55(3): 998-1003.

Haumann J, van Kuijk SMJ, Geurts JW, et al.: Methadone versus fentanyl in patients with radiation-induced nociceptive pain with head and neck cancer: A randomized controlled noninferiority trial. Pain Pract. 2018; 18(3): 331-340.

Aiyer R, Mehta N, Gungor S, et al.: A systematic review of NMDA receptor antagonists for treatment of neuropathic pain in clinical practice. Clin J Pain. 2018; 34(5): 450-467.

Wiffen PJ, Wee B, Derry S, et al.: Opioids for cancer pain—An overview of Cochrane reviews. Cochrane Database Syst Rev. 2017; 7(7): CD012592. DOI: 10.1002/14651858.CD012592.pub2.

Finnerup NB, Attal N, Haroutounian S, et al.: Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. Lancet Neurol. 2015; 14(2): 162-173. DOI: 10.1016/S1474-4422(14)70251-0.

Anghelescu DL, Patel RM, Mahoney DP, et al.: Methadone prolongs cardiac conduction in young patients with cancer-related pain. J Opioid Manag. 2016; 12(2): 131-138.

Earnshaw V, Smith L, Copenhaver M: Drug addiction stigma in the context of methadone maintenance therapy: An investigation into understudied sources of stigma. Int J Ment Health Addiction. 2013; 11(1): 110-122.

Poulain P, Michenot N, Delorme T, et al.: Mise au point sur l’utilisation pratique de la méthadone dans le cadre des douleurs en oncologie. Douleurs: Evaluation-Diagnostic-Traitement. 2014; 15(4): 146-159.

Plonk WM: Simplified methadone conversion. J Palliat Med. 2005; 8(3): 478-479.

Scholes CF, Gonty N, Trotman IF: Methadone titration in opioid-resistant cancer pain. Eur J Cancer Care. 1999; 8(1): 26-29.

Tse DMW, Sham MMK, Ng DKH, et al.: An ad libitum schedule for conversion of morphine to methadone in advanced cancer patients: An open uncontrolled prospective study in a Chinese population. Palliat Med. 2003; 17(2): 206-211.

Poulain P, Berleur M-P, Lefki S, et al.: Efficacy and safety of two methadone titration methods for the treatment of cancer-related pain: The EQUIMETH2 trial (methadone for cancer-related pain). J Pain Symptom Manage. 2016; 52(5): 626-636.e1.

Baumrucker S, Jbara M, Rogers R: A new mathematical approach to methadone conversion. J Pharmacol Pharmacother. 2016; 7(2): 93.

Trofimovitch D, Hutchinson L, Baumrucker SJ: Preliminary validation for the “BJR method”—A possible new mathematical approach to methadone conversion. J Pain Palliat Care Pharmacother. 2019; 33(1-2): 42-48.

Moksnes K, Dale O, Rosland JH, et al.: How to switch from morphine or oxycodone to methadone in cancer patients? A randomised clinical phase II trial. Eur J Cancer. 2011; 47(16): 2463-2470.

Weschules DJ, Bain KT: A systematic review of opioid conversion ratios used with methadone for the treatment of pain. Pain Med. 2008; 9(5): 595-612.1.

Leppert W: The role of methadone in opioid rotation—A polish experience. Support Care Cancer. 2009; 17(5): 607-612.

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 Manag. 2015; 50(2): 248-259.e1.

Parry R, Fingas S: The EQUIMETH2 trial. J Pain Symptom Manag. 2017; 53(4): e4-e5.

Ripamonti C, Groff L, Brunelli C, et al.: Switching from morphine to oral methadone in treating cancer pain: What is the equianalgesic dose ratio? J Clin Oncol. 1998; 16(10): 3216-3221.

Cubero DI, del Giglio A: Early switching from morphine to methadone is not improved by acetaminophen in the analgesia of oncologic patients: A prospective, randomized, double-blind, placebo-controlled study. Support Care Cancer. 2010; 18(2): 235-242.

Porta-Sales J, Garzon-Rodriguez C, Villavicencio-Chavez C, et al.: 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(8): 981-987.

Gagnon B, Bielech M, Watanabe S, et al.: The use of intermittent subcutaneous injections of oxycodone for opioid rotation in patients with cancer pain. Support Care Cancer. 1999; 7(4): 265-270.

Mercadante S, Casuccio A, Fulfaro F, et al.: Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: A prospective study. J Clin Oncol. 2001; 19(11): 2898-2904.

Ayonrinde OT, Bridge DT: The rediscovery of methadone for cancer pain management. Med J Aust. 2000; 173(10): 536-540.

de Stoutz ND, Bruera E, Suarez-Almazor M: Opioid rotation for toxicity reduction in terminal cancer patients. J Pain Symptom Manage. 1995; 10(5): 378-378.

Mercadante S, Casuccio A, Calderone L: Rapid switching from morphine to methadone in cancer patients with poor response to morphine. J Clin Oncol. 1999; 17(10): 3307-3312.

Mercadante S, Ferrera P, Villari P, et al.: Rapid switching between transdermal fentanyl and methadone in cancer patients. J Clin Oncol. 2005; 23(22): 5229-5234.

Mercadante S, Ferrera P, Villari P, et al.: Switching from oxycodone to methadone in advanced cancer patients. Support Care Cancer. 2012; 20(1): 191-194.

Benitez-Rosario MA, Feria M, Salinas-Martin A, et al.: Opioid switching from transdermal fentanyl to oral methadone in patients with cancer pain. Cancer. 2004; 101(12): 2866-2873.

Auret K, Roger Goucke C, Ilett KF, et al.: Pharmacokinetics and pharmacodynamics of methadone enantiomers in hospice patients with cancer pain. Ther Drug Monit. 2006; 28(3): 59-366.

Parsons HA, de la Cruz M, El Osta B, et al.: Methadone initiation and rotation in the outpatient setting for patients with cancer pain. Cancer. 2010; 116(2): 520-528.

Rhondali W, Tremellat F, Ledoux M, et al.: Methadone rotation for cancer patients with refractory pain in a palliative care unit: An observational study. J Palliat Med. 2013; 16(11): 1382-1387.

Morley JS, Makin MK: The use of methadone in cancer pain poorly responsive to other opioids. Pain Rev. 1998; 5: 51-58.

Walmsley R, Robson P, Lee MA: Use of methadone for uncontrolled pain: An alternative dosing regimen. J Pain Symptom Manage. 2010; 40(6): e3-e4.

Cornish CJ, Keen JC: An alternative low-dose ad libitum schedule for conversion of other opioids to methadone. Palliat Med. 2003; 17(7): 643-644.

Nauck F, Ostgathe C, Dickerson ED: A German model for methadone conversion. Am J Hosp Palliat Care. 2001; 18(3): 200-202.

Ostgathe C, Voltz R, Van Aaaken A, et al.: Practicability, safety, and efficacy of a “German model” for opioid conversion to oral levo-methadone. Support Care Cancer. 2012; 20(9): 2105-2110.

Dennis B, Bawor M, Paul J, et al.: Pain and opioid addiction: A systematic review and evaluation of pain measurement in patients with opioid dependence on methadone maintenance treatment. Curr Drug Abuse Rev. 2016; 9(1): 49-60.




DOI: https://doi.org/10.5055/jom.2022.0742

Refbacks

  • There are currently no refbacks.