· Describe appropriate and inappropriate candidates for initiation or full conversion to methadone based on risk factor assessment in patients with advanced illness.
· Describe methadone dosing strategies for opioid-naive and opioid-tolerant patients, including a full conversion to methadone and the role of methadone as an adjuvant analgesic.
· Describe consensus recommendations for pre-emptive and ongoing monitoring for methadone safety and efficacy in patients with advanced illness on hospice or receiving palliative care services.
Methadone has unique pharmacokinetic and pharmacodynamics properties that make it an appealing analgesic in treating pain in patients with advanced illnesses; however, these same properties render dosing and monitoring more demanding than other opioids. Consensus guidelines were published in 2014 by...
Methadone has unique pharmacokinetic and pharmacodynamics properties that make it an appealing analgesic in treating pain in patients with advanced illnesses; however, these same properties render dosing and monitoring more demanding than other opioids. Consensus guidelines were published in 2014 by the American Pain Society and The College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. A consensus-building meeting was held recently to determine the relevance of these published guidelines for patients receiving hospice care or palliative care services. Specifically, the group considered the intensity of recommended pre-emptive and continued monitoring (eg, ECG and other monitoring) for patients admitted to hospice care and patients receiving palliative care services, either concurrently with disease-modifying therapy or without disease-modifying therapy. Consensus was gained on characteristics of methadone-appropriate patients (both opioid-naïve and opioid-tolerant) and clinical situations that would indicate using methadone in more of an adjunctive role as opposed to completely switching to methadone. Recommendations were made regarding which risk factors should be considered prior to instituting methadone therapy, and when it is appropriate to obtain an ECG, and frequency of monitoring if appropriate. Dosing strategies for both opioid-naïve and opioid-tolerant patients were recommended, and recommended strategies when interacting drugs are present. A monitoring strategy to assess therapeutic effectiveness and potential toxicity was developed, including use of a sedation scale with action steps. The role of methadone as an adjunctive analgesic and dosing strategies also were discussed by the expert panel. Hospice and palliative care practitioners need guidance that is specific to this practice setting to maximize safety and efficacy of methadone. This consensus-building process will provide guidance to those who care for patients with advanced illness in the use of methadone.