The Use of Very-Low-Dose Methadone for Palliative Pain Control and the Prevention of Opioid Hyperalgesia.

J Palliat Med. 2013 Apr 4;
Salpeter SR, Buckley JS, Bruera E

Abstract Background: Opioid dose escalation may cause hyperalgesia, mediated by the N-methyl-D-aspartate (NMDA) pathway. Methadone is an atypical opioid that inhibits hyperalgesia through NMDA-blockade, especially at low doses. Objective: To evaluate the efficacy of using very-low-dose methadone as the sole long-acting opioid agent in a hospice practice. Design: A retrospective, observational study of the use of methadone, ?15?mg daily, with as-needed short-acting opiates. Adjuvant nonopioid medications included haloperidol, which may have NMDA-blocking effects. Setting/Subjects: We reviewed the records of 240 patients admitted to a community-based hospice from July 1, 2011 to April 1, 2012, with data collected until hospice discharge or until April 30, 2012. Measurements: Descriptive statistics were used to summarize patient demographics, medication regimens, and reported pain scores measured on a numeric rating scale from 0 to 10. Results: All patients received short-acting opiates, in a morphine-equivalent dose of 5?mg every 4 hours as needed, while 40% also received methadone at a median daily dose of 5?mg. Of those on methadone, almost half received scheduled haloperidol. The population had a median reported pain score of 0 and a peak score of 3, with similar results seen for cancer and noncancer groups. Two-thirds of patients never reported a pain score greater than 3. Conclusion: The use of very-low-dose methadone in conjunction with adjuvant haloperidol resulted in excellent pain control without dose escalation or opioid-induced hyperalgesia, for both cancer and noncancer diseases. We conclude that low-dose methadone should be part of first-line treatment in palliative pain management.
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