Methadone-based Multimodal Analgesia Provides the Best-in-class Acute Surgical Pain Control and Functional Outcomes With Lower Opioid Use Following Major Posterior Fusion Surgery in Adolescents With Idiopathic Scoliosis

Abstract

Introduction: Posterior spinal fusion for idiopathic scoliosis is extremely painful, with no superior single analgesic modality. We introduced a methadone-based multimodal analgesia protocol, aiming to decrease the length of hospital stay (LOS), improve pain control, and decrease the need for additional opioids. Methods: We analyzed 122 idiopathic scoliosis patients with posterior instrumented spinal fusion. They were matched by age, sex, surgeon, and the number of levels fused before and after the implementation of the new protocol. This analysis included 61 controls (intrathecal morphine, gabapentin, intravenous opioids, and adjuncts) and 61 patients on the new protocol (scheduled methadone, methocarbamol, ketorolac/ibuprofen, acetaminophen, and oxycodone with intravenous opioids as needed). The primary outcome was LOS. Secondary outcomes included pain scores, total opioid use (morphine milligram equivalents), time to a first bowel movement, and postdischarge phone calls. Results: New protocol patients were discharged earlier (median LOS, 2 days) compared with control patients (3 days; P < 0.001). Total inpatient morphine consumption was lower in the protocol group ( P < 0.001). Pain scores were higher in the protocol group on the day of surgery, similar on postoperative day (POD) 1, and lower by POD 2 ( P = 0.01). The new protocol also reduced the median time to first bowel movement ( P < 0.001), and the number of postdischarge pain-related phone calls ( P < 0.006). Conclusion: Methadone-based multimodal analgesia resulted in significantly lower LOS compared with the conventional regimen. It also provided improved pain control, reduced total opioid consumption, and early bowel movement compared with the control group.

Scheduled methadone reduces overall opioid requirements after pediatric posterior spinal fusion: A single center retrospective case series

“…They also noted cost benefits associated with omitting PCA opioids. 21 More recently, the same group published pharmacokinetic data for this regimen in a mixed population of posterior spinal fusion and pectus excavatum repair. 18 Although patients had lower plasma levels of methadone than previously reported as effective for analgesia, clinical outcomes included lower pain scores and lower opioid use than historical controls.…”

Novel Associations Between Cyp2B6 Polymorphisms, Perioperative Methadone Metabolism and Clinical Outcomes in Children

“…We have previously reported the safety and efficacy of the multiple small dose methadone regimen in a similar study cohort, compared with a historical cohort that received non-methadone-based analgesia [ 20 ]. We have also examined the pharmacokinetics of the same regimen and ascertained safe plasma methadone levels (<100 ng/ml) without any clinical respiratory depression even after repeated doses administered every 12 h. Other major concern that is specific to methadone is QT prolongation, which has been mostly reported in long term methadone maintenance therapy and use for chronic pain, where doses as high as 120 mg per day are used [ 21 ].…”

Error traps in acute pain management in children

“…49 When used as a postoperative analgesic, its long half-life and prolonged clearance allow for less frequent dosing and potentially reduce postoperative opioid requirements. 50 However, its long half-life comes with an increased risk of delayed oversedation and respiratory depression. If multiple doses of methadone are planned, dose escalation should occur no more frequently than every 2-3 days.…”