Methadone in Swedish specialized palliative care—Is it the magic bullet in complex cancer-related pain?

Abstract

ContextDespite being associated with dependence and social stigma, methadone is a potential end-of-life option in complex cancer pain. ObjectivesTo explore attitudes and opinions about methadone and its potential role and current use in complex end-of-life pain. MethodsSemi-structured interviews (n = 30) with physicians in specialized palliative care, transcribed and analyzed with conventional qualitative content analysis. ResultsAccording to the physicians, patients and relatives expressed unexpectedly few negative attitudes, not affecting methadone's use as an analgesic. Complex pain in bone-metastatic cancer of the prostate, breast and kidney, as well as pancreatic cancer and sarcomas were recurrent suggestions of appropriate indications.Most of the informants stated that they applied a mechanism-based treatment and mainly prescribed low-dose methadone as an add-on to an existing opioid therapy to benefit from methadone´s proposed NMDA-receptor inhibiting properties, e.g. in cases with reduced opioid sensitivity. Despite its complex pharmacokinetics with a long half-life, most informants expressed defined strategies to avoid side-effects such as respiratory depression, especially when initiating treatment in the home-care setting.While many palliative care physicians expressed an overly enthusiastic attitude, others stressed the risks of overconfidence, low precision in use, and overlooked treatment options. Besides the obvious physical pain-relieving effects, they stated that effective pain relief could result in a reduced workload and emotional empowerment, both for physicians and staff.

The Use of Low-Dose Methadone as Add-On to Ongoing Opioid Treatment in Palliative Cancer Care—An Underrated Treatment?

“…In the described studies, the indication for prescribing low-dose methadone in addition to another opioid in about 70–80% of cases was either assessed complex pain, that is, pain with difficult-to-treat mixed nociceptive and neuropathic components, or only neuropathic pain [ 45 , 46 , 48 ]. This was also supported in the interviews with physicians [ 47 ]. They described that, in addition to existential pain and death anxiety, pain with mixed components is often the most complex and difficult to alleviate in specialized palliative care, but that low-dose add-on of methadone may in these cases be a way to achieve better pain relief fast.…”

“…The third study was slightly different [ 47 ]. It aimed at broadening and deepening the understanding of attitudes about, potential significance of and practical aspects regarding the use of methadone for pain in specialized palliative care.…”

Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center

“…Another major reason was to provide better pain relief by converting to parenteral drug delivery and, when judged necessary, by adding parenteral methadone. The need for better pain relief may be due to mixed nociceptive and neuropathic pain in two thirds of the patients in this study, a combination of pain mechanisms often difficult to treat [14].…”

“…Low-dose add-on peroral methadone in combination with other opioids for pain is proposed to be a useful alternative to methadone therapy for better pain control at the end of life [8][9][10][11][12]. The addition of methadone is reported to improve pain relief in complex pain situations but, so far, only peroral or intermittent parenteral administration of low-dose add-on methadone has been studied, routes that are often not feasible in the imminently dying patient [13][14][15]. Alternative routes of methadone administration are therefore needed and there is a need for further exploration of the effects, and possible adverse effects, of CSCI in this patient group [13,14].…”

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“…There may be no symptoms at the time of diagnosis even in the advanced states [2]. Blood in the urine and semen [3], recurrent pain in the affected area [4], difficulty in urinating [5], sudden or frequent urination [6], unexplained weight loss [7], pain in the pelvis [8], thighs and back [9], pain or abnormal symptoms in the penis [10], poor urination, and bone pain [11] are signs of cancer progression.…”