Pro-Con Debate: Role of Methadone in Enhanced Recovery After Surgery Protocols—Superior Analgesic or Harmful Drug?

Abstract

Enhanced recovery after surgery (ERAS) protocols are standardized and designed to provide superior analgesia, reduce opioid consumption, improve patient recovery, and reduce hospital length of stay. Yet, moderate-to-severe postsurgical pain continues to afflict over 40% of patients and remains a major priority for anesthesia research. Methadone administration in the perioperative setting may reduce postoperative pain scores and have opioid-sparing effects, which may be beneficial for enhanced recovery. Methadone possesses a multimodal profile consisting of µ-opioid agonism, N-methyl-d-aspartate (NMDA) receptor antagonism, and reuptake inhibition of serotonin and norepinephrine. Furthermore, it may attenuate the development of chronic postsurgical pain. However, caution is advised with perioperative use of methadone in specific high-risk patient populations and surgical settings. Methadone's wide pharmacokinetic variability, opioid-related adverse effects, and potential negative impact on cost-effectiveness may also limit its use in the perioperative setting. In this PRO-CON commentary article, the authors debate whether methadone should be incorporated in ERAS protocols to provide superior analgesia with no increased risks.

We Need to Talk About Methadone: Adding Discussions With Patients to Our Care Pathways

“…We agree with Malta et al 1 that respiratory complications are significant adverse events that can occur following iSLNB. We examined complications of US-guided iSLNB in this study.…”

“…Finally, we express our gratitude to the author for reminding us that a double-blind study design can increase the credibility of the research results. 1 We fully agree with the author's opinion. 1 However, we need to pay more attention to whether the control group can receive the same amount of normal saline as a negative control due to ethical limitations.…”

“…1 We fully agree with the author's opinion. 1 However, we need to pay more attention to whether the control group can receive the same amount of normal saline as a negative control due to ethical limitations. Although ultrasound visualization was able to observe the direction of diffusion of local anesthetic, it was important to evaluate whether the block was effective compared to previous studies.…”

“…2 We eagerly anticipate future research on this topic, and further investigation is warranted to ensure the safety of US-guided iSLNB. 1 The authors provided a comprehensive summary of the available literature and raised compelling points for and against using methadone in Enhanced Recovery After Surgery (ERAS) protocols. 1 Notable by its absence was a consideration of the patient in the decision to include or exclude methadone from ERAS care.…”

Perioperative Methadone: Perilous or Pain Panacea?

“…Although some anesthesiologists and chronic pain specialists advocate for the use of methadone in various surgical patients, others fear potential complications related to methadone and avoid its perioperative use. In this issue of Anesthesia & Analgesia , we are presented with evidence-based arguments for (Pro commentary by D’Souza 1 ) and against (Con commentary by Esfahani and Dunn 1 ) the use of perioperative methadone. Some of the key concepts and discussion points to understand and consider in this ongoing debate include…”