Challenges of using methadone in the Indian pain and palliative care practice

Abstract

Palliative care providers across India lobbied to gain access to methadone for pain relief and this has finally been achieved. Palliative care activists will count on the numerous strengths for introducing methadone in India, including the various national and state government initiatives that have been introduced recognizing the importance of palliative care as a specialty in addition to improving opioid accessibility and training. Adding to the support are the Non-Governmental Organizations (NGOs), the medical fraternity and the international interactive and innovative programs such as the Project Extension for Community Health Outcome. As compelling as the need for methadone is, many challenges await. This article outlines the challenges of procuring methadone and also discusses the challenges specific to methadone. Balancing the availability and diversion in a setting of opioid phobia, implementing the amended laws to improve availability and accessibility in a country with diverse health-care practices are the major challenges in implementing methadone for relief of pain. The unique pharmacology of the drug requires meticulous patient selection, vigilant monitoring, and excellent communication and collaboration with a multidisciplinary team and caregivers. The psychological acceptance of the patient, the professional training of the team and the place where care is provided are also challenges which need to be overcome. These challenges could well be the catalyst for a more diligent and vigilant approach to opioid prescribing practices. Start low, go slow could well be the way forward with caregiver education to prescribe methadone safely in the Indian palliative care setting.

Methadone in Cancer Pain

“…Dose escalation needs to be gradual and low incremental due to its enzymatic auto-induction on chronic usage. [ 3 22 26 27 ]…”

“…[ 1 37 ] The challenge is in accepting methadone as a main stream first line opioid, from being considered as a second line replacement/substitution drug all these years. [ 7 26 ] This can become practical by identifying methadone by its unique pharmacology, carefully done low dose initiation and gradual dose titration by an experienced palliative care clinician, vigilant monitoring for QTc prolongation and respiratory depression, proper patient selection, minimizing drug interactions, advocating a safety checklist and formulating opioid rotation protocols could go a long way in establishing safety of methadone as a first line opioid in cancer pain management. [ 1 7 23 29 30 31 32 33 34 ]…”

“…[ 12 ] Methadone has been established to be safe when used in opioid naïve patients with careful titration instituted in an ambulatory setting and has equal success in opioid rotation in outpatient setup. [ 26 ] Methadone has been established to be safe beyond the hospital setting and has been corroborated by various studies to be safe despite the inherent risk of respiratory depression and the risk of arrhythmia due to QTc prolongation. [ 14 59 60 61 62 ]…”

Medical Use, Decriminalization, and Legalization of Narcotic Drugs and Psychotropic Substances—What Does It Mean and What Is Its Current Status in India?

“…Also, the availability and use of these medicines remain limited in the country, and many potential beneficiaries do not have access to these evidence-based treatments. 9 The Telepsychiatry Operational Guidelines 2020 of India prohibit the prescription of psychotherapeutic medicines listed in the NDPS Act during telepsychiatry consultation. 10 Decriminalization Decriminalization refers to an approach aimed at removing criminal penalties for drug-law violations, usually possession for personal use.…”

Breaking the barrier: Challenges of methadone use – An introductory observation

“…Many years of advocacy and efforts by activists have resulted in methadone being now available for sale in India for the purpose of pain management. [ 5 ]…”