Improved Pain Control in Terminally Ill Cancer Patients by Introducing Low-Dose Oral Methadone in Addition to Ongoing Opioid Treatment

Abstract

Addition of low-dose oral methadone to regular high-dose opioid treatment in cancer patients with complex pain close to death improves pain control, but also increases the risk for sedation and delirium.

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

“…Methadone was highlighted as an important component of the palliative toolbox because it was easy to handle and had rapid onset, often within a few hours. The notion of methadone treatment being successful in 50-90% of selected patients is mainly in line with previous reports of the effects of low-dose methadone add-on therapy [15,18,35,36].…”

“…There is emerging evidence that low-dose methadone as an add-on twice daily to already existing high-dose opioid treatment increases the pain-relieving effect in complex pain [14][15][16][17][18]. This is also the general opinion in the current study.…”

“…According to our informants, selected patients may benefit from the use of methadone; either as a primary therapy or, when time is limited, unexpectedly good and safe analgesia can be achieved with low-dose add-ons to high doses of other opioids. This regimen can also be used in home care, a finding which is supported by recent studies [17,18]. Also, patients with complex cancer-related pain involving central sensitization were considered to be the most appropriate candidates for methadone treatment.…”

“…This is of particular interest in complex pain syndromes. In such cases, combining an ongoing high-dose opioid treatment with a low fixed dose of methadone has become increasingly popular in specialized palliative care, not least in Sweden [14][15][16][17][18]. Still, the appropriate indications for, as well as practical uses of, low-dose methadone have been insufficiently defined.…”

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

“…96 Retrospective studies have also reported that low-dose methadone may improve pain control when used as a coanalgesic in patients with cancerrelated pain that were receiving a different, regularly scheduled opioid analgesic. 97,98 There is evidence suggesting that high doses of methadone (120 mg and above) may lead to QTc prolongation and torsades de pointes, which may lead to sudden cardiac death. [99][100][101] A study conducted in patients with cancer suggests that QT interval changes exist commonly at baseline and are not changed with the addition of methadone.…”