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Methadone in the Management of Intractable Neuropathic Noncancer Pain

Published online by Cambridge University Press:  02 December 2014

D. E. Moulin ,
D. Palma ,
C. Watling  and
V. Schulz
D. E. Moulin*
Affiliation:
Department of Clinical Neurological Sciences, Faculty of Medicine, University of Western Ontario, London, Ontario, Canada
D. Palma
Affiliation:
Department of Clinical Neurological Sciences, Faculty of Medicine, University of Western Ontario, London, Ontario, Canada
C. Watling
Affiliation:
Department of Clinical Neurological Sciences, Faculty of Medicine, University of Western Ontario, London, Ontario, Canada
V. Schulz
Affiliation:
Department of Anesthesia and Perioperative Medicine, Faculty of Medicine, University of Western Ontario, London, Ontario, Canada
*
London Regional Cancer Centre, 790 Commissioners Rd. E., London, Ontario, N6A 4L6, Canada
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Abstract:

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Objective:

To evaluate the role of methadone in the management of intractable neuropathic noncancer pain.

Methods:

A case series of 50 consecutive noncancer pain patients who were seen at a tertiary care centre and treated with oral methadone for a variety of intractable neuropathic pain states.

Results:

The mean age was 52.7 years and the mean duration of follow-up was 13.9 months. Post-discectomy nerve root fibrosis, complex regional pain syndrome, peripheral neuropathy and central spinal cord pain syndromes were the most common diagnoses. Over 90% had been treated with one or more tricyclic antidepressants and anticonvulsants and a similar number had received other adjuvant analgesics. All patients had failed treatment with one or more conventional opioid analgesics (mean 2.8) at a mean maximal morphine dose of 384 mg (or equivalents) per day. Twelve patients had failed spinal cord stimulation. Nineteen patients (38%) did not tolerate initial methadone titration or thought their pain was worse on methadone. Five patients (10%) declared initial benefit but required repetitive dose escalation and eventually became non-responders. Twenty-six patients (52%) reported mild (4), moderate (15), marked (6) or complete (1) pain relief and continued on methadone at a mean maintenance dose of 159.8 mg/day for a mean duration of 21.3 months. Fourteen patients (28%) reported improved function on methadone relative to previous treatments.

Conclusions:

Methadone appears to have unique properties including N-methyl-D-aspartate antagonist activity that may make it especially useful in the management of intractable neuropathic pain. This observation needs to be tested in randomized, controlled trials.

Résumé:

RÉSUMÉ: Objectif:

Évaluer le rôle de la méthadone dans le traitement de la douleur névropathique rebelle d’origine non cancéreuse.

Méthodes:

Nous décrivons un groupe de 50 patients consécutifs référés à un centre de soins tertiaires et traités avec de la méthadone par voie orale pour des douleurs névropathiques rebelles non cancéreuses.

Résultats:

L’âge moyen des patients était de 52,7 ans et la durée moyenne du suivi était de 13,9 mois. Les diagnostics les plus fréquents étaient une fibrose radiculaire postdiscectomie, un syndrome de douleur régionale complexe, une neuropathie périphérique et un syndrome de douleur centrale suite à une lésion de la moelle épinière. Plus de 90% des patients avaient reçu un ou plusieurs antidépresseurs tricycliques et des anticonvulsivants, et autant de patients avaient reçu d’autres adjuvants des analgésiques. Tous les patients n’avaient pas répondu aux analgésiques opioïdes conventionnels (moyenne de 2,8) à une dose moyenne maximale de morphine de 384 mg par jour ou l’équivalent. Chez douze patients, la stimulation spinale avait été inefficace. Dixneuf patients (38%) n’ont pas toléré la dose initiale de méthadone ou ont eu l’impression que leur douleur était pire sous méthadone. Cinq patients (10%) ont éprouvé un bénéfice au début du traitement, mais ont eu besoin de doses de plus en plus élevées et sont éventuellement devenus des non-répondeurs. Vingt-six patients (52%) ont rapporté un soulagement léger (4), modéré (15), important (6) ou complet (1) de la douleur et ont continué le traitement à une dose moyenne de maintien de 159,8 mg/jour, pour une durée moyenne de 21,3 mois. Quatorze patients (28%) ont rapporté une amélioration de leur état fonctionnel sous méthadone par rapport aux traitements antérieurs.

Conclusions:

La méthadone semble posséder des propriétés uniques dont une activité antagoniste du N-méthyl-D-aspartate qui peut s’avérer particulièrement utile dans le traitement de la douleur névropathique rebelle. Cette observation doit être validée par des essais cliniques contrôlés et randomisés.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 32 , Issue 3 , August 2005 , pp. 340 - 343
Copyright
Copyright © The Canadian Journal of Neurological 2005

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