Hostname: page-component-586b7cd67f-t7czq Total loading time: 0 Render date: 2024-11-21T16:54:35.669Z Has data issue: false hasContentIssue false
  • English
  • Français

Methadone in the treatment of pain and terminal delirum in advanced cancer patients

Published online by Cambridge University Press:  13 April 2006

NATALIE MORYL ,
MARIA KOGAN ,
CHRISTOPHER COMFORT  and
EUGENIE OBBENS
NATALIE MORYL
Affiliation:
Memorial Sloan-Kettering Cancer Center, New York, New York, USA
MARIA KOGAN
Affiliation:
Calvary Hospital, Bronx, New York, USA
CHRISTOPHER COMFORT
Affiliation:
Calvary Hospital, Bronx, New York, USA
EUGENIE OBBENS
Affiliation:
Memorial Sloan-Kettering Cancer Center, New York, New York, USA
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective: This prospective study documents the use of methadone as part of an opioid rotation strategy in patients with uncontrolled pain and severe delirium admitted for terminal care to a tertiary cancer palliative care hospital.

Methods: We reviewed the treatment of 20 patients with severe pain and delirium at the end of life who's delirium did not improve 24 h or longer after starting a neuroleptic medication.

Results: Ten male and 10 female patients, 47 to 77 years old, were rotated or “switched” to methadone due to uncontrolled pain in the setting of delirium, limiting further opioid dose escalation. At 2 weeks, a total of 10 patients had expired. Of the 10 patients who were alive 2 weeks after starting methadone, 7 patients were stable on an average of 1.1 mg/h methadone, 2 patients were restarted on morphine IV and one on Percocet. The calculated average equianalgesic dose of methadone was 9% (2%–17%) of the previous morphine-equivalent dose. Of the 20 patients who were switched to methadone for what appeared to be terminal delirium, the pain control was significant in 15, moderate in 3, and unchanged in 2 patients. Average analgesia was good to excellent (average Numeric Analog Scale rating [NAS] decreased from 8.2 to 2.5). Sedation had decreased from 1.65 to 0.55 on a scale of 0 to 3. Of the 20 patients, improvement of cognitive status was significant in 9, moderate in 6, partial in 2, and none in 3 patients. The Memorial Delirium Assessment Scale (MDAS) showed improvement from an average of 23.6 prior to the switch to 10.6 3 days after. Decreased alertness on methadone was devoid of agitated features.

Significance of results: Our study suggests that methadone can be effective in the treatment of both refractory pain and what appears to be terminal delirium. Most patients in our group had at least a short-term improvement in mental status as well as significant and lasting improvement in analgesia.

Keywords

MethadoneDeliriumCancerPainSedationPalliative
Type
ORIGINAL ARTICLES
Information
Palliative & Supportive Care , Volume 3 , Issue 4 , December 2005 , pp. 311 - 317
Copyright
© 2005 Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

American Pain Society. (2005). Principles of analgesic use in the treatment of acute pain and cancer pain. (5th ed.). Glenview, IL: Author.
Breitbart, W. & Strout, D. (2000). Delirium in the terminally ill. Clinical Geriatric Medicine, 16, 357–372.Google Scholar
Crews, J.C., Sweeney, N.J., & Denson, D.D. (1993). Clinical efficacy of methadone in patients refractory to other mu-opioid receptor agonist analgesics for management of terminal cancer pain. Case presentations and discussion of incomplete cross-tolerance among opioid agonist analgesics. Cancer, 72, 2266–2272.Google Scholar
Estfan, B., LeGrand, S.B., Walsh, D., et al. (2005). Opioid rotation in cancer patients: Pros and cons. Oncology, 19, 511–516; discussion 516–518, 521–523, 527–528.Google Scholar
Fainsinger, R., Schoelle, T., & Bruera, E. (1993). Methadone in the management of cancer pain: A review. Pain, 52, 137–147.Google Scholar
Foley, K.M. & Houde, R.W. (1998). Methadone in cancer pain management: Individualized dose and titrate to effect. Journal of Clinical Oncology, 16, 3213–3215.Google Scholar
Ho, R.C.S. (1994). Pain in the cancer patient. A Cancer Journal for Clinicians, 44, 259–261.Google Scholar
Khojainova, N., Santiago-Palma, J., Kornick, C., et al. (2002). Olanzapine in the management of cancer pain. Journal of Pain and Symptom Management, 23, 346–350.Google Scholar
Lawlor, P.G. & Bruera, E.D. (2002). Delirium in patients with advanced cancer. Hematology Oncology Clinics of North America, 16, 701–714.Google Scholar
Lawlor, P.G., Turner, K.S., Hanson, J., et al. (1998). Dose ratio between morphine and methadone in patients with cancer pain: A retrospective study. Cancer, 82, 1167–1173.Google Scholar
Manfredi, P.L., Borsook, D., Chandler, S.W., & Payne, R. (1997). Intravenous methadone for cancer pain unrelieved by morphine and hydromorphone: Clinical Observations. Pain, 70, 99–101.Google Scholar
Mercadante, S. (1997). Methadone in cancer pain. European Journal of Pain, 1, 77–85.Google Scholar
Mercadante, S., Casuccio, A., Fulfaro, F., et al. (2001). Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: A prospective study. Journal of Clinical Oncology, 19, 2898–2904.Google Scholar
Portenoy, R.K. & Lesage, P. (1999). Management of cancer pain. Lancet, 15, 1695–1700.Google Scholar
Santiago-Palma, J., Khojainova, N., Kornick, C., Fischberg, D.J., Primavera, L.H., Payne, R., & Manfredi, P. (2001). Intravenous methadone in the management of chronic cancer pain: Safe and effective starting doses when substituting methadone for fentangl. Cancer, 92, 1919–1925.Google Scholar
Tucker, G.J. (1991). DSM-IV: Proposals for revision of diagnostic criteria for delirium. International Psychogeriatrics, 3, 197–208.Google Scholar
Yennurajalingam, S., Braiteh, F., & Bruera, E. (2005). Pain and terminal delirium research in the elderly. Clinical Geriatric Medicine, 21, 93–119.Google Scholar