“I don't think there is any standard of care that has developed. I think that we probably need to be cognizant of the fact that methadone may prolong the QTc interval,” Dr. Gazelle said. She advises thinking about what the goals of care are for individual patients and discussing with them the potential cardiac risks.
There are several opioid/methadone conversion protocols, including the U.K. Hospice model (Pain Rev. 1998;5:51-8), the Milan model (J. Clin. Oncol. 1998;16:3216-21), the Edmonton model (Cancer 1996;78:852-7), the German model (Am. J. Hosp. Palliat. Care 2001;18:200-2), and the Royal Perth Hospital model (Med. J. Aust. 2000;173:536-40).
For physicians with adequate experience prescribing methadone, the drug should be considered under the following circumstances:
▸ When starting a patient on a long-acting opioid.
▸ For patients already on very high doses of a long-acting opioid.
▸ When side effects from current pain medications are unacceptable.
▸ When a patient has inadequate pain control.
▸ For the treatment of neuropathic pain.
▸ For patients with current or recurrent substance abuse problems.
▸ When there is concern about drug diversion.
Despite the complexity of proper use, with methadone “we can really change a patient's level of suffering, in ways that we sometimes can't with other opioids,” Dr. Gazelle observed.
Neither Dr. Loitman nor Dr. Gazelle had any relevant financial relationships to disclose.