Management of Malignant Pain with Methadone

1
Management of Malignant Pain with Methadone

• Michelle Phelan, ACNP, AOCN
• Overton Brooks VA Medical Center
• Shreveport, LA

2
Cancer Pain Management

• 60 to 80 of patients with advanced cancer
  require pain management.
• Oral treatment of pain, utilizing WHO guidelines,
  can provide relief to 70-90 of this population.

3
Individualized Therapy

• Veteran population ranges from the frail elderly
  to young adults
• Side effect concerns
• Quality of life issues
• Cost
• Social issues

4
Side Effects of Treatment

• Constipation
• Nausea
• Somnolence or Confusion

5
Quality of Life Issues

• Dosing schedulesease of use
• Need for other medicationsadjuvant medications
  for pain control

6
Cost of Therapy

• MS Contin 15mg tablet-0.30
• Oxycontin 10mg tablet-0.70
• Fentanyl Patch 25mcg-78.80
• Methadone 10mg tablet-0.05

7
Social issues

• Misappropriation of pain medications by others
• Morphine stigma

8
Morphine vs. Methadone

• Morphine considered the standard of care
• Familiarity among prescribers
• Known side effect profile
• Methadone
• Methadone clinic drug
• Unfamiliar to prescribers

9
Methadone Advantages

• Conversion of other opioids notes a significant
  reduction in doseup to 90.
• Reliable absorption
• Long half-life
• Low cost
• Multiple routes of administration available
• Few drug interactions

10
Methadone Disadvantages

• Conversion may be a timely process
• QT interval prolongation at high doses
• Potentially fatal dysrhythmia
• Torsade de pointes

11
Case Study

• Floyd is a 55 y/o male with metastatic colon
  cancer diagnosed in 2000.
• Presented to VA after lose of employment brought
  about lose of insurance.
• Social Factors
• Married
• History of tobacco, ETOH use and occasional
  recreational drug use.

12
Case Study

• Treatment with palliative chemotherapy did not
  bring chronic pain under control.
• Chronic Pain Management included
• Oxycontin
• MS Contin
• Methadone

13
Case Study

• Currently patient controlled with
• Methadone 10mg po bid with breakthrough pain
  medication of Tramadol 50mg po every 6 hours prn