Download Management of Malignant Pain with Methadone

Management of Malignant Pain
with Methadone
Michelle Phelan, ACNP, AOCN
Overton Brooks VA Medical Center
Shreveport, LA
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.
Individualized Therapy
• Veteran population ranges from the
frail elderly to young adults
– Side effect concerns
– Quality of life issues
– Cost
– Social issues
Side Effects of Treatment
• Constipation
• Nausea
• Somnolence or Confusion
Quality of Life Issues
• Dosing schedules—ease of use
• Need for other medications—adjuvant
medications for pain control
Cost of Therapy
•
•
•
•
MS Contin 15mg tablet-$0.30
Oxycontin 10mg tablet-$0.70
Fentanyl Patch 25mcg-$78.80
Methadone 10mg tablet-$0.05
Social issues
• Misappropriation of pain medications
by others
• “Morphine” stigma
Morphine vs. Methadone
• Morphine considered the standard of care
– Familiarity among prescribers
– Known side effect profile
• Methadone
– Methadone clinic drug
– Unfamiliar to prescribers
Methadone Advantages
• Conversion of other opioids notes a
significant reduction in dose—up to 90%.
• Reliable absorption
• Long half-life
• Low cost
• Multiple routes of administration available
• Few drug interactions
Methadone Disadvantages
• Conversion may be a timely process
• QT interval prolongation at high doses
– Potentially fatal dysrhythmia
– Torsade de pointes
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.
Case Study
• Treatment with palliative chemotherapy did
not bring chronic pain under control.
• Chronic Pain Management included:
– Oxycontin
– MS Contin
– Methadone
Case Study
• Currently patient controlled with
– Methadone 10mg po bid with breakthrough
pain medication of Tramadol 50mg po every 6
hours prn