Oral methadone for chronic noncancer pain: a systematic literature review of reasons for administration, prescription patterns, effectiveness, and side effects.
ABSTRACT To assess the indications, prescription patterns, effectiveness, and side effects of oral methadone for the treatment of chronic noncancer pain.
We conducted searches of several electronic databases, textbooks and reference lists for controlled or uncontrolled studies in humans. Effectiveness was assessed using a dichotomous classification of "meaningful" versus "nonmeaningful" outcomes.
Twenty-one papers (1 small randomized trial, 13 case reports, and 7 case series) involving 545 patients with multiple noncancer pain conditions were included. In half of the patients, no specific diagnosis was reported. Methadone was administered primarily when previous opioid treatment was ineffective or produced intolerable side effects. Starting dose ranged from 0.2 to 80 mg/day and maximum dose ranged from 20 to 930 mg/day. Pain outcomes were meaningful in 59% of the patients in the uncontrolled studies. The randomized trial demonstrated a statistically significant improvement in pain for methadone (20 mg/day) compared to placebo. Side effects were considered minor.
Oral methadone is used for various noncancer pain syndromes, at different settings and with no prescription pattern that could be identifiable. Starting, maintenance, and maximum doses showed great variability. The figure of 59% effectiveness of methadone should be interpreted very cautiously, as it seems overrated due to the poor quality of the uncontrolled studies and their tendency to report positive results. The utilization of oral methadone for noncancer pain is based on primarily uncontrolled literature. Well-designed controlled trials may provide more accurate information on the drug's efficiency in pain syndromes and in particular neuropathic pain.
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ABSTRACT: The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.The Spine Journal 01/2008; 8(1):185-94. DOI:10.1016/j.spinee.2007.10.020 · 2.80 Impact Factor
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ABSTRACT: Healthcare safety and quality surveillance is increasingly conducted by public health agencies. We describe a biomedical informatics method that uses multiple public health data sources to perform surveillance of methadone-related adverse drug events. Data from Utah medical examiner records, vital statistics, emergency department encounter administrative data and a database of controlled substances prescriptions are used to examine trends in state-wide adverse events related to methadone. From 1997 to 2004, population-adjusted methadone prescriptions increased 727%, with evidence to suggest the rise in the methadone prescription rate is for treatment of pain, not addiction therapy. During the same period of time, population adjusted, accidental methadone-related deaths in medical examiner data increased 1770%. Population adjusted methadone-related emergency department encounters rose 612% from 1997 to 2003. Our results suggest that the increase in methadone prescription rates from 1997 to 2004 was accompanied by a concurrent increase in methadone-related morbidity and mortality. Although patient data is not linked between data sources, our results demonstrate that utilizing multiple public health data sources captures more cases and provides more clinical detail than individual data sources alone. Our approach is a successful biomedical informatics approach for surveillance of adverse events and utilizes widely available public health data sources, as well as an emerging source of public health data, controlled substance prescription registries.Journal of Biomedical Informatics 09/2007; 40(4):382-9. DOI:10.1016/j.jbi.2006.10.004 · 2.48 Impact Factor
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ABSTRACT: The synthetic opioid methadone is a promising analgesic for the management of chronic neuropathic pain. Methadone therapy is increasing as its advantages are being realized over other opioids. Methadone's lack of known active metabolites, high oral bioavailability, low cost, and its additional receptor activity as an antagonist of N-methyl-D-aspartate receptors make it an attractive analgesic. We surveyed 550 pain physicians to determine their prescribing practices of methadone. The study was approved by our Institutional Review Board. A list of 550 pain physicians, which included practitioners in private practice, university settings, and community hospitals, were obtained and surveys sent via mail. The list was obtained through the American Pain Society's membership list. Out of 550 surveys sent, 124 replies were returned. The 124 surveys that were returned included pain physicians from various settings: 20 responses from physicians practicing at a university setting, 16 responses from a community setting, 54 responses from a private setting, one from university and community settings, 7 from community and private settings, 3 from university and community and private settings; 23 did not specify. Of the 124 physicians, 111 prescribe methadone in their pain practice. Of the 13 physicians who do not prescribe methadone, the main reason for not using the drug for 5 physicians was because of social stigma, 2 because of minimal experience with the drug, 2 because the drug was not effective, one because of lack of knowledge, and one because of potential adverse effects. Of the 111 physicians who use methadone, 55 stated that social stigma was the most common reason patients refuse to take methadone for the treatment of pain, 44 because of adverse effects, and 5 stated "other" as the reason patients refuse to take methadone. Of 111 physicians who prescribe methadone, 100 prescribed it for neuropathic pain, 101 for somatic pain, 80 for visceral pain, 78 for cancer pain, and 34 for sickle cell pain. Also, 21 stated that methadone was the primary opioid they prescribed. Of the 111 physicians who prescribe methadone, 86 start methadone at low dose and titrate up to minimize side effects. Fourteen clinicians load methadone and titrate down to minimize adverse effects while maintaining analgesia. The majority of survey responders (90%) prescribed methadone in their pain practice, but on a very limited basis; 59% state <20% of their patients are on methadone. Three times a day dosing schedule was the most typical regimen (57%) while 77% prefer to titrate up on the dosage. It seems interesting that many clinicians do not prescribe methadone as a primary analgesic. One reason for this is due to the social stigma of its use in treatment of heroin addicts. Also, a lack of widely recognized treatment algorithms or guidelines to assist clinicians with opioid conversions and maintenance might be playing a role. The role of stigma as a barrier to adequate treatment of chronic pain among pain physicians prescribing practices is a fundamental, yet unexplored issue.Pain physician 13(3):289-93. · 4.77 Impact Factor