Methadone Guidelines Focus On Primary Care

New guidelines drafted by the American Pain Society (APS) for the safe administration of methadone for the first time focus particular attention on the potential for abuse and misuse of the drug, highlighting the need for additional awareness and education within the pain management community, after a significant increase in deaths related to its use.

The new guidelines, which were published in the April issue of The Journal of Pain (2014;15:338-365), address several key areas, including patient assessment, patient education/counseling and treatment monitoring; in some cases, they also propose the use of alternative medications. Among other recommendations, the new guidelines call for stratification of patients based on their risk for substance abuse prior to methadone treatment, and suggest that the drug be administered at a low starting dose (30-40 mg daily; slow titration as needed) to reduce the incidence of unintended drug accumulation and accidental overdose.

The guidelines also address the cardiovascular risks associated with the drug. A statement released by the APS in conjunction with the new guidelines describes earlier methadone protocols as focusing primarily on these risks, while ignoring the potential for abuse and misuse. According to Roger Chou, MD, head of the APS Clinical Practice Guideline Program and associate professor of medicine at Oregon Health & Sciences, University in Portland, “alarming data” on methadone-related deaths prompted the society to change the focus. He cited Centers for Disease Control and Prevention (CDC) statistics that show an increase in deaths associated with methadone, from less than 1,000 in 1999 to nearly 5,000 in 2008. He added that although methadone accounts for “about 10% or less” of all opioids prescribed, the CDC has linked the drug with roughly one-third of all prescription opioid-related deaths.

“These trends occurred in the context of markedly increased prescribing of opioids in general for chronic pain, and increased use of methadone as a less expensive alternative to other long-acting opioids,” he said.

In addition to addressing its use in the management of pain, the new guidelines focus on methadone as a treatment for patients with opioid addiction. In this context, the authors recommend that routine patient monitoring include echocardiograms and urine drug testing. They also propose buprenorphine as an alternative for these patients.

Although the guidelines were written for use by all clinicians who prescribe methadone, Dr. Chou, who served as lead author, admitted that many of the recommendations were aimed at primary care physicians. “A lot of prescribing for chronic pain occurs in primary care settings, where some clinicians may perceive methadone to be interchangeable with other opioids, when that clearly isn’t the case due to its long half-life and potential for QTc prolongation,” he told Pain Medicine News. “It is important for clinicians to understand the unique properties of methadone that can increase risk, the steps that can be taken to reduce risks, and consider alternative opioids and other treatments before prescribing methadone.”

Family practitioner Louis Kurzitzky, MD, said that the “limitations of methadone are well recognized” at his clinic, but he acknowledged that some of his colleagues may not be aware of proper monitoring protocols for patients receiving the drug for the treatment of pain. His only concern is that not all primary care physicians read The Journal of Pain, and he recommended that the authors seek to publish the guidelines in other journals, with wider readership across specialties and disciplines.

“The guidelines are a critical step forward, [as they] put clinicians on notice that methadone deserves its own special categorization because of differences in administration and monitoring [compared with] other opioids,” said Dr. Kuritzky, who is also clinical assistant professor at the University of Florida in Gainesville. He was not involved in the development of the new guidelines.