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New Guidelines on Opioids for Chronic Pain Include Caution on Methadone

Started by ronr, February 13, 2009, 10:48:40 AM

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New Guidelines on Opioids for Chronic Pain Include Caution on Methadone

By John Gever, Senior Editor, MedPage Today
Published: February 12, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.   

PORTLAND, Ore., Feb. 12 -- Although methadone has become an increasingly popular option for treating chronic pain, it is one of the most unpredictable opioids and should be used cautiously, according to new guidelines issued this week. Action Points 
Explain to interested patients that opioids reduce chronic pain in most patients but seldom eliminate it altogether. Breakthrough pain is common even in patients taking maximal safe doses.

Explain that long-term use of opioids can have a variety of adverse effects and that the prescribed dosing schedule should be followed exactly.
The methadone caution was one of 25 recommendations in the guidelines, developed by the American Pain Society and the American Academy of Pain Medicine and published in the February issue of the Journal of Pain.

The guidelines were based on an extensive literature review and analysis, published as separate papers in the journal. They are the first joint guideline effort of the two societies.

"Use of methadone for chronic noncancer pain has increased dramatically," wrote Roger Chou, M.D., of Oregon Health and Science University here, and colleagues on the guideline panel.

But they noted that its pharmacokinetics and clinical effects are highly variable, and the drug has been associated with prolonged QTc, arrhythmias, and an increasing number of deaths.

For these reasons, the guidelines recommend that clinicians start with low doses of methadone -- 2.5 mg every eight hours in opioid-naive patients -- and titrate slowly. Some patients may need 12 days to achieve a steady state, the authors said.

They also recommended that methadone never be used for breakthrough pain or be prescribed "as needed."

The guideline writers said the methadone recommendation was backed by moderate-quality evidence -- making it among the best-supported in the entire guideline.

They lamented the generally poor state of research on the use of opioids for chronic noncancer pain.

"The panel identified numerous research gaps," they wrote. "In fact, the panel did not rate any of its 25 recommendations as supported by high quality evidence. Only four recommendations were viewed as supported by even moderate quality evidence."

Nevertheless, the authors said there was little dissent on the panel about any of the recommendations.

Among the strongest:

Patient selection and risk stratification at the beginning of opioid therapy is vital.
Clinicians should counsel patients on realistic expectations from therapy and on the precautions necessary to avoid diversion or other misuse.
Doses need to be carefully titrated.
Frequent monitoring and re-evaluation is necessary.
Additional therapies targeting psychosocial factors should be considered.
Patients should have a medical home to ensure that treatment of pain, the underlying condition, and comorbidities is coordinated.

The authors also said that research is most urgently needed on methods for obtaining informed consent, the best makeup of management plans worked out with patients, approaches to high-dose opioid therapy, usefulness of rotating different opioids, and treatment of breakthrough pain.

They added that much remains unknown about how regulations and policies restricting opioid prescription and dispensing affects clinical outcomes.

"Surveys show that clinicians have a poor or limited understanding of the laws, regulations, and other policies" governing opioid distribution and usage, Dr. Chou and colleagues said.

How much this lack of knowledge affects healthcare practices and patient care has received little formal study, they said.

The guidelines are available at Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain.

The review and guideline preparation was funded by the American Pain Society.

Other authors reported a wide range of relationships with commercial entities including pharmaceutical companies marketing opioid pain medications.

Primary source: Journal of Pain
Source reference:
Chou R, et al "Opioid treatment guidelines: clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain" J Pain 2009; 10: 113-30.
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