White Paper Spotlights Safe, Appropriate Methadone Use in Hospice and Palliative Care

Publication offers guidance for hospice and palliative care practitioners that aims to maximize benefits and minimize risks of methadone therapy in patients with serious illness.

By Malissa Carroll
July 2, 2019

More than a dozen experts across the fields of hospice and palliative care came together to publish a white paper that offers guidelines for the safe and appropriate use of methadone in patients near the end-of-life. Led by Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE, professor and executive director of advanced post-graduate education in palliative care in the Department of Pharmacy Practice and Science (PPS) at the University of Maryland School of Pharmacy, and Kathryn Walker, PharmD, BCPS, CPE, associate professor in PPS at the School, the expert team aimed to build on recommendations issued by the American Pain Society, the College on Problems of Drug Dependence, and the Heart Rhythm Society in 2014.

The paper – titled “Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper” – was published in the March issue of the Journal of Pain and Symptom Management.

“Methadone is a highly valuable opioid in our armamentarium for treating pain,” says McPherson. “However, it is a drug that requires special attention to dosing and monitoring how patients respond. Many organizations have published guidelines that speak to the safe and effective use of methadone when treating patients with chronic, non-cancer pain. Our goal was to apply our knowledge to patients who have a serious illness, or who might be very close to the end-of-life, to help health care practitioners gain some consistency in dosing and selecting appropriate candidates for this therapy.”

Methadone is an opioid pain reliever that is often used to treat severe pain in people who are expected to need consistent pain relief over an extended period of time. It possesses a number of unique features that make it an attractive option to alleviate pain in patients with serious illnesses, including a long duration of action; the availability of different dosage formulations, such as tablets and oral solutions; and low cost.

However, the exponential increase in opioid-related deaths reported in recent years has raised concerns about the safety of methadone. “Treatment with methadone can be magical, but a lot of practitioners are fearful of the drug. Our goal was to remove some of the fear factor and help health care practitioners embrace a consistent approach to dosing methadone and selecting patients appropriate for this therapy,” says McPherson.

The white paper follows the 2014 publication of the methadone safety guidelines established by the American Pain Society, College on Problems of Drug Dependence, and Heart Rhythm Society, which did not address the use of methadone to relieve severe pain among hospice and palliative care patients.

“The guidelines published by the American Pain Society and its peer organizations informed a lot of decision making around methadone and how to use it safely, but they focused on populations whose long-term survival was much greater than that of the patients that we treat in hospice and palliative care,” says Walker. “We wanted to be able to tell other hospice and palliative care clinicians what they ought to do, and also what is safe to do, in a space where not a lot of strong evidence is available to guide such decision making. My hope is that our recommendations help support these clinicians in their efforts to do what is best for their patients when trying to manage their symptoms.”

The authors – who spanned the disciplines of medicine, nursing, and pharmacy – conducted an extensive review of the existing literature surrounding methadone use in patients at the end-of-life, combining the findings with their knowledge and firsthand experience using methadone in hospice and palliative care settings across the United States and Canada to achieve consensus for the white paper. The guidelines included in the publication address a number of important topics, including how to select patients who might be appropriate candidates for methadone, how to correctly dose methadone for those patients, and how to monitor patients who have been prescribed methadone. The publication also examined how to treat patients with a history of substance use disorder, monitor for drug interactions, use alternate routes of administration, and provide patient, family, and caregiver education.

The authors aimed to help health care providers in the fields of hospice and palliative care maximize the benefit and minimize the risks associated with methadone therapy in patients with advanced illness.  They noted that, while the benefits and risks for each medication prescribed to patients must be carefully considered, it is important to understand how those elements of care can change as a patient approaches the end of his or her life. “For a patient with advanced illness, the benefits and burdens associated with drug therapy may shift as his or her goals of care change. The benefits might be even greater, while the burdens become less burdensome and more acceptable to the patient and his or her family,” says McPherson.

Health care providers who are interested in learning more about best practices for methadone use in hospice and palliative care patients are encouraged to apply to the online Master of Science and Graduate Certificates in Palliative Care program at the School of Pharmacy, for which understanding safe and effective methadone use in this patient population is a required competency.

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