Lessons from the Literature

2021; Volume 22, No 2, February

Under My Microscope

Dr. Tania Pastrana. Used with permission.

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

The Use of Low-Dose Methadone as Add-On to Regular Opioid Therapy in Cancer-Related Pain at End of Life: A national Swedish survey in specialized palliative care

Fürst P, Lundström S, Klepstad P, Strang P. J Palliat Med 2020; 23(2): 226-32. DOI: 10.1089/jpm.2019.0253

Pain is one of the most common and distressing symptoms of patients with cancer. Methadone is used as a first-line opioid treatment for cancer pain, with great effectiveness. 1 Due to its pharmacokinetic and pharmacological interactions, it should only be prescribed by experts. In 2016, a Swedish team led by Dr. Peter Strang presented a retrospective study showing good results using low-dose oral methadone as a co-analgesic to ongoing opioid therapy.2 Now, his team has published a prospective multicentric study that collected data for one year.

A cohort of 410 patients received methadone “as an add-on to ongoing opioid therapy, mostly because of poor pain control due to mixed nociceptive and neuropathic pain.” The dose began at 7 mg and rose to 21 mg per 24 hours (daily); 94% of the patients reported pain relief and 20% reported no severe adverse effects.

This could be a good solution for teams with little experience in the use of methadone, as a way of taking advantage of this effective and low-priced opioid. But I wonder what can happen—particularly in settings where availability of opioids is scarce—if rotation to methadone is needed? And what would be special indications beside other co-analgesics?

This paper was one of the “top-read 2020 articles” in the Journal of Palliative Medicine.

  1. Peirano GP, Mammana GP, Bertolino MS, Pastrana T, Vega GF, et al. Methadone as First-Line Opioid Treatment for Cancer Pain in a Developing Country Palliative Care Unit. Support Care Cancer 2016; 24(8): 3551-6. DOI: 10.1007/s00520-016-3191-5
  2. Fürst P, Lundström S, Klepstad P, Runesdotter S, Strang P. Improved Pain Control in Terminally Ill Cancer Patients by Introducing Low-Dose Oral Methadone in Addition to Ongoing Opioid Treatment. J Palliat Med 2018; 21(2): 177-181. DOI: 10.1089/jpm.2017.0157

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Background: Low-dose methadone in addition to another ongoing opioid therapy is a promising approach for managing complex cancer-related pain and is, despite limited evidence, used in clinical practice.

Objective: To investigate the use of low-dose methadone in specialized palliative care in Sweden.

Design: Specialized palliative care services in Sweden answered a survey regarding methadone use in individual patients over 12 months.

Setting/Subjects: The survey was an add-on to the Swedish Register of Palliative Care's (SRPC) mandatory end-of-life questionnaire (ELQ).

Results: Sixty of 133 invited units (45%) participated in the study. A total of 4780 ELQs were registered. Four hundred ten of these patients received methadone (9%). In 96% of these patients, methadone was prescribed as an add-on to ongoing opioid therapy, mostly because of poor pain control due to mixed nociceptive and neuropathic pain (70%). Methadone was used for a median of 21 days, in 86% of cases until death. Mean daily methadone doses increased from 7 mg at start to 21 mg (p < 0.005) during the last 24 hours. Corresponding morphine equivalent daily doses of other opioids were 184 and 199 mg (p < 0.05), respectively. A pain-relieving effect was reported in 94% of the patients. Adverse effects were seen in 20% of the patients; none of these was severe.

Conclusion: The addition of low-dose methadone to an ongoing opioid therapy in patients with complex cancer-related pain is well established in Swedish specialized palliative care. It appears to have good pain-relieving effects and to be safe.

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Media Watch: COVID-19

The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.

Maintaining Control: A qualitative study of being a patient in need of specialized palliative care during the COVID-19 pandemic

Progress in Palliative Care | Online – 18 January 2021 – The aim of this study was to explore the experiences of patients with specialized palliative care (PC) needs during the period of restrictions requiring social distancing due to the COVID-19 pandemic. The participants were patients living in their own homes who were being treated by the outpatient clinic PC unit at the Herlev & Gentofte University Hospital in Denmark. Participants’ main concern was maintaining control during the pandemic. They achieved this by aiming to secure a meaningful life by remaining occupied during the day, balancing social contact, contemplating the reopening of society, and seeking help from healthcare professionals (HCPs). Participants were concerned about losing control and this concern increased with the reopening of society. HCPs must ensure that they provide support and care for patients with specialized PC needs when societal restrictions change. DOI: 10.1080/09699260.2021.1872139

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Dying at Home of COVID-19: Meeting the need for home-based care

Preventive Medicine | Online – 31 December 2020 – The U.S. Centers for Disease Control & Prevention and World Health Organization recognize the heightened risks of COVID-19 for older adults; however, both organizations presuppose that most cases of COVID-19 will be mild to moderate and recoverable at home. Older patients are more susceptible to experiencing severe illness at home from which they may not recover; and if they do seek medical care, they tend to suffer worse outcomes than younger patients in intensive care settings. Given their likelihood of severe illness, worse outcomes in intensive care settings, and potential difficulty accessing resources, frail, disabled, and otherwise vulnerable older patients may face COVID-19 at home without adequate resources, information, or support for home-based care. The authors propose three approaches to prevent needless suffering and ensure that this vulnerable population continues to receive needed care. DOI: 10.1016/j.ypmed.2020.106409

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Psychological Risk Factors of Functional Impairment following COVID-19 Deaths

Journal of Pain & Symptom Management | Online – 18 January 2021 – This is the first study to focus on psychological factors that could increase risk of functional impairment following bereavement from COVID-19. The predicted worldwide tsunami of grief from this pandemic is likely to be associated with much functional impairment experienced by grieving persons, particularly for bereaved individuals reporting symptoms of separation distress, dysfunctional grief, and posttraumatic stress. Efficacious and cost-effective strategies to identify, limit, and treat functional impairment experienced by people bereaved by COVID-19 are urgently needed. Palliative care grapples with questions concerning who to provide bereavement support, when and what to provide, and on what basis. Psychologists and other mental health professionals are ideally placed to provide evidence-based guidance. Yet, the role of psychologists within end-of-life care is under-developed. DOI: 10.1016/j.jpainsymman.2021.01.006

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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