Moryl, N., Kogan, M., Comfort, C., & Obbens, E. (2005). Methadone in the treatment of pain and terminal delirium in advanced cancer patients. Palliative and Supportive Care, 3, 311–317.doi: 10.1017/S1478951505050479
To document the use of methadone as part of an opioid-rotation strategy for the treatment of uncontrolled pain in patients with delirium at the end of life
Ten patients rotated from morphine, five from fentanyl, two from hydromorphone, and three from fentanyl-morphine or morphine- hydromorphone combinations. Authors were purposefully conservative in calculating the starting methadone dose. Within the first week four patients expired, one changed to IV methadone, and two rotated back to morphine because of worsening delirium and inadequate analgesia. At two weeks, 10 patients had expired. Of the remaining 10, seven stayed on methadone. The average dose was 1.1 mg/hour. Two patients returned to morphine, and one was rotated to Percocet.
Nonrandomized open-label prospective study
Pain control was significant in 15 of 20 patients; average analgesia was good to excellent. Sedation rating decreased from 1.65 to 0.55 on 1–3 scale. Cognitive status improved for nine patients. Six patients achieved moderate improvement in cognitive status; two, partial improvement; and three, no improvement. Three days after the switch from an opiod, average MDAS score improved from 23.6 to 10.6. Decreased alertness on methadone was devoid of agitation.
Methadone can be an acceptable alternative to an opioid in the treatment of refractory pain and terminal delirium. The use of methadone can minimize the need for sedation to treat delirium.