Understanding the Use of Methadone in End-of-Life Care

Posted on Thursday April 4, 2019 in Hospice Education

Methadone is one of the most effective and most misunderstood medications in hospice and palliative care. It’s important to get past the myths and misconceptions to understand the true risks and benefits of methadone for hospice and palliative care patients.

Methadone was developed in the 1940s as a medication for pain relief. It was approved for use in the United States in 1947.

Meanwhile, heroin use began to soar in the United States in the decades following the end of World War II and leading into the Vietnam War. In 1971, President Richard Nixon called drug addiction “public enemy number one.”

To address the problem, clinics began to offer methadone as a treatment for heroin addiction that promised to reduce withdrawal symptoms and pain perception, while preventing the euphoric feelings or “high” that led to their addiction.

Over time, methadone became synonymous with drug addiction – and the stigma caused it to fall out of favor with many physicians despite its effectiveness in pain relief.

Advantages of Methadone for Pain Relief in Hospice & Palliative Care

Methadone offers rapid onset of long-acting pain relief that can be delivered via pill or liquid form, which makes it a useful medication for patients with advanced dementia, kidney disease, and patients who can no longer swallow pills. It is also the only opiate that specifically targets neuropathic pain which is caused by damage or disease that affects the nervous system and is described by patients as burning, stabbing, tingling, or hot.

In addition, as a synthetic opioid, methadone has a chemical structure unrelated to other opium derivatives so it can often be used when a patient has a true allergy to other opioids.

Methadone has lower incidence of neurotoxic side effects compared to other opioids including hallucinations, agitation, or muscle jerks and twitches. Methadone also has the advantage of lower incidence of constipation compared to other opioids.

Finally, most patients are able to find relief with a much lower dose of methadone which also has a much lower cost, making it a very affordable option for pain relief in hospice and palliative care.

methadone end of life

Disadvantages of Methadone in Hospice & Palliative Care

Like any medication, there are risks in using methadone that patients, caregivers, and physicians need to consider when prescribing it for pain relief. Methadone is very complex medication that should only be used in experienced hands.

It can take several days to adjust dosages and it requires close monitoring when a patient first begins methadone. Specific protocols must be followed if they are switching from another opioid. Due to the long half-life of methadone, it must be adjusted gradually to avoid cumulative toxicity – particularly in the elderly. It may also cause depression, especially in the first two weeks as it does not have the same euphoric effect of other opioids.

A careful medication review is necessary before prescribing methadone for pain relief at end of life as there are also a wide variety of drug interactions that can increase or decrease serum methadone levels.

In rare instances, methadone has been shown to cause changes in breathing and heart rate. Some patients may choose to get an EKG before starting on methadone. Physicians should use extra caution when prescribing to someone with heart disease.

The Bottom Line on Methadone in Hospice & Palliative Care

With proper education, methadone is an effective tool in relieving pain in patients at end of life. It offers vastly superior control of neuropathic pain compared to other opioids, and patients often receive greatly improved control of non-neuropathic pain.

It can also be a useful tool when a patient has a history of substance abuse or if there are concerns about drug diversion in the home.

To learn more about the medication hospice patients receive, please call us at 1-888-564-3405.