PERT Program

Tip of the Month: July 2004


PRESCRIBING METHADONE FOR THE OPIOID-NAÏVE NURSING HOME RESIDENT

As previously described, there are several reasons for using methadone to manage persistent pain.

See also:
May 2004 · An Overview of Methadone

June 2004 · Methadone Use in Opioid-Tolerant Residents

Because of its complex pharmacology, methadone has its own set of prescribing and titration guidelines. The usual guidelines for calculating equianalgesic dose conversion do not apply to methadone. Neither do the typical recommendations for breakthrough medication. Before using methadone in any clinical setting, we recommend that staff receive detailed education on the need for close nursing assessment and monitoring of the resident, especially for sedation. Many experts believe that methadone should only be used in consultation with a clinician who is experienced in prescribing methadone for persistent pain and/or a pharmacist familiar with its use and conversion.

A resident is considered opioid-naïve if he or she has not previously been on opioids, or has been on very low doses of intermittent opioids for a brief period (for example, a few hydrocodone/apap over 2 weeks). Experienced pain and geriatrics specialists have differing opinions regarding whether to use methadone for the opioid-naïve nursing home resident. Two of our consulting specialists do not advocate the use of methadone in this population. Their reluctance stems from concerns regarding the inexperience of prescribers, likelihood of resident oversedation, and the challenge of closely monitoring side effects in settings where the ratio of residents to nursing staff is high.

Prescribers who do use methadone to treat neuropathic pain in frail elders, use it cautiously. One consultant reported using methadone for nursing home residents with challenging pain management issues. One particular group who may benefit from methadone are those residents, aged 70 to 85, with post-stroke neuropathic pain who do not tolerate gabapentin or tricyclic antidepressants. It also may be a good choice for residents with limited financial resources.

Clinicians who have experience prescribing methadone for opioid-naïve elders generally initiate treatment using a 2.5 mg dose at bedtime. They titrate methadone slowly, in increments of 2.5 mg, until pain is controlled. They supplement methadone with a short acting opioid (e.g., hydrocodone, immediate release morphine, or oxycodone) as necessary.

The following table shows one method of initiating methadone for the resident who has not been on another strong opioid. The titration schedule is followed by a case example.

Initial Methadone Titration Schedule
(For residents who are opioid-naïve or on a low dose of opioids)
  Week 1 Week 2 Week 3 Week 4 Week 5
Morning   2.5 mg 2.5 mg 2.5 mg 5.0 mg
Noon       2.5 mg 5.0 mg
Evening 2.5 mg 2.5 mg 5.0 mg 5.0 mg 5.0 mg


Any time methadone is prescribed, be vigilant in assessing pain control and side effects, especially sedation. Use an alternative short-acting oral opioid with a short half-life (e.g., hydrocodone 5 mg / acetaminophen 325 mg) to provide pain relief during the titration phase. Even if the resident needs 4–5 doses of hydrocodone per day, do not hurry the titration of the methadone. If the pain is controlled, report your observations to the prescriber. Be prepared to stop titration and monitor for side effects.


Case example:

Mrs. G., an 88-year-old resident, has chronic arthritis pain that has been treated with long-term NSAIDs. She has developed kidney problems and needs to discontinue her NSAIDs and start on opioids. In light of Mrs. G’s renal compromise, the physician decides to switch her to methadone. (Remember, methadone is primarily excreted via the feces, an advantage over other opioids.)

For the 1st week, Mrs. G. takes methadone 2.5 mg at 8pm only. She requires hydrocodone 5 mg/acetaminophen 325 mg 2 tabs 2–3 times per day throughout the week. She obtains fair pain relief (pain level 4/10), experiences minimal sedation, and has worsening constipation.

For the 2nd week, Mrs. G. takes methadone 2.5 mg at 8am and 8pm. On days 8–11, she takes two doses of hydrocodone/apap (2 tabs, or 10 mg hydrocodone) for breakthrough pain. Day 12, Mrs. G. has a bad day and requires 3 doses of breakthrough med. On Day 13 she has one dose of hydrocodone/apap. On day 14 she requires no breakthrough meds. She continues on 2.5 mg methadone every 12 hours and still experiences pain that interferes with her ADLs. Her constipation improves after an adjustment in bowel medications. She experiences mild sedation that requires no intervention.

For the 3rd week, Mrs. G. takes methadone 2.5 mg at 8am, and 5 mg at 8pm. She uses only an occasional hydrocodone/apap 1 tab, but cannot comfortably ambulate to the dining hall or activities. She continues to rate her pain as 4/10 most of the time. She is alert and oriented and denies sedation. She is no longer constipated.

For the 4th week, Mrs. G. takes methadone 2.5 mg at 8am, 2.5 mg at 2pm and 5 mg at 8pm. She has not required breakthrough pain meds. She is quite comfortable by Day 24, stating her pain is at level 2/10. She is alert, oriented, and able to ambulate with her walker. She has intermittent mild nausea that is not bothersome, and she remains on an effective bowel regimen.

Her physician stops the titration, and maintains Mrs. G. on a schedule of methadone 5 mg po every 12 hours with hydrocodone/apap 2 tabs every 6 hours prn for breakthrough pain.



The consulting specialists who reviewed this month’s tip are:


Anna Du Pen, ARNP, MN, Pain Nurse Practitioner, Peninsula Pain Clinic, Bremerton, WA

Polly Mazanec, MSN, APRN, BC, AOCN, Palliative Care Consultant, University Hospitals of Cleveland, Ireland Cancer Center, Cleveland, OH

Elizabeth Ford Pitorak, MSN, RN, CHPN, Director of the Hospice Institute, Hospice of the Western Reserve, Cleveland, OH

Wendy Stein, MA, NHA, MD, CMD, Staff Physician and Medical Director, Long Term Care Services, San Diego Hospice, San Diego, CA

Mary Jane Lambert, MD, Chief, Nursing Home Services, Group Health Cooperative, Seattle, WA


Questions or comments? Please send them to us via the PERT Advisor or you can reach us via the PERT Program contact page. We'll make certain your communication is forwarded to the appropriate experts. Their responses will be posted on this website.