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.

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.

• The sample was composed of 20 patients with cancer who were experiencing severe pain and delirium at the end of life and whose delirium did not resolve 24 hours after administration of a neuroleptic.
• The age range of patients was 47–77 years.
• Ten males and 10 females participated in the study.
• The study included patients with a variety of cancer diagnoses.

United States

Nonrandomized open-label prospective study

• Numeric analog scale (NAS), to measure pain
• Scale, 0–3, to measure sedation
• Memorial Delirium Assessment Scale (MDAS)
• Opioid dose

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.

• The study had a small sample. Sample size decreased as patients expired.
• Authors did not specify the process of converting from an opioid to methadone.
• Many patients must be rotated to a different drug.