Methadone Dosing Recommendations for Treatment of Chronic Pain

− Methadone is a safe and effective long-acting opioid analgesic that is useful in managing chronic pain. − Although it has unique pharmacokinetic and pharmacodynamic properties, the general principles of dosing methadone are similar to those of other opioids. − In general, as with other opioids, methadone should be used as one aspect of a comprehensive pain management plan, as agreed upon by the practitioner and the patient. − Methadone is most easily titrated by using small initial doses or adjusting the initial dose according to the previous opioid dose. − A number of methods are available for titrating methadone using conversion ratios, as detailed below. However, titration should be based on patient response and not solely based on equianalgesic dosing tables. − Methadone should be initiated by or in consultation with a practitioner who has the relevant knowledge. If a practitioner or consultant with experience in using methadone for chronic pain is not available, then another long-duration opioid may be used until such consultation can be obtained. Background Methadone should be used when a strong opioid is needed and the patient has not achieved adequate pain relief on escalating doses of controlled-release morphine or has experienced intolerable adverse effects on controlled-release morphine. Commonly, nonsteroidal anti-inflammatory drugs and adjuvant agents (e.g., tricyclic antidepressants) should be used in combination with methadone. Methadone's duration of effect is not dependent upon a specialized delivery system, as is the case with transdermal fentanyl or sustained release formulations of morphine or oxycodone. It is the only long-duration opioid available as an oral solution.