Anghelescu, D.L., Faughnan, L.G., Hankins, G.M., Ward, D.A., & Oakes, L.L. (2010). Methadone use in children and young adults at a cancer center: A retrospective study. Journal of Opioid Management, 7, 353–361.

To augment the literature on methadone applications in pediatric oncology

This was a retrospective review of all patients treated with methadone at St. Jude Children’s Research Hospital over a five-year period (October 2001–September 2006).

• N = 41
• AGE = 7 patients were younger than 10 years old, 16 patients were aged from 11–17 years, and 18 patients were aged 18 years or older.
• MALES: 58.5%, FEMALES: 41.5%
• KEY DISEASE CHARACTERISTICS: Leukemia/lymphoma (31.2%), solid tumor (56.1%), hematologic/congenital disorders (9.8%)

• SITE: Single setting
• SETTING TYPE: Three inpatient units, multiple outpatient units
• LOCATION: Tertiary cancer center

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

• Retrospective review of demographic characteristics, diagnoses, type of pain (i.e., nociceptive, neuropathic, mixed), causes of pain, and indications, dose regimens, adverse effects, and outcomes of methadone treatment

• Inpatients and outpatients who received methadone during the study period were identified by reviewing the institution’s pharmacy records. Data were abstracted from the medical records. Data included age, sex, primary oncology diagnosis, type of pain experienced (i.e., nociceptive, neuropathic, or mixed) at the time of methadone prescription, and the clinical context of pain (i.e., chemotherapy, bone marrow transplant, amputation, limb-sparing surgery, tumor,  other).
• The clinical uses of methadone also were ascertained from the medical records and were categorized as  nociceptive pain unresponsive to other opioids (33.3%), neuropathic pain (39.2%), facilitation of opioid weaning and prevention of withdrawal (21.6%), and pain management at the end of life (5.9%).
• Pain intensity scores were recorded at the beginning of treatment with methadone, at weekly intervals during the first month, and at monthly intervals thereafter for the duration of treatment or six months.
• Adverse effects of methadone were captured by review of the outpatient clinic notes or the inpatient nursing or physician notes. Sedation, nausea, constipation, confusion, respiratory depression, and pruritus were recorded as present or absent.
• A successful outcome was defined as a reduction of pain scores between the start and end of methadone treatment and/or documentation of the effectiveness of treatment for the specified indication.
• Age-appropriate pain assessment tools were used as per the institution’s pain standard of care—the Face, Legs, Activity, Cry, Consolability (FLACC) scale for children younger than 3 years, the Wong-Baker FACES Pain Rating Scale for children aged 4–6 years, and the numeric rating scale for children aged 7 years or older.

Methadone dosing data were available for 37 patients. Four patient records lacked baseline doses because methadone was initiated at another institution. Starting doses ranged from 0.06–3.8 mg/kg/d. The highest methadone dose was 9.4mg/kg/d. More than one-third of the patients (34.1%) had no documented adverse effects. The most common adverse effect was sedation (24.4%). No respiratory depression or pruritus were documented. Pain reduction was reported by comparing the maximum pain score on the day that methadone was discontinued to the maximum pain score on the day that methadone was initiated. Fourteen of the 41 patients had documented pain scores for both time points. Nine patients (64.3%) showed reduction of the pain score, and seven (50%) had complete resolution of pain.

Methadone was effective for pediatric patients with neuropathic pain or nociceptive pain unresponsive to other opioids, and it effectively prevented opioid withdrawal.

• Small sample size
• Retrospective design

Prospective studies are needed to evaluate specific methadone regimens for each of the clinical entities described and to determine opioid conversion scales to and from methadone in the pediatric population.