As health care providers recognize a growing demand for pediatric hospices and palliative care, more people are turning to methadone for those patients instead of more commonly used pain relievers like morphine. Effective pain management, or lack thereof, has a significant impact on hospice family satisfaction scores, which are important considerations for potential payers and referral partners.
A 2014 study found that patients and families view pain and symptom management as their top priority with regard to the quality of hospice care. With consumers and referral organizations paying more attention to publicly reported quality data, dissatisfaction with pain treatment can hurt an organization’s bottom line.
Pain management for pediatric patients is complex, especially when it comes to opioids. The use of methadone in pediatric patients poses several challenges for healthcare providers. While the drug is long-acting in both adults and children, methadone may need to be administered more frequently to pediatric patients, according to Melissa Hunt, pediatric clinical pharmacist at Optum Hospice Pharmacy Services. Hunt is also a member of the National Hospice and Palliative Care Organization Pediatrics Advisory Council.
“In an adult, the half-life of methadone is between 24 and 36 hours, so it’s quite long-acting compared to all these other drugs,” Hunt told Hospice News. “In children, that will be eliminated more quickly, just because their organ function and all of their metabolic pathways are much more effective overall.”
According to a study in the Journal of Pain and Symptom Management (JPSM), methadone’s long-acting pain modulation mechanisms make it attractive for pain management in pediatric patients, as it allows hospice providers to administer it even to young children. However, the use of methadone by pediatric clinicians is limited because the half-life of the drug can be unpredictable. Many clinicians also lack training or experience in safely prescribing and monitoring side effects.
According to the JPSM study, nearly a quarter (23% or 24 clinicians) of the 105 pediatric palliative care providers surveyed nationwide in 2019 indicated that they did not prescribe methadone to patients in their facilities. Of these clinicians, 33% (8 clinicians) reported being able to prescribe long-acting opioids but not methadone, while 67% (24 clinicians) reported not prescribing long-acting opioids.
Methadone is more effective for planned management of neuropathic pain compared to most other opioids, according to Hunt.
“The advantage of methadone is that it is structurally different from morphine,” Hunt said. “If you have patients who are allergic to morphine, you can still use the methadone – there is no contraindication there. Methadone has a lot of benefits.”
Methadone dosing in younger children can be a difficult path for hospices to walk, Hunt said. Infants under six months of age do not have the fully developed metabolic pathways necessary to metabolize morphine, nor fully developed elimination pathways to excrete it. This can put you at an increased risk of several side effects, as methadone can build up more quickly in these patients. Hospice providers should use a much smaller dose for babies under six months of age, Hunt said.
“For general pediatric dosing recommendations, methadone accumulates over time, and your body also becomes tolerant to all opioids in general and then the opioid is not as effective for pain and you need higher and higher doses to get the same effect,” said Hunt. . “If they get higher and higher doses of morphine equivalents, it’s less effective. There are quite a few different conversion tables available. In kids, it’s a small percentage who get those super high doses of methadone or morphine and not that often, but it happens.”
A lack of available information on the use of methadone in pediatric patients poses an additional challenge to healthcare providers, with much of the research coming from case studies of clinical experience and expert experience, said Marisa Todd, chief of clinical pharmacy and manager of service benefits at Enclara Pharmacia.
In 2019, a panel of 15 US and Canadian experts developed the first specific guidelines for hospice and palliative care for the safe and effective use of methadone. Hospice care providers are increasingly turning to methadone as an effective and cost-effective method of managing patients’ pain, but guidelines for safe practices for prescribing and administering the drug were often lacking. Methadone is often seen as a cheaper alternative to traditional therapies such as morphine or oxycodone.
Hospice providers need to focus on many different things when switching to opioids such as methadone for pediatric patients with moderate to severe pain, with these patients often having “a mixed picture of pain” at the end of life, Todd told Hospice News. Managing nerve, muscle, and internal or organ pain with opioids such as morphine can be challenging for hospices to “get the right level of pain relief that the patient desires.”
“Those are the persistent cases that we can consider starting methadone,” Todd said. “Methadone works on many different types of nerve pain, muscle aches and pains, as well as your internal and organ pain. It is very convenient in the [pediatric] population for that reason. That is really where it is in place of therapy.”