As providers recognize a growing demand for pediatric hospice and palliative care, more are turning to methadone for those patients rather than more frequently used pain medications like morphine. Effective pain management, or the lack thereof, has a significant impact on a hospice’s family satisfaction scores, which are key considerations for potential payers and referral partners.
A 2014 study found patients and families view pain and symptom management as their top priority related to quality of hospice care. With consumers and referral organizations paying increased attention to publicly reported quality data, dissatisfaction with pain treatment can hurt an organization’s bottom line.
Pain management for pediatric patients is complex, particularly when it comes to opioids. Using methadone in pediatric patients poses several challenges for 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 also serves on the National Hospice and Palliative Care Organization Pediatrics Advisory Council.
“In an adult, methadone half-life is anywhere from 24 to 36 hours, so it’s pretty really long-acting compared to any of these other agents,” Hunt told Hospice News. “In kids, that’s going to be eliminated more quickly just because their organ function and all their metabolic pathways are much more effective in general.”
Methadone’s long-acting pain-modulation mechanisms make it appealing for pain management in pediatric patients since it allows hospice providers to administer it even in young children, according to a study in the Journal of Pain and Symptom Management (JPSM). However, methadone use by pediatric clinicians is limited because the drug’s half-life can be unpredictable. Many clinicians also lack training or experience in safely prescribing and monitoring the side effects.
Nearly a quarter (23% or 24 clinicians) of 105 pediatric palliative care clinicians surveyed nationwide in 2019 indicated that they did not prescribe methadone to patients at their institutions, according to the JPSM study. Of these clinicians, 33% (8 clinicians) reported that they could prescribe long-acting opioids but not methadone, while 67% (24 clinicians) reported they do not prescribe any long-acting opioid.
Methadone is more effective for scheduled management of neuropathic pain compared to most other opioids, according to Hunt.
“The advantage of methadone is that it’s structurally different from morphine,” Hunt said. “If you have patients that have allergies to morphine, you can still use the methadone — there is not a contraindication there. Methadone has a ton of advantages.”
Methadone dosing in younger children can be a difficult path for hospice providers to walk, according to Hunt. Infants less than six months old do not have the fully-developed metabolic pathways needed to be able to metabolize morphine nor fully-developed elimination pathways to excrete it. This can pose increased risk for different adverse effects because methadone can accumulate more quickly in these patients. Hospice providers should use a much smaller dose for infants less than six months of age, stated Hunt.
“For general pediatric dosing recommendations, methadone accumulates over time, and your body also becomes tolerant to any opioids in general and then the opioid isn’t as effective for pain and you need higher and higher doses to get the same effect,” Hunt said. “When they get to 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 to those super high doses of methadone or morphine and not as often, but it happens.”
A lack of available information on methadone use in pediatric patients poses an additional challenge for hospice providers, with much of the research stemming from case studies of clinician experience and expert experience, according to Marisa Todd, clinical pharmacy lead and service benefits manager at Enclara Pharmacia.
A panel of 15 U.S. and Canadian experts developed the first hospice- and palliative care-specific guidelines for safe and effective use of methadone in 2019. Hospice providers have increasingly turned to methadone as an effective and cost-effective method of managing patients’ pain, but often lacked guidance on safe practices for prescribing and administering the drug. Methadone is often seen as a less expensive alternative to traditional therapies such as morphine or oxycodone.
Hospice providers need to focus on lots of different things when moving into opioids such as methadone for pediatric patients with moderate to severe pain, with these patients often having “a mixed pain picture” at the end of life, Todd told Hospice News. Managing nerve, muscle aches, and internal or organ pain with opioids such as morphine can be challenging for hospice clinicians to get “the right level of pain relief that the patient desires.”
“Those are the refractory cases that we may consider starting methadone,” said Todd. “Methadone works on a lot of different types of nerve pain, muscle aches and pains, as well as your internal and your organ pain. It’s very useful in the [pediatric] population for that reason. That’s really where it is in its place of therapy.”