A case study—prescribing methadone for pain

The following case study sends an important message to physicians about the benefits of prescribing methadone for chronic pain.

"Lilian" is 76 years old and has successfully been treated for colon cancer with surgery and adjuvant chemotherapy. The chemotherapy exacerbated her mild peripheral neuropathy from type 2 diabetes. She now has severe burning pain in her feet and hands. In the morning, she experiences intermittent electric shock-like pains when she first puts weight on her feet. Tricyclic medication causes postural hypotension and weight gain, and therapeutic doses of gabapentin cause unsteadiness. She does not tolerate codeine, morphine or oxycodone because of nausea and constipation despite laxatives, and hydromorphone is ineffective for her pain. She is not able to become sufficiently opioid-tolerant to start on a fentanyl patch. Lilian is becoming depressed and socially isolated. 

When Lilian attends the local cancer centre's pain and symptom management clinic she is started on methadone 0.5mg every eight hours. Within two days she reports a substantial 50% reduction in her pain and is now able to go outside in proper shoes rather than slippers. She increases the dose as instructed after three days to 1 mg every eight hours, and the next week, when contacted by the clinic nurse, she reports further improvement: the pain is now 90% gone and she is driving again. 

Three weeks later, she attends the clinic again and no further changes are needed. The clinic provides a letter to her family practice clinic requesting that they take over prescribing methadone (including detailed instructions on how to do it), but Lilian is told that none of the physicians there have an authorization to prescribe methadone for analgesia. Her own physician is about to retire and has declined to take this on. Lilian is told that the practice does not support patients who take opioids for non-cancer pain. She approaches a number of family physicians’ offices and walk-in clinics and is told at each one that they do not “do methadone” and she “needs to go to a methadone clinic for this.”
 
Lilian returns to the cancer clinic three months later, having stopped the methadone on her own, and is now tearful, depressed, and in severe pain. Within two days of resuming methadone 1 mg every eight hours her pain is under control. The cancer centre pain and symptom management clinic now has a four-week wait for new consults because of inability to discharge Lilian and many patients like her, and the need to see them all every three months.

Lilian’s case is a very real and ever growing problem. Methadone is frequently used in management of chronic and palliative pain situations. When patients are started and stabilized in the hospital setting, they are discharged with a request for ongoing monitoring and prescribing by their family physician. Some physicians may be reluctant to accept this responsibility, but if patients are refused such care, patients are destabilized causing significant, unnecessary, and prolonged pain and suffering. Physicians have an obligation to provide timely and appropriate care to patients, and must not discriminate against them or refuse treatment based on patients’ diagnoses or care needs. The College encourages physicians to consider prescribing methadone for this group of patients in their time of need. 

The College has made significant changes in the past two years to make the analgesia authorization process easier. Physicians can quickly and easily get temporary exemptions for methadone for a patient by filling out a one-page form on the College website. Temporary exemptions are granted for up to 120 days, and physicians can use this time to meet requirements for full authorization if they wish. The specialist clinic or the original prescriber can usually provide ongoing guidance and support for physicians new to prescribing methadone. Similarly, physicians are encouraged to contact the College’s drug programs for information or assistance.

Note: Health Canada has announced that effective May 19, 2018, prescribers will no longer require a federal exemption to prescribe methadone.

Note: All details that could identify the patient or physicians involved in this case have been removed to protect privacy and confidentiality.

Registrants interested in sharing a case for publication in a future edition of the College Connector can contact the Prescription Review Program at prp@cpsbc.ca or 604-733-7758 extension 2629. Identifiable information should not be included. All confidentiality will be maintained.