Prescribing Methadone for Pain

Of all the strong narcotic analgesics in our formulary used to treat severe or intractable pain, methadone (Dolophine, Lilly) is surrounded by a mystique perhaps greater than any other agonist medication available for use legally. Unlike other powerful opiates or opioids, like meperidine (Demerol,) morphine sulfate, fentanyl (Duragesic transdermal system,) oxycodone (Percocet, Percodan, OxyContin) or hydromorphone (Dilaudid,) methadone has been singled out as the only acceptable opioid for use in detoxification from narcotic addiction. Methadone is also the only narcotic approved in the United States for use in maintenance programs designed to treat opiate or opioid dependent individuals. Within these programs, most often heroin (or other narcotic) addicts are given single daily dosages of a form of methadone called Methadose. The purpose here is to prevent the addict from going through a withdrawal or abstinence syndrome upon cessation of use of his or her narcotic drug of preference. This is done in federally licensed NTP's (or Narcotic Treatment Programs) located virtually everywhere in the nation.

Like it or not, accept it or not, a powerful stigma has been attached to methadone as a result of its status as the only legally approved drug for management of opiate and/or opioid addiction. Methadone also happens to be a superb and most efficacious medication for treatment of intractable pain. And here is where a figurative line begins to blur. It is a commonly accepted fact that different people respond differently to one medication over another, despite the fact that two or more drugs may be generally regarded as effective analgesics for use in cancer or other severe pain which presents as difficult to control. Hence, it should be no surprise that for some, no drug is superior to methadone in medication resistant cases of pain management.

Only a few years ago, private practice physicians were either outright prohibited, or simply discouraged from prescribing methadone in the course of their medical practice for the purpose of managing or relieving pain and associated suffering within their patients so unfortunate as to be plagued with this horrific malady. Laws in this regard varied from state-to-state, further complicating the issue. And doctors had no real choice but to order some "second best" medication for these patients. It would be impossible now to calculate or even estimate just how much needless suffering resulted from the presence and enforcement of these laws, delineated to "protect" us.

Today, circumstances have changed, although to what degree remains a matter of much discord and debate. It is now legal throughout the United States for any licensed medical doctor to prescribe methadone for any patient deemed to require it. However, the system which governs this prescribing is still replete with complexities. For example, let us cite, in everyday language, the plethora of requirements faced by a General Practitioner devoted to providing comfort and increased quality of life for a patient suffering with severe pain. Our mythic patient in this context clearly responds best to methadone; not at all an unusual factor, rather one routinely encountered in pain management. Our doctor must, as a precursor to treatment, begin by demonstrating, in writing, why methadone would be preferable to any other very potent narcotic agonist. By its very nature, this is a volatile declaration, extremely vulnerable to debate. So in order for our physician to undertake his preferred course of therapy, he or she must be well prepared to defend this decision should some highly zealous drug enforcement personnel elect to vehemently disagree. This is the sort of thing that can cause a license to practice medicine to be suspended or revoked. Or at the least, it can be a position phenomenally expensive to defend. In all likelihood, the best evidence our practitioner will have that methadone indeed should be used as opposed to another strong opiate will be, quite singularly, the testimonial of the suffering patient.

One "brighter side," albeit to a geographically-dependent, potentially dim side as well is the advent of medical operations devoted exclusively to the practice of pain management. This can mean "problem solved" for patients living in large metropolitan areas. Ah, but if you suffer with severe pain (and most assuredly if it's from a cause other than cancer, the whole nightmare begins anew for those in rural areas.

So what is the promulgating factor, the driving force behind this didactic governmental edict? The primary concern of the Drug Enforcement Administration with regard to methadone is diversion e.g. large scale, illegal reappropriation of supplies from legitimate channels to the black market. This whole-hearted bureaucratic mindset emerges not because there truly exists a large, great and danger-ridden diversion issue with methadone. In truth and conversely, methadone is not the hyperfocal supertarget of misuse many would have you believe. Because methadone blocks, at opiate receptors in the brain, other narcotics from being even close to fully and normally effective was in great part the reason it was chosen as the detox and maintenance drug of choice. For this very same reason, seasoned narcotic addicts do not particularly care for it. Certainly methadone can and is a drug subject to misuse, and its control status on Schedule II is appropriate. However, for purposes akin to "getting high," devoted druggies would quickly and readily cleave onto virtually any other very potent narcotic pursuant to the realization of that endeavor.

The remaining question? Whom, just exactly whom is left to most likely suffer from the benefits of laws governing the use and distribution of methadone? If you're a severe pain sufferer who obtains superior analgesic effects from methadone, you.

By David J. Wilmont, M.D.