USE OF METHADONE TO TREAT PAIN

To acknowledge that methadone has a role in pain management and that its pharmacologic properties present unique risks to patients; further,

To oppose the payer-driven use of methadone as a preferred treatment option for pain; further,

To advocate that pain management experts, payers, and manufacturers collaborate to provide educational programs for healthcare professionals on treating pain with opioids, including the proper place in therapy for methadone; further,

To advocate that all facilities that dispense methadone, including addiction treatment programs, participate in state prescription drug monitoring programs.

Rationale

Over 16,000 people die each year in the U.S. from opioid overdose. Although methadone accounts for only two percent of opioid prescriptions each year, it is estimated to be responsible for over one third of overdose deaths, according to a 2012 Mortality and Morbidity Weekly Report (MMRW) Vital Signs report. The use of methadone to treat pain and its contribution to overdose deaths is an urgent public health concern.

Methadone was approved in 1947 as an analgesic and antitussive, and in 1972 it received approval for use in treating opioid addiction. In 1995, over 100,000 people in the U.S. received addiction treatment with methadone.

There are significant risks associated with the use of methadone for pain management because of its pharmacokinetic and pharmacodynamic properties. Methadone has a long half-life and short duration of analgesic effect. The respiratory effects last longer, and there is also a risk of QT interval prolongation. In 2006, the FDA released a medication safety alert on the dangers of methadone use for the treatment of pain that included a black-box warning and increased the recommended dosing interval from 3 to 8 hours. In 2008, the Drug Enforcement Agency requested manufacturers to restrict distribution of high-dose formulations to addiction treatment programs and hospitals. Federal regulations restrict the dispensing of methadone; for example, dispensing for opioid addiction treatment is limited to programs certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and for emergency situations to bridge patients to a treatment program.

Despite these dangers, 30 state Medicaid programs include methadone on the preferred drug list for treatment of pain, primarily due to its low cost. The Centers for Disease Control and Prevention (CDC) has recommended that insurance companies and other payers remove methadone from the preferred lists for treating noncancer pain. Several organizations and federal agencies have recommended against the use of methadone as a first-line agent to treat pain, including the FDA, CDC, the American Academy of Pain Medicine (AAPM), and the American Society of Interventional Pain Physicians. In May 2015, the Energy and Commerce Committee of the U.S. Senate held a hearing to assess what the federal government is doing to combat the opioid abuse epidemic and identified use of methadone for treatment of pain as a concern. ASHP joins AAPM in advocating that pain management experts, payers, and manufacturers collaborate to provide educational programs on best practices for prescribing opioids, including methadone.