Viewpoint
by Forest Tennant, MD, DrPH
 The recent spate of news reports,
together with FDA warnings implicating methadone in a number of deaths, has created an
environment of fear regarding the use of methadone in treating pain patients.
Notwithstanding its unusual metabolism and the extreme care required in its application,
Dr. Forest Tennant maintains that methadone remains a valuable tool in the pain
physician’s armamentarium. This Viewpoint continues the dialog on the issues
surrounding methadone prescribing.
An anti-methadone salvo has come forth from the US Food and Drug Administration. It has
issued a “black box” warning to prescribing doctors that methadone is a
potential death hazard if not properly prescribed. Their basis for this warning is soundly
based on increasing methadone deaths. Between 1999 and 2004 methadone poisoning deaths
rose from 786 to 3,849, a 390% increase. The rise in all-poisoning deaths rose only 54%.
In 2003, methadone-related deaths rose 29% while all poisonings rose only 6%.
The crux of the problem can be found in a 2004 consensus report from the Substance
Abuse and Mental Health Services Administration that concluded the increase in
methadone-related deaths are caused by the growing use of the drug for pain treatment
rather than as a treatment for opioid addiction.
Let’s be abundantly clear. Methadone often provides pain control in severe chronic
pain patients far superior to other long-acting opioids. The same is true for Oxycontin«.
We now have some severe pain patients who have taken methadone over 20 years and literally
have extended their life over this time period. Methadone is not only a potent mu agonist
with a long serum half-life that prevent opioid withdrawal symptoms and pain flares, it is
an N-methyl-d-aspartate (NMDA) antagonist. No wonder this compound works so well and must
remain available to physicians and their patients for pain treatment. Yes, it has some
cardiac conduction problems if it isn’t slowly titrated upward from a low first
day’s dose. In actuality, all long-acting opioids may have complications if the
initial dose is not started low and worked upward over time. The bottom line is that pain
treatment and addiction treatment can’t do without methadone. The current situation
echoes that of Oxycontin« which was implicated in diversion, abuse, and death. The latter
fiasco was at least partially caused by some misguided physicians prescribing without
safeguards in place to monitor their patients and carefully manage dose titration.
Please refer to the April 2007 issue for the complete text. In the event you need to order a back issue, please click here.
— April 2007
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