Pain emerging when methadone for OST is tapered

Particular challenges arise when patients treated with methadone for addiction experience emerging pain on dose taper.  Methadone is a recognised drug treatment for pain and longer-term analgesia may be achieved by splitting the methadone dose and administering 12 hourly. If the 12 hourly methadone regimen appears to be effective as part of a broader pain management plan, there may be justification for continuing the regimen. It is important that individual management plans are generated with agreement from all local stakeholders.

In general, a pragmatic solution may be that for patients who meet the following criteria:

• The pain is related to obvious organic disease
• The symptoms have previously been masked by heroin use or methadone maintenance,
• The pain emerges on methadone taper
• The patient is compliant with treatment plans (not using on top etc)
• The patient has been assessed by a pain specialist with special interest in opioids and addiction
• The patient is deemed safe for opioid therapy and
• Other evidence based interventions are not appropriate then

The patient may be maintained on methadone split into two daily doses prescribed for convenience by their GP but with a firm guarantee from both pain and substance misuse services that if the GP has concerns, he/she has rapid access to support from pain and substance misuse services. This has to be agreed case by case within a MDT setting, although the MDT decision may be virtual.   These very specific circumstances should take into account the prescribing experience of local primary care teams and cases should be managed only by clinicians familiar with the pharmacology and clinical use of methadone.