A Case Series Investigating the efficacy of Rotation to Methadone in Palliative Patients with Cancer Related Pain

There are 3 phases to this case series intervention. During Phase 1 all patients will have their baseline narcotic increased by at least 30% with actual dose being determined by the treating physician. After 3-5 days if pain levels persist above 4 on a Numeric Rating Scale (NRS) with values ranging from 0 (none) to 10 (unbearable) or the patient reports unacceptable narcotic side-effects and the patient is in agreement they will be admitted to a specialist palliative care unit (if not already an inpatient). Phase 2 involves the patient having their current narcotic ceased and an equianalgesic dose of methadone(physeptone) commenced. Patients will be ordered appropriate breakthrough medications during this time. Patients will be monitored for emergent signs of central nervous system toxicity including respiratory depression while doses of methadone are titrated until the patient is stabilized with pain scores less than 4 on the NRS. Phase 3 involves the patient being discharged home and monitored for a further 4 days. If people are improved with rotation to methadone then they can keep taking it. Throughout the study period patients will be asked to keep a daily diary. The primary outcome variable is change in rated pain from pre to post methadone rotation. The secondary outcome variables include subjective ratings of nausea and vomiting, cognitive impairment (drowsiness and unclear thinking), constipation, mood and quality of life. These changes will be assessed in the same way as subjective pain. Duration is approximately 2 to 3 weeks