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Methadone rotation for cancer pain: an observational study
  1. Christina Tan1,
  2. Jade Fui Wong1,
  3. Choon Meng Yee2,3 and
  4. Allyn Hum2,3
  1. 1 Department of Pharmacy, Tan Tock Seng Hospital, Singapore
  2. 2 Palliative Care Centre for Excellence in Research and Education, Singapore
  3. 3 Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore
  1. Correspondence to Dr Allyn Hum, Palliative Medicine, Tan Tock Seng Hospital, Singapore; allyn_hum{at}


Context Methadone is a useful option in the treatment of cancer pain. Despite its advantages, methadone use is complicated due to high interindividual variability in pharmacokinetics. Various rotation methods from other opioids have been proposed in mostly Caucasian populations.

Objectives This study aims to describe our experience with opioid rotation to methadone for management of cancer pain in a predominantly Asian population.

Methods A retrospective review of 52 inpatients initiated on methadone for cancer pain from June 2015 to June 2018 was conducted. Our institution protocol for methadone rotation involves either one of two methods (‘Stop-and-go’ or the Edmonton 3-day rotation) based on the morphine-equivalent daily dose (MEDD), using an equianalgesic ratio of 10:1 for MEDD <1000 mg. To account for incomplete cross-tolerance, we further reduce the calculated dose by 30%.

Results The majority of patients had mixed nociceptive-neuropathic pain (83%) and the predominant reason for methadone rotation was ineffective analgesia with other opioids (75%). The median MEDD before rotation was 104 mg. Effective analgesia (defined as a decrease in numerical rating scale (NRS) of ≥1 or attainment of NRS ≤3) was achieved within 3 days after rotation in 89% of patients. Patients with an MEDD ≤100 mg/day required a greater degree of uptitration of methadone dose after rotation compared with those with an MEDD >100 mg/day.

Conclusion Rotation to methadone according to our protocol is effective in achieving adequate analgesia in most patients experiencing nociceptive-neuropathic pain. Our results also suggest that a fixed equianalgesic ratio of 10:1 may be adequate for patients at low-to-moderate MEDD <400 mg/day.

  • pain
  • symptoms and symptom management
  • hospital care

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  • Presented at This study was previously presented as an abstract at the 16th World Congress of the European Association for Palliative Care and the Singapore Heath and Biomedical Congress 2019.

  • Contributors AH conceived the study objective and supervised the project. All authors were involved in the planning and study design. CT and JFW were involved in acquisition and analysis of data and wrote the first draft of the manuscript. CMY and AH were involved in data analysis, interpretation, vetting and revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.