Table 1

Details of included articles

AuthorContextObjectiveMethodResultsAuthors' conclusionsLevel of evidence
Blinderman et al 5 USA (NYC speciality outpatient pain clinic)
53 HIV/AIDs cases with pain syndrome (36M, 17F), mostly Latino, African-American
To evaluate efficacy and safety of initiating and maintaining additional methadone for chronic pain in HIV/AIDs patients in pain including cancer pain with ongoing MMTRetrospective chart review (March 2005–April 2006)
No control group
12-month follow-up; pain measured at 1, 3, 6 and 12 months
Pain well controlled using methadone as separate agent from MMT (average NRS 9.4±1.0 at baseline, 4.2±1.4 at 12 months), initial dose 67% of total daily dose then titrated according to needs to ∼200% of MMT dose, low side effect profile. Few (13%) patients actively using heroin at 12 monthsMethadone use for analgesia in addition to MMT dose improved pain levels
No serious adverse events noted if titrated properly
Low ongoing heroin use
Retrospective cohort; relevant population, outcomes, good follow-up. However, lack of control group
Hines et al 11 Australia, 1 centre, inpatient tertiary care hospital
67 case, 67 control 1:1 M:F median age 35 case 39 control
To compare pain management between MMT and non-MMT patients for an acute pain admissionCase–control restrospective chart review (1998–2004)
Chronic pain excluded
Case and control did not differ in morphine dose received or pain report per day
There is trend that those with no methadone dose increase are more likely to discharge AMA
MMT patients have more behavioural problems than non-MMT
Inadequate analgesia leads to behavioural problems and premature discharge 2
Retrospective case–control, however, less relevant comparison for the current research question; does not compare pain management strategies in MMT patients
Hoffman et al 16 USA, NY
N=2, 32M, 37M
To discuss pain management in opioid-addicted patients with cancer and its challengesCase series (1991)Use of methadone as analgesia by increasing dose and frequency of administrationEarly psychiatric intervention is important aside from pharmacological interventions 3
Case series with no comparison
Manfredi et al 12 USA, cancer centre, NY
6 cases (3M,3F) age: 34–55
Demonstrate use of methadone for acute pain in MMT patients with cancerCase series (2001)
Compared pain control before and after use of methadone for analgesia
Aggressive titration of methadone provides pain relief in opioid refractory pain with no adverse effectsUse methadone early, low threshold to titrate aggressively or switch to methadone 3
Case series, pre–post comparison with high risk of bias
Ostgathe et al 15 Germany N=1, 38 years/F palliative care IPUTo present the pain management in an opioid-addicted patient with cancer and the challengesCase report (2008)High doses of l- methadone were needed initially, followed by signs of opioid-toxicity, followed by adequate control at lower doses.
Adjuvant regimens and IDT approach were also used
Difficult to determine substance abuse relapse versus pseudoaddiction; use of l-methadone at high dose can achieve good pain control with adjuvant modalities 3
Single case without comparison (no other opioid attempted)
Rowley et al 14 Dublin, Ireland Palliative care referrals,1 centre
(8M, 4F) Age: 24–62
To review the use of opioids for analgesia in MMT patients and present case seriesChart review 2006–2010It was difficult to control patients’ pain, multiple agents required in 70%
Methadone used in only 1/12
IDT approach should be used
Methadone is underused and should be used early for these patients
Case series; no comparison between methadone and other opioid analgesics, dose and frequency of methadone not specified
Sulistio and Jackson13 Australia N=1, 48M Hospice IPUTo describe the difficulty in treating pain in terminally ill cancer patient on MMT
To review current guidelines
Case report (2013)Used increased methadone doses given at frequent intervals; also used ketamine and adjuvantsIt is challenging to determine an appropriate starting dose for breakthrough; MTT patients require larger, more frequent dosing even in face for risk of relapse 3
Case report; did not compare use of methadone versus other opioids, did not achieve good, lasting pain control