The article by Elaine Amella, "Geriatrics and palliative care-collaboration for quality of life until death"1 in the January-March issue of the journal was an interesting and informative piece. Dr Amella did an excellent job of presenting the assessment and monitoring of symptoms experienced by the elderly at the end of life.

Under the "PAIN" subhead, the author mentions that methadone, due to long half-life, makes the older adult more prone to sedation, dizziness, falls, and delirium and should be avoided. 1^(p43-44) With our new understanding of methadone and subsequent anecdotal reports, it has been shown that with cautious titration and careful monitoring, it can be used quite effectively in the geriatric population with pain.

Using methadone requires cautious titration and careful monitoring, especially during the first week after initiation. The plan of care must be highly individualized. This opioid is an NMDA antagonist. It works on both the mu and delta receptor sites, which makes it an effective drug for nociceptive and neuropathic pain. This combination of pain etiologies is frequently noted in our geriatric palliative care population. Methadone has an excellent drug bioavailability with a wide variety of routes for administration, including oral, sublingual, rectal, intravenous, and subcutaneous (although this latter method is irritating). In addition, it may be a safer choice than morphine in the patient with renal compromise due to the absence of active metabolites.

Because of its long half-life, methadone takes an average of five days to reach steady state. It is advisable to consider that in the elderly steady state might not be reached in as much as 10 days. It is absorbed rapidly into adipose tissue, which accounts for the fact that its analgesic half-life is shorter than its serum half-life. It has been shown to be useful for both maintenance (usually every 8 to 12 hours dosing schedules at steady state) and breakthrough dosing.

Hospice of the Western Reserve calculates the 24-hour oral morphine dose (if not on morphine, utilize an equianalgesic table for conversion). The methadone dose is then be determined by calculating 1/10 of the 24-hour oral morphine dose to a maximum of 20 mg of methadone. At this time, it is advisable to stop the current opioid in use. The fixed methadone dose is then initiated every 3 hours as needed, and the patient is assessed for pain every 3 hours to determine the need for additional doses or a change in dose strength. Without exception, a nurse calls or visits the patient daily. On day 6 of methadone use, the nurse calculates the average methadone dose used between days 4 and 5. This becomes the patient's maintenance dose, using an every 12-hour (q12) dosing schedule. The breakthrough dose will be 10% of the 24-hour dose, administered every 8 hours as needed. This procedure was adapted from guidelines presented by Morley and Maken. 2

Further study of methadone and its use in geriatric palliative care patients is warranted. Resistance to the use of methadone exists primarily because of use in those with drug addiction (methadone clinics) and the associated stigma. We praise Dr. Amella for writing this article and bringing so many educational points to the forefront. This information is essential as palliative care continues to evolve and the many aspects of patient management unfold.

Maryjo Prince-Paul, MSN, APRN

Judy Bartel, MSN, APRN

Charles Wellman, MD

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