Use of Methadone as an Adjuvant Medication to Low-Dose Opioids for Neuropathic Pain in the Frail Elderly: A Case Series

Palliative care clinicians are increasingly involved in the care of elderly patients suffering from chronic malignant and nonmalignant illnesses, of which neuropathic pain is a prevalent problem. As a person becomes more frail, pain medications such as opioid analgesics and adjuvant pain medications can result in unwanted effects such as sedation, confusion, and increased risk of falls. Treating pain in patients with advanced dementia or neurodegenerative diseases that can affect swallowing is particularly challenging because most adjuvant pain medications used to ameliorate neuropathic pain must be taken orally. Furthermore, dosing of neuropathic medications is limited by renal function, which is often impaired in the elderly due to both normal aging and renal disease. Methadone is an opioid analgesic that is effective in the treatment of neuropathic pain, is excreted by the bowels, is highly lipophilic, and can be administered through the oral, buccal, or sublingual routes. We present three cases highlighting the use of low-dose adjuvant methadone to manage complex neuropathic pain in the frail elderly.