Indian Journal of Palliative Care
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   2018| January  | Volume 24 | Issue 5  
    Online since January 16, 2018

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Methadone is now available in India: Is the long battle over?
MR Rajagopal
January 2018, 24(5):1-3
DOI:10.4103/IJPC.IJPC_201_17  PMID:29497246
Context: Morphine and fentanyl had so far been the only available opioids in India in step three of the World Health Organization analgesic ladder. Especially for those not tolerating morphine and particularly for those developing neurotoxicity, an inexpensive alternative was essential. Many years of advocacy by palliative care activists have resulted in methadone being now available for sale in India for pain management. However, the characteristic pharmacokinetics and pharmacodynamics of methadone raise potential issues of safety. Aims: This study aimed to recommend the essential steps for ensuring availability of methadone for improved pain relief in India, while at the same time ensuring safe use. Conclusions: Two steps are suggested. Firstly, the palliative care community in India must launch an educational program on methadone freely available to all potential prescribers of this medicine. Secondly, we must advocate with drug controllers of states and union territories for making methadone available only through recognized medical institutions and for ensuring that indiscriminate sale through pharmacies is avoided.
  5,595 133 -
Practical pharmacology of methadone: A long-acting opioid
MM Sunilkumar, Kashelle Lockman
January 2018, 24(5):10-14
DOI:10.4103/IJPC.IJPC_180_17  PMID:29497249
Methadone is a naturally long-acting analgesic with unique pharmacodynamic and pharmacokinetic properties compared to other opioids, available now in India, to treat severe pain. It has the potential to dramatically relieve suffering among patients with serious illness who are living with persistent physical pain. However, clinicians must appreciate its unique pharmacologic properties and its use in clinical practice safely and effectively. The available formulation in India is a racemic mixture of the S- and R-enantiomers, and as such, it will have a propensity for drug-drug and drug-genetic interactions that can increase the risk of Torsades de Point and respiratory depression. Appropriate patient selection, careful dosing and thorough monitoring of methadone will mitigate these risks.
  4,242 133 -
Practical guide for using methadone in pain and palliative care practice
Gayatri Palat, Srini Chary
January 2018, 24(5):21-29
DOI:10.4103/IJPC.IJPC_186_17  PMID:29497251
Since the 2014 Amendment to the NDPS Act methadone has been released in India for pain management. The methadone is supplied as racemic mixture with R & S methadone with benefit in pain management and associated adverse effects. Physicians need to be aware of adverse effects so that methadone can be administered safely. Similarly, patients and families need to store and use methadone carefully and experience the benefits and not increase the risk of further morbidity. Considerable amount of literature on methadone is available and sometimes conflicting, hence the article is attempting to guide a physician to use methadone safely to acquire experience and expertise over time.
  4,082 141 -
Methadone for pain management: Past, present and future
Srini Chary
January 2018, 24(5):6-9
DOI:10.4103/IJPC.IJPC_173_17  PMID:29497248
Methadone for pain management in this article describes briefly pain, methadone as a Level 3 World Health Organization ladder opioid in the context of India and rest of the world, as well as the relationship to past, present, and future possibilities of pain management. Acute pain is proportional to the injury most of the times, and such proportionality may not exist in chronic pain. Pain management over decades has changed because of knowledge and availability of molecules and compounds to reduce chronic pain. Naturally occurring opioids from “poppy” such as morphine and heroin were available through cultivation and trade for pain management and recreational use in different parts of the world for centuries. Methadone has been a synthetic molecule discovered in the 1930s in Germany. It has been used for harm reduction for opioid use disorder in the form of “methadone maintenance treatment”. This program exists since the 1950s while pain management started around the late 1970s in Europe and North America. More recently, the knowledge of acute and chronic pain at a molecular level, including ion channel modification, allowed the use of coanalgesics and opioids prudently. The concept of “total pain, neuroplasticity, and neurotransmitters” how they could be modified for better pain management with pharmaceuticals and nonpharmacological methods are being investigated, and evidence is being practiced clinically. In the present context, education for physicians, allied health professionals, patients, and family caregivers is important. Education to the physicians can skill and capacity build in the community and can be associated with educational research and peer-reviewed publications. The future remains promising, as innovations such as pharmacogenomics, nanotechnology, molecular, and quantum biology may create evidence, along with physical and psychological rehabilitation, to prevent and holistically better pain management.
  3,481 110 -
When to use methadone for pain: A case-based approach
Gayatri Palat, Nandini Vallath, Srini Chary, Ann Broderick
January 2018, 24(5):15-20
DOI:10.4103/IJPC.IJPC_182_17  PMID:29497250
The case studies are written in this article to illustrate how methadone might be used for pain in the Indian context. These cases might be used for discussion in a multidisciplinary team, or for individual study. It is important to understand that pain requires a multidisciplinary approach as opioids will assist only with physical, i.e. neuropathic and nociceptive pain, but not emotional, spiritual, or relational pain or the pain of immobility. The social determinants of pain were included to demonstrate how emotional, relational, and psychological dimensions of pain amplify the physical aspects of pain. The case studies follow a practical step-wise approach to pain while undergoing cancer treatment, pain toward the end-of-life and needing longer acting opioid. Methadone in children, and methadone in conditions of opioid toxicity or where there is a need for absorption in the proximal intestine cases are included.
  3,153 90 -
Challenges of using methadone in the Indian pain and palliative care practice
Vidya Viswanath, Gayatri Palat, Srini Chary, Ann Broderick
January 2018, 24(5):30-35
DOI:10.4103/IJPC.IJPC_168_17  PMID:29497252
Palliative care providers across India lobbied to gain access to methadone for pain relief and this has finally been achieved. Palliative care activists will count on the numerous strengths for introducing methadone in India, including the various national and state government initiatives that have been introduced recognizing the importance of palliative care as a specialty in addition to improving opioid accessibility and training. Adding to the support are the Non-Governmental Organizations (NGOs), the medical fraternity and the international interactive and innovative programs such as the Project Extension for Community Health Outcome. As compelling as the need for methadone is, many challenges await. This article outlines the challenges of procuring methadone and also discusses the challenges specific to methadone. Balancing the availability and diversion in a setting of opioid phobia, implementing the amended laws to improve availability and accessibility in a country with diverse health-care practices are the major challenges in implementing methadone for relief of pain. The unique pharmacology of the drug requires meticulous patient selection, vigilant monitoring, and excellent communication and collaboration with a multidisciplinary team and caregivers. The psychological acceptance of the patient, the professional training of the team and the place where care is provided are also challenges which need to be overcome. These challenges could well be the catalyst for a more diligent and vigilant approach to opioid prescribing practices. Start low, go slow could well be the way forward with caregiver education to prescribe methadone safely in the Indian palliative care setting.
  3,093 91 -
Safe use of methadone for cancer pain using “Opioid circle of safety”
Sushma Bhatnagar
January 2018, 24(5):4-5
DOI:10.4103/IJPC.IJPC_188_17  PMID:29497247
  2,574 89 -
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