Methadone for Surgical Patients

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What Is the Issue? Opioids such as morphine and hydromorphone are commonly used to treat postoperative pain; however, they are associated with serious risks such as respiratory depression. Methadone (a synthetic opioid) has been proposed as a potential option for preoperative or postoperative analgesia that may improve pain relief and reduce overall opioid requirements. What Did We Do? We sought to identify and summarize studies of the clinical effectiveness and safety of oral methadone for preoperative or postoperative analgesia in adults as well as recommendations from evidence-based guidelines. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included publications, and narratively summarized the findings. What Did We Find? We identified 1 randomized controlled trial (RCT) that evaluated the use of preoperative oral methadone versus placebo in adults undergoing sternotomy for isolated coronary artery bypass graft surgery. We did not identify any studies that compared oral methadone to other analgesics that met our criteria. We did not identify any evidence-based guidelines that included recommendations on the use of oral methadone for preoperative and postoperative analgesia. There were no differences in pain scores 24, 48, and 72 hours postoperatively in patients who received oral methadone versus placebo. Postoperative morphine requirements were lower in the methadone group than the placebo group at 24 hours; however, there were no differences between groups at 48 or 72 hours. There were no differences in common side effects related to opioid use (nausea, vomiting, pruritus, constipation, urinary retention, hypoventilation, or hypoxia) between patients undergoing surgery treated with oral methadone versus placebo at 24, 48, or 72 hours. What Does It Mean? We identified very limited evidence on the use of oral methadone for preoperative or postoperative analgesia in patients undergoing surgery. There were no differences between patients undergoing surgery treated preoperatively with oral methadone versus placebo in most of the pain outcomes measured in the included RCT. Additional evidence may be necessary to aid decision-making around the use of oral methadone as preoperative or postoperative analgesia for adult patients undergoing surgery.