Methadone and tonsillectomy
Myron Yaster MD and Lynne G. Maxwell MD
Tonsillectomy is one of the most common surgical procedures performed in children each year. “Posttonsillectomy pain is common, often severe, underappreciated, and associated with persistent negative postoperative behavioral change.”1 Over the past few months several PAADs have reviewed “opioid free”, “opioid sparing”, multi-modal analgesia with continuous, around the clock NSAIDs and acetaminophen, selective COX2 inhibitors (celecoxib), ketorolac, and apnea monitoring in these patients.2-5
In the United States (and at the authors’ institution), low dose fentanyl, a very rapid onset and short acting opioid continues to be one of the most commonly used perioperative analgesics for the management of intraoperative anesthesia and postoperative analgesia. Einhorn et al. wondered if methadone, a rapid onset long duration opioid analgesic “would result in less postoperative opioid use in the first 7 days after surgery compared with short-duration opioids in children after tonsillectomy?” As discussed in several previous PAADs, methadone is usually used in surgeries with high pain intensities like spine and pectus excavatum surgery; children undergoing tonsillectomy is a novel patient population for its use.
Editorial
Berde CB, Cunningham MJ. Improving Pain Management after Tonsillectomy. Anesthesiology. 2024 Sep 1;141(3):425-427. doi: 10.1097/ALN.0000000000005096. PMID: 39136481; PMCID: PMC11323751.
Original article
Einhorn LM, Hoang J, La JO, Kharasch ED. Single-dose Intraoperative Methadone for Pain Management in Pediatric Tonsillectomy: A Randomized Double-blind Clinical Trial. Anesthesiology. 2024 Sep 1;141(3):463-474. doi: 10.1097/ALN.0000000000005031. PMID: 38669011; PMCID: PMC11321919.
“This study found that patients who received a single intraoperative dose of methadone 0.15 mg/kg age-ideal body weight required less opioid in the first week after pediatric tonsillectomy. These results support the hypothesis that intraoperative methadone may result in less postoperative opioids than intermittent fentanyl for pediatric tonsillectomy. The opioid-sparing effect of methadone compared to fentanyl is most likely explained by the longer methadone elimination half-life of 1 to 2 days6 compared to fentanyl (redistribution half-life, 13 min; elimination half-life, 4 h)7.”1 “Based on our results, a dose of methadone 0.15 mg/kg age-ideal body weight in children ages 3 to less than 12 yr appears better than 0.1 mg/kg. However, even at this dose, almost half of children still required rescue opioid (oxycodone) in the PACU and beyond. Thus, future studies may consider investigating a higher dose. Regardless of treatment group, adolescents used more opioid than children and may require a higher dose than 0.15 mg/kg. This is an additional area of future study.”1
Berde and Cunningham in their accompanying editorial8 urge caution, noting the small number of patients studied, considering this to be more of pilot study and not a definitive clinical trial, in part because of the small number of patients studies, but particularly because many patients presenting for tonsillectomy are often obese and have sleep disordered breathing and are often exquisitely sensitive to opioids. Would a larger trial find complications and even fatalities, which a small pilot study would miss? A larger trial should include a more diverse population, including patients of higher BMI and a larger proportion of adolesceants. Berde and Cunningham speculate that the safety and efficacy of methadone will need to be individualized base on a patient’s individual characteristics and that in the near future “there will be an app to help guide us in making drug and drug dosing calculations.”
What do you think? Are you currently using or willing to add methadone to the tonsillectomy multi-modal pain armamentarium? Does your hospital/outpatient surgical center even have methadone for ANY patient? Send your thoughts to Myron who will post in a Friday reader response.
References
1. Einhorn LM, Hoang J, La JO, Kharasch ED. Single-Dose Intraoperative Methadone for Pain Management in Pediatric Tonsillectomy: A Randomized Double Blind Clinical Trial. Anesthesiology 2024 (In eng). DOI: 10.1097/aln.0000000000005031.
2. Amin SN, Thompson T, Wang X, et al. Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2024;170(2):610-617. (In eng). DOI: 10.1002/ohn.534.
3. Martin LD, Franz AM, Rampersad SE, et al. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Pediatric Anesthesia 2023;33(9):699-709. DOI: https://doi.org/10.1111/pan.14705.
4. Shaikh N, Kais A, Dewey J, Jaffal H. Effect of perioperative ketorolac on postoperative bleeding after pediatric tonsillectomy. International journal of pediatric otorhinolaryngology 2024;180:111953. (In eng). DOI: 10.1016/j.ijporl.2024.111953.
5. Anne S, Mims JW, Tunkel DE, et al. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2021;164(2_suppl):S1-s42. (In eng). DOI: 10.1177/0194599821996297.
6. Sharma A, Tallchief D, Blood J, Kim T, London A, Kharasch ED. Perioperative pharmacokinetics of methadone in adolescents. Anesthesiology 2011;115(6):1153-61. (In eng). DOI: 10.1097/ALN.0b013e318238fec5.
7. Ziesenitz VC, Vaughns JD, Koch G, Mikus G, van den Anker JN. Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review. Clinical pharmacokinetics 2018;57(2):125-149. (In eng). DOI: 10.1007/s40262-017-0569-6.
8. Berde CB, Cunningham MJ. Improving Pain Management after Tonsillectomy. Anesthesiology 2024;141(3):425-427. (In eng). DOI: 10.1097/aln.0000000000005096.