Intraoperative methadone: Proceed with caution

In recent years, there has been increasing interest in the use of a single dose of intraoperative intravenous methadone to improve postoperative pain relief. In Australia, concerns have been expressed about this practice, specifically the potential risk of harm from opioid-induced ventilatory impairment (respiratory depression). In this paper, the current evidence for potential benefits and harms is reviewed. While benefits are said to include improved pain relief and lower additional opioid requirements after surgery, the evidence is conflicting and the clinical significance remains uncertain. There have been no significant safety issues reported in published studies; however, the evidence is limited. This paper therefore begins with a focus on some of the original clinical pharmacology studies of methadone to explain the basis of concerns regarding a potential increased risk of opioid-induced ventilatory impairment and the calls for a more cautious approach. Differences in Australian acute pain management practices (e.g., national prescribing guidelines recommending age-based initial doses of shorter-acting opioids which allow significantly higher doses and a shortened dose interval for younger patients with acute severe pain) compared with other countries may also influence the validity of some of the conclusions that have previously been made regarding efficacy and safety.