Opioid rotation: A case example using methadone in spinal cord injury


  • Jayne Pawasauskas, PharmD, BCPS




methadone, opioid rotation, spinal cord injury


Opioid rotation is a practice used when patients with chronic pain have insufficient analgesia, experience unwanted opioid-related adverse reactions, or other pharmacologic challenges with their current opioid. Methadone is an opioid with unique pharmacological properties, which render it clinically distinct from other opioids. The drug's potential clinical benefits in treating nociceptive and neuropathic pain are coupled with risks of serious, life-threatening adverse reactions. Its unique pharmacokinetic profile contributes added complexity; therefore, clinicians should be experienced with its dosing and monitoring. This report discusses the successful use of methadone during opioid rotation for chronic pain secondary to spinal cord injury.

Author Biography

Jayne Pawasauskas, PharmD, BCPS

Clinical Professor of Pharmacy, University of Rhode Island College of Pharmacy, Kingston, Rhode Island; Pharmacy Specialist –Pain Management, Kent Hospital, Warwick, Rhode Island


National Spinal Cord Injury Statistical Center: Spinal Cord Injury (SCI) Facts and Figures at a Glance. Birmingham, AL: National SCI Statistical Center, 2014. Available at https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202014.pdf. Accessed September 14, 2015.

Ma VY, Chan L, Carruthers KJ: Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the united states: Stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil. 2014; 95(5): 986-995.

Masri R, Keller A: Chronic pain following spinal cord injury. Adv Exp Med Biol. 2012; 760: 74-88.

Baastrup C, Finnerup NB: Pharmacological management of neuropathic pain following spinal cord injury. CNS Drugs. 2008; 22(6): 455-475.

D’Angelo R, Morreale A, Donadio V, et al.: Neuropathic pain following spinal cord injury: What we know about mechanisms, assessment and management. Eur Rev Med Pharmacol Sci. 2013; 17(23): 3257-3261.

Teixeira MJ, Paiva WS, Assis MS, et al.: Neuropathic pain in patients with spinal cord injury: Report of 213 patients. Arq Neuropsiquiatr. 2013; 71(9-A): 600-603.

Margolis JM, Juneau P, Sadosky A, et al.: Health care resource utilization and medical costs of spinal cord injury with neuropathic pain in a commercially insured population in the United States. Arch Phys Med Rehabil. 2014; 95(12): 2279-2287.

Nakipoglu-Yuzer GF, Atci N, Ozgirgin N: Neuropathic pain in spinal cord injury. Pain Physician. 2013; 16(3): 259-264.

Alschuler KN, Jensen MP, Sullivan-Singh SJ, et al.: The association of age, pain, and fatigue with physical functioning and depressive symptoms in persons with spinal cord injury. J Spinal Cord Med. 2013; 36(5): 483-491.

Attal N, Mazaltarine G, Perrouin-Verbe B, et al.: Chronic neuropathic pain management in spinal cord injury patients. What is the efficacy of pharmacological treatments with a general mode of administration? (oral transdermal, intravenous). Ann Phys Rehabil Med. 2009; 52: 124-141.

Burgess FW, Pawasauskas J: Methadone analgesia for persistent pain: Safety and toxicity considerations. Med Health R I. 2008; 91(9): 273-275.

Haroutiunian S, McNicol ED, Lipman AG: Methadone for chronic non-cancer pain in adults (Review). Cochrane Database Syst Rev. 2012; 11: CD008025.

Snedecor SJ, Sudharshan L, Cappelleri JC, et al.: Systematic review and comparison of pharmacologic therapies for neuropathic pain associated with spinal cord injury. J Pain Res. 2013; 6: 539-547.

Mehta S, McIntyre A, Dijkers M, et al.: Gabapentinoids are effective in decreasing neuropathic pain and other secondary outcomes after spinal cord injury: A meta-analysis. Arch Phys Med Rehabil. 2014; 95(11): 2180-2186.

Lyrica® [package insert]. New York, NY: Parke-Davis, 2013.

Fine PG, Portenoy RK: Establishing “best practices” for opioid rotation. Conclusions of an expert panel. J Pain Symptom Manage. 2009; 38(3): 418-425.

Smith HS, Pepin JF: Toward a systematic approach to opioid rotation. J Pain Res. 2014; 7: 589-608.

Morlay JS, Bridson J, Nash TP, et al.: Low-dose methadone has an analgesic effect in neuropathic pain: A double-blind randomized controlled crossover trial. Palliat Med. 2003; 17(7): 576-587.

Moulin DE, Palma D, Watling C, et al.: Methadone in the management of intractable neuropathic noncancer pa in. Can J Neurol Sci. 2005; 32: 340-343.

Chou R, Fancuillo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130.

McLean S, Twomey F: Methods of rotation from another strong opioid to methadone for the management of cancer pain: A systematic review of the available evidence. J Pain Symptom Manage. 2015; 50(2): 248-259.

Moksnes K, Dale O, Rosland JH, et al.: How to switch from morphine or oxycodone to methadone in cancer patients? A randomized phase II trial. Eur J Cancer. 2011; 47(16): 2463-2470.

Chou R, Cruciani RA, Fiellin DA, et al.: Methadone safety guidelines. Methadone safety: A clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014; 15(4): 321-337.

Ehret GB, Viode C, Gex-Fabry M, et al.: Drug-induced long QT syndrome in injection drug users receiving methadone: High frequency in hospitalized patients and risk factors. Arch Intern Med. 2006; 166: 1280-1287.



How to Cite

Pawasauskas, PharmD, BCPS, J. “Opioid Rotation: A Case Example Using Methadone in Spinal Cord Injury”. Journal of Opioid Management, vol. 11, no. 5, Sept. 2015, pp. 443-8, doi:10.5055/jom.2015.0294.