Conversion of other opioids to methadone: a retrospective comparison of two methods.

CONTEXT: A rapid method of methadone conversion known as the Perth Protocol is commonly used in Australian palliative care units. There has been no follow-up or validation of this method and no comparison between different methods of conversion. OBJECTIVES: The primary objective of this study was to test the hypothesis that the achieved doses of methadone are independent of the conversion method (rapid vs slower). The secondary objectives included examining the relationship between calculated target doses, actual achieved doses and duration of conversions. METHODS: This is a retrospective chart audit conducted at two hospital sites in the Brisbane metropolitan area of Australia which used different methadone conversion methods. RESULTS: Methadone conversion ratios depended on previous opioid exposure and on the method of conversion used. The method most commonly used in Australia for calculating target doses for methadone when converting from strong opioids is a poor predictor of actual dose achieved. More appropriate conversion ratios are suggested. CONCLUSION: Further research is needed to refine the ratios used in practice when converting patients from strong opioids to methadone. Caution and clinical expertise are required. A palliative methadone registry may provide useful insights.

Management of hiccups in palliative care patients.

Persistent hiccups are a frustrating experience for palliative care patients, and can have a profound impact on their quality of life. This article provides an evidence-based approach overview of the causes and treatment of this not infrequently debilitating condition for such patients, with a management algorithm. In situations where no readily reversible cause is identified, or where simple physical manoeuvres, such as breath holding have failed, a systematic approach is required. Hiccups can be broadly divided into central and peripheral types. These respond differently to pharmacological intervention. The drug of choice for central causes of persistent hiccups is baclofen, with metoclopramide recommended as the first choice for peripheral causes. Midazolam may be useful in cases of terminal illness. Interventional procedures such as vagal or phrenic nerve block or stimulation should be considered in patients who are refractory to medications. The management of persistent hiccups still presents an ongoing clinical challenge however, requiring further research on pathophysiology and treatment strategies. Multinational randomised controlled trials to evaluate and compare both current and new medications or procedures to better manage this difficult condition are suggested as a means of reaching this goal.