FEBRUARY 18, 2025
Pediatric patients who received a single-dose of intraoperative methadone needed fewer opioids in the first week after a tonsillectomy compared with those who received intermittent fentanyl, according to a study published in Anesthesiology (2024;141[3]:463-474).
In the study, researchers analyzed data from 60 children ranging in age from 3 to 17 years. They found the total opioid use over seven days was significantly lower in patients treated with methadone. The study was divided into three age
Pediatric patients who received a single-dose of intraoperative methadone needed fewer opioids in the first week after a tonsillectomy compared with those who received intermittent fentanyl, according to a study published in Anesthesiology (2024;141[3]:463-474).
In the study, researchers analyzed data from 60 children ranging in age from 3 to 17 years. They found the total opioid use over seven days was significantly lower in patients treated with methadone. The study was divided into three age groups, with primary outcomes showing the seven-day opioid use was 1.5 in the control group, compared with 0.9 after methadone at 0.1 mg/kg and 0.5 after methadone at 0.15 mg/kg.
“The opioid-sparing effect of methadone compared to fentanyl is most likely explained by the longer methadone elimination half-life of one to two days compared to fentanyl’s four hours. In addition, participants in the methadone groups required less rescue dexmedetomidine, had clinically and statistically meaningful shorter PACU stays, and greater number of opioid-free postoperative days than those in the control group,” lead author Lisa Einhorn, MD, FAAP, an associate professor of anesthesiology at Duke University School of Medicine, in Durham, N.C., said in a statement.
Secondary outcomes indicated PACU opioid use to be 0.15 in controls, 0.04 after methadone at 0.1 mg/kg and 0.0 after methadone at 0.15 mg/kg. Postoperative pain scores remained unchanged between the groups, with no serious adverse events found.
Debnath Chatterjee, MD, FAAP, FASA, the chair of the Pediatric Anesthesia Committee for the American Society of Anesthesiologists, who was not involved in the study, calls methadone “an effective analgesic with a rapid onset and long duration of action.”
He noted a single dose of intraoperative methadone has been shown to be effective in major orthopedic, spine, abdominal and cardiac surgeries in adults and children.
Exploratory outcomes showed no clinically meaningful differences between groups in operating room and extubation times. However, the authors noted a statistically significant difference in PACU length of stay (in minutes) of 119 for the control group, 83 in the methadone group at 0.1 mg/kg and 76 in the methadone arm at 0.15 mg/kg.
“This was a small study that was adequately powered to determine a difference in opioid use in the first seven days after surgery between the methadone and control groups. It was underpowered to detect statistically significant differences in pain scores between groups,” Einhorn said.
The study was limited by its small size, a lack of distinction between PACU and post-PACU opioid consumption, and a majority cohort in the youngest age category, which prevented age-specific conclusions about optimal methadone dosing.
The investigators recommended that “a larger comparative investigation, using this trial as preliminary data to power postoperative outcomes at different time points and in different age groups, is needed for generalizability, specific subpopulation analyses and determination of the optimal age-specific methadone dose in pediatric tonsillectomy patients.”
Einhorn agreed, emphasizing the need for a larger comparative investigation. She noted, “This trial is fully powered to analyze safety and efficacy outcomes including pain intensity and opioid use at various time points, adverse events and functional outcomes that identify optimal age-specific, weight-based dose of intraoperative methadone for pediatric tonsillectomy.”
Chatterjee added that further research in a larger study should distinguish between PACU and post-PACU opioid consumption, saying that “more studies are needed before methadone can be routinely administered as a part of the analgesic regimen for tonsillectomy in children.”
Einhorn called tonsillectomy the most common painful elective surgery for U.S. children and said there is a need to treat the pain associated with the procedure.
“Currently, opioid prescribing practices after tonsillectomy are highly variable, largely dependent on individual surgeons and susceptible to over- and under-prescribing in an era when opioids have become a major public health concern,” she said. “Methadone has unique pharmacokinetic properties that makes it highly favorable for use in the perioperative period.”
—Sherree Geyer
