This case report describes a patient affected by a
neuropathic pain syndrome, which was secondary to a
renal cell carcinoma metastatic to the spine, and complicated by incidental components and somatization. Due to a rapid development of tolerance and toxicity from
hydromorphone, a rotation to
methadone was made, with a decrease of the
morphine equivalent daily dose (MEDD) from 1050 to 36. After 4 mos of good
pain relief, a switch over back to
hydromorphone was necessary due to worsening
pain, associated with
myoclonus and sedation secondary to
methadone; the MEDD this time escalated from 480 to 4950. The use of
hydromorphone was complicated by the onset of intractable
nausea and sedation. After 2 wks, the patient was rotated again to
methadone, with a decrease of the MEDD to 24. He achieved good
pain control and was free of
opioid toxicity. Our findings illustrate a role of
methadone in the management of
cancer pain associated with poor prognostic indicators, the development of tolerance towards its effects, and the regaining of sensitivity to
methadone, by temporary rotation to another
opioid. Possible mechanism for
opioid tolerance and its reversal are discussed.