PAINWeek Course Preview: Could Levorphanol Levitate Above Methadone Misadventure?

Give us a brief overview of your course at PAINWeek 2015?

Abigail Brooks, PhD: Refereed by Dr. Fudin, my colleague Courtney Kominek and I hope to foster a lively debate over the use of methadone versus levorphanol for chronic non-malignant pain or cancer pain. We’ll provide an overview of both methadone and levorphanol, including mechanism of action, dosing, adverse effect profile, and equianalgesic dosing. We’ll be employing interactive audience polling questions and patient cases for discussion.

Jeffrey Fudin, PharmD: Although methadone has a role in the treatment of opioid dependence, its unique mechanism of action, oral bioavailability, absence of active metabolites, and delayed withdrawal syndrome makes it a viable option for chronic pain management. With these benefits come multiple pitfalls, including variable pharmacokinetics, pharmacogenetic considerations, potential for multiple drug interactions, QTc prolongation, and an extended titration period. Thus, the risks of methadone therapy may outweigh the benefits in some patients. Levorphanol, less commonly used or prescribed compared to methadone, shares all the benefits but avoids almost all of the risks associated with methadone resulting in an overall more favorable risk-to-benefit profile for the treatment of chronic and neuropathic pain.

Who should plan to attend?

Jeffrey Fudin, PharmD: I would recommend it for any clinician who prescribes opioids, and especially for those who are fearful of prescribing methadone.

Abigail Brooks, PhD: Also, for providers who may be wondering about alternatives to methadone, whether or not they have prior experience with levorphanol.

What will course participants learn that they can take back to their practices?

Abigail Brooks, PhD: Course participants will become familiar with the mechanism of action, dosing, adverse effect profile, and equianalgesic dosing for levorphanol. They’ll also learn the benefits of levorphanol over methadone, and be equipped to identify patients who would benefit from levorphanol over methadone for chronic pain.

Jeffrey Fudin, PharmD: Participants will learn about a viable methadone alternative that is grossly underutilized in practice and they will walk away with a better understanding of the advantages and disadvantages of methadone and how to avert potential disasters and miscalculated risks.

What is the “essential pearl” that PAINWeek participants will miss, if they miss your course?

Jeffrey Fudin, PharmD: They will learn that levorphanol is the opioid levorotatory enantiomer of dextromethorphan, the shocking similarities and enormous differences, and how certain opioids may be advantageous in treating neuropathic pain over the vast majority of others.

Abigail Brooks, PhD: Levorphanol may be the "forgotten opioid", but has both opioid receptor and NMDA activity, with possible advantages over methadone including more predictable pharmacokinetic profile and no risk of QTc prolongation.

As you review the Schedule at a Glance and design your course agenda for PAINWeek 2015, think about improving your expertise in this vital aspect of pain pharmacology. We look forward to your participation at PAINWeek: The National Conference on Pain for Frontline Practitioners!

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