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Methadone for 'Adenocarcinopathic' Pain Treatment (METHADOPT)

Primary Purpose

Cancer Pain, Adenocarcinoma

Status
Withdrawn
Phase
Phase 3
Locations
Study Type
Interventional
Intervention
Methadone
Morphine
Sponsored by
Ottawa Hospital Research Institute
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Cancer Pain focused on measuring Cancer, Methadone, Morphine, Hydromorphone, Adenocarcinoma

Eligibility Criteria

18 Years - 75 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Cancer type is adenocarcinoma;
  • In the physician's opinion, mechanism of pain is most likely linked to an adenocarcinoma 'in proximity to' or invading a nerve or nerve plexus (i.e., 'adenocarcinopathic' pain; ACPP);
  • Experiencing poorly controlled pain (defined as pain of 4 or higher on a 10-point visual analogue scale) despite the use of non-opioid analgesics or despite the regular use of up to 60 mg morphine equivalent daily dose (MEDD);
  • Eastern Cooperative Oncology Group Performance Status (ECOG PS) of 0 to 2;
  • Estimated prognosis of at least 3 months;
  • Able to fill out questionnaires and understand procedures in English and/or French;
  • Able to provide first person informed consent;
  • Physician deems it appropriate to start the patient on the opioid.

Exclusion Criteria:

  • Known QTc prolongation (QTc greater than 500ms, QRS less than 120ms) or known congenital QTc prolongation syndrome;
  • Taking at least one medication that increases risk of Torsades de Pointes (TdP): cisapride, disopyramide, dofetilide, flecainide, procainamide, propafenone, quinidine, quinine, sotalol;
  • History of opioid abuse or dependence using Edmonton Pain Classification;
  • Has geographic difficulties with follow-up in person;
  • Has any of the following comorbidities: documented class 3 or 4 New York Heart Association (NYHA) heart failure, myocardial infarction in the last 3 months, unstable angina, pericardial disease, oxygen dependent pulmonary diseases, Parkinson's disease, suspected or diagnosed dementia, bipolar disorder, poorly managed major depression (current or treated) or anxiety disorder;
  • Taking medication known to have clinically significant interactions with the CYP450 enzyme: carbamazepine, efavirenz, phenobarbital, rifampicin, azole antifungals, antiretrovirals, grapefruit juice, clarithromycin, erythromycin;
  • Diagnosed with Child-Pugh class B and/or C cirrhosis;
  • Has hepatic insufficiency, defined as jaundice with irreversible hyperbilirubinemia of at least 34 micromol/L despite biliary tract stents (severity criteria in Child-Pugh-Turcotte score);
  • Received radiation or any nerve block or plexus block on the same side as the pain in the past 14 days or PLANNED within the next 14 days;
  • PLANNED prescription for daily co-analgesia with pregabalin, gabapentin, or dexamethasone during the next 14 days (not including dexamethasone with chemotherapy);
  • Taking medication associated with major risk of serotonin syndrome (monoamine oxidase inhibitors; MAOIs): linezolid, moclobemide, rasagiline, selegiline;
  • Taking medication known to be an opioid agonist, antagonist, or partial agonist: naltrexone, buprenorphine, tapentadol, tramadol;
  • Other negative characteristic as per physician discretion (e.g., reduced renal function).

Sites / Locations

    Arms of the Study

    Arm 1

    Arm 2

    Arm Type

    Experimental

    Active Comparator

    Arm Label

    Methadone

    Morphine

    Arm Description

    DESCRIPTION: Blinded methadone 1mg tablets PO -- DOSAGE: A) For patients initially taking 0-30 mg MEDD: Starting dose: 0.5mg Q4H x 4 doses + 1.0mg QHS + 0.5mg Q2H PRN (max 4 doses) First increase: 1.0 mg Q4H x 4 doses + 2.0mg QHS + 0.5mg Q2H PRN (max 4 doses) Second increase: 1.5mg Q4H x 4 doses + 3.0mg QHS + 0.5mg Q2H PRN (max 4 doses) Third increase: 2.0mg Q4H x 4 doses + 4.0mg QHS + 1.0mg Q2H PRN (max 4 doses) Fourth increase: 2.5mg Q4H x 4 doses + 5.0mg QHS + 1.0mg Q2H PRN (max 4 doses) B) For patients initially taking 31-60 mg MEDD: Starting dose: 1.0mg Q4H x 4 doses + 2.0mg QHS + 0.5mg Q2H PRN (max 4 doses) First increase: 1.5mg Q4H x 4 doses + 3.0mg QHS + 1.0mg Q2H PRN (max 4 doses) Second increase: 2.0mg Q4H x 4 doses + 4.0mg QHS + 1.0mg Q2H PRN (max 4 doses) Third increase: 2.5mg Q4H x 4 doses + 5.0mg QHS + 1.5mg Q2H PRN (max 4 doses) Fourth increase: 3.0mg Q4H x 4 doses + 6.0mg QHS + 1.5mg Q2H PRN (max 4 doses)

    DESCRIPTION: Blinded morphine 5mg tablets PO -- DOSAGE: A) For patients initially taking 0-30 mg MEDD: Starting dose: 2.5mg Q4H x 4 doses + 5.0mg QHS + 2.5mg Q2H PRN (max 4 doses) First increase: 5.0 mg Q4H x 4 doses + 10.0mg QHS + 2.5mg Q2H PRN (max 4 doses) Second increase: 7.5mg Q4H x 4 doses + 15.0mg QHS + 2.5mg Q2H PRN (max 4 doses) Third increase: 10.0mg Q4H x 4 doses + 20.0mg QHS + 5.0mg Q2H PRN (max 4 doses) Fourth increase: 12.5mg Q4H x 4 doses + 25.0mg QHS + 5.0mg Q2H PRN (max 4 doses) B) For patients initially taking 31-60 mg MEDD: Starting dose: 5.0mg Q4H x 4 doses + 10.0mg QHS + 2.5mg Q2H PRN (max 4 doses) First increase: 7.5mg Q4H x 4 doses + 15.0mg QHS + 5.0mg Q2H PRN (max 4 doses) Second increase: 10.0mg Q4H x 4 doses + 20.0mg QHS + 5.0mg Q2H PRN (max 4 doses) Third increase: 12.5mg Q4H x 4 doses + 25.0mg QHS + 12.5mg Q2H PRN (max 4 doses) Fourth increase: 15.0mg Q4H x 4 doses + 30.0mg QHS + 12.5mg Q2H PRN (max 4 doses)

    Outcomes

    Primary Outcome Measures

    Pain control
    Proportion of patients reporting pain of 3 or less on a 10-point scale

    Secondary Outcome Measures

    Pain control
    Proportion of patients reporting pain of 3 or less on a 10-point scale
    Pain relief
    Proportion of patients reporting at least 50% pain relief since start of treatment
    Pain relief
    Proportion of patients reporting at least 50% pain relief since start of treatment
    Patient satisfaction
    Proportion of patients who are satisfied (yes or no) with their current level of pain control
    Patient satisfaction
    Proportion of patients who are satisfied (yes or no) with their current level of pain control
    Physician confidence
    Proportion of patients for whom physicians felt confident in treating with methadone or morphine
    Global change
    Patient's global impression of change (PGIC)
    Side effects
    Proportion of patients who experienced or had worsening opioid side effects

    Full Information

    First Posted
    April 5, 2022
    Last Updated
    December 1, 2022
    Sponsor
    Ottawa Hospital Research Institute
    Collaborators
    Bruyere Research Institute, The Ottawa Hospital
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    1. Study Identification

    Unique Protocol Identification Number
    NCT05325164
    Brief Title
    Methadone for 'Adenocarcinopathic' Pain Treatment
    Acronym
    METHADOPT
    Official Title
    Methadone for 'Adenocarcinopathic' Pain Treatment: Methadone vs. Morphine Vanguard RCT
    Study Type
    Interventional

    2. Study Status

    Record Verification Date
    December 2022
    Overall Recruitment Status
    Withdrawn
    Why Stopped
    Trial not started; change in Sponsor and Principal Investigator, trial to be registered again by new Sponsor/Investigator if it is started.
    Study Start Date
    September 2022 (Anticipated)
    Primary Completion Date
    August 2023 (Anticipated)
    Study Completion Date
    September 2023 (Anticipated)

    3. Sponsor/Collaborators

    Responsible Party, by Official Title
    Sponsor
    Name of the Sponsor
    Ottawa Hospital Research Institute
    Collaborators
    Bruyere Research Institute, The Ottawa Hospital

    4. Oversight

    Studies a U.S. FDA-regulated Drug Product
    No
    Studies a U.S. FDA-regulated Device Product
    No
    Data Monitoring Committee
    Yes

    5. Study Description

    Brief Summary
    Methadone is an opioid that has been used for over 80 years to treat various types of pain, including cancer pain. Despite its increasing popularity as a co-analgesic and first-line treatment for cancer pain, there remain some outstanding questions regarding its use in treating cancer pain, such as its efficacy compared to other opioids and its appropriateness as a first-line treatment. The investigators will conduct a Vanguard Randomized Clinical Trial (RCT) to estimate the efficacy of methadone compared to morphine for the treatment of a newly defined type of cancer pain, which the investigators have termed 'adenocarcinopathic' pain (ACPP).
    Detailed Description
    Background: Methadone is an opioid that has been used for over 80 years to treat various types of pain, including cancer pain. Its use as a co-analgesic and first-line treatment for cancer pain is becoming more widespread. Despite its increasing popularity, there remain some outstanding questions regarding its use in treating cancer pain, such as its efficacy compared to other opioids and its appropriateness as a first-line treatment. Traditional classifications of cancer related chronic pain is classified as neuropathic and nociceptive (somatic or visceral). This classification is based on clinical descriptors as opposed to pathophysiologic mechanisms. The investigators propose a new mechanism, called 'adenocarcinopathic' pain (ACPP), which can be defined as pain caused by an adenocarcinoma that is in 'proximity' to or invading a nerve or nerve plexus. The suggested mechanism of ACPP is that the tumour excretes excess glutamate, which activates NMDA receptors on nearby sensory nerves, causing the pain sensation. As methadone is an NMDA antagonist (and mu receptor agonist), it becomes an interesting molecule for ACPP in comparison to other opioids (such as morphine) that are unable to suppress NMDA receptors. Study Hypothesis: Methadone will demonstrate superior efficacy to morphine for the treatment of ACPP, and physicians will demonstrate satisfactory confidence in its use. Study Objectives: Monitor safety and response to treatment Evaluate the confidence of physicians Study Design: Participants will be randomized to receive either methadone or morphine. Patients will be observed for a period of 14 days, plus one physician follow-up after 28 days. Sample Size & Study Population: The investigators will aim to enrol n=40 patients total across all sites. Eligible outpatients are those for whom a strong opioid is being initiated or escalated for the treatment of ACPP. Intervention: For patients previously taking 0-30mg morphine equivalent daily dose (MEDD), starting dose is 0.5mg Q4H for methadone, 2.5mg for morphine. For those previously taking 31-60 mg MEDD, starting dose is 1.0mg Q4H for methadone, 5.0mg for morphine. Up to 4 breakthrough analgesia doses allowed per day. Dose escalations can be made at each patient encounter according to a standard dosing schedule. Study Outcome Measures: Using validated questionnaires, the patient's degree of pain control & relief, degree of satisfaction, global impression of change, and any side effects will be assessed. In addition, physicians will be asked to rate their confidence in treating each patient. Expected Outcomes: Positive results should provide justification to prolong the study to complete a phase III trial.

    6. Conditions and Keywords

    Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
    Cancer Pain, Adenocarcinoma
    Keywords
    Cancer, Methadone, Morphine, Hydromorphone, Adenocarcinoma

    7. Study Design

    Primary Purpose
    Treatment
    Study Phase
    Phase 3
    Interventional Study Model
    Parallel Assignment
    Masking
    ParticipantCare Provider
    Allocation
    Randomized
    Enrollment
    0 (Actual)

    8. Arms, Groups, and Interventions

    Arm Title
    Methadone
    Arm Type
    Experimental
    Arm Description
    DESCRIPTION: Blinded methadone 1mg tablets PO -- DOSAGE: A) For patients initially taking 0-30 mg MEDD: Starting dose: 0.5mg Q4H x 4 doses + 1.0mg QHS + 0.5mg Q2H PRN (max 4 doses) First increase: 1.0 mg Q4H x 4 doses + 2.0mg QHS + 0.5mg Q2H PRN (max 4 doses) Second increase: 1.5mg Q4H x 4 doses + 3.0mg QHS + 0.5mg Q2H PRN (max 4 doses) Third increase: 2.0mg Q4H x 4 doses + 4.0mg QHS + 1.0mg Q2H PRN (max 4 doses) Fourth increase: 2.5mg Q4H x 4 doses + 5.0mg QHS + 1.0mg Q2H PRN (max 4 doses) B) For patients initially taking 31-60 mg MEDD: Starting dose: 1.0mg Q4H x 4 doses + 2.0mg QHS + 0.5mg Q2H PRN (max 4 doses) First increase: 1.5mg Q4H x 4 doses + 3.0mg QHS + 1.0mg Q2H PRN (max 4 doses) Second increase: 2.0mg Q4H x 4 doses + 4.0mg QHS + 1.0mg Q2H PRN (max 4 doses) Third increase: 2.5mg Q4H x 4 doses + 5.0mg QHS + 1.5mg Q2H PRN (max 4 doses) Fourth increase: 3.0mg Q4H x 4 doses + 6.0mg QHS + 1.5mg Q2H PRN (max 4 doses)
    Arm Title
    Morphine
    Arm Type
    Active Comparator
    Arm Description
    DESCRIPTION: Blinded morphine 5mg tablets PO -- DOSAGE: A) For patients initially taking 0-30 mg MEDD: Starting dose: 2.5mg Q4H x 4 doses + 5.0mg QHS + 2.5mg Q2H PRN (max 4 doses) First increase: 5.0 mg Q4H x 4 doses + 10.0mg QHS + 2.5mg Q2H PRN (max 4 doses) Second increase: 7.5mg Q4H x 4 doses + 15.0mg QHS + 2.5mg Q2H PRN (max 4 doses) Third increase: 10.0mg Q4H x 4 doses + 20.0mg QHS + 5.0mg Q2H PRN (max 4 doses) Fourth increase: 12.5mg Q4H x 4 doses + 25.0mg QHS + 5.0mg Q2H PRN (max 4 doses) B) For patients initially taking 31-60 mg MEDD: Starting dose: 5.0mg Q4H x 4 doses + 10.0mg QHS + 2.5mg Q2H PRN (max 4 doses) First increase: 7.5mg Q4H x 4 doses + 15.0mg QHS + 5.0mg Q2H PRN (max 4 doses) Second increase: 10.0mg Q4H x 4 doses + 20.0mg QHS + 5.0mg Q2H PRN (max 4 doses) Third increase: 12.5mg Q4H x 4 doses + 25.0mg QHS + 12.5mg Q2H PRN (max 4 doses) Fourth increase: 15.0mg Q4H x 4 doses + 30.0mg QHS + 12.5mg Q2H PRN (max 4 doses)
    Intervention Type
    Drug
    Intervention Name(s)
    Methadone
    Other Intervention Name(s)
    Dolophine, Methadose
    Intervention Description
    Methadone
    Intervention Type
    Drug
    Intervention Name(s)
    Morphine
    Other Intervention Name(s)
    MS Contin, Kadian
    Intervention Description
    Morphine
    Primary Outcome Measure Information:
    Title
    Pain control
    Description
    Proportion of patients reporting pain of 3 or less on a 10-point scale
    Time Frame
    2 weeks
    Secondary Outcome Measure Information:
    Title
    Pain control
    Description
    Proportion of patients reporting pain of 3 or less on a 10-point scale
    Time Frame
    1 week
    Title
    Pain relief
    Description
    Proportion of patients reporting at least 50% pain relief since start of treatment
    Time Frame
    1 week
    Title
    Pain relief
    Description
    Proportion of patients reporting at least 50% pain relief since start of treatment
    Time Frame
    2 weeks
    Title
    Patient satisfaction
    Description
    Proportion of patients who are satisfied (yes or no) with their current level of pain control
    Time Frame
    1 week
    Title
    Patient satisfaction
    Description
    Proportion of patients who are satisfied (yes or no) with their current level of pain control
    Time Frame
    2 weeks
    Title
    Physician confidence
    Description
    Proportion of patients for whom physicians felt confident in treating with methadone or morphine
    Time Frame
    2 weeks
    Title
    Global change
    Description
    Patient's global impression of change (PGIC)
    Time Frame
    2 weeks
    Title
    Side effects
    Description
    Proportion of patients who experienced or had worsening opioid side effects
    Time Frame
    2 weeks

    10. Eligibility

    Sex
    All
    Minimum Age & Unit of Time
    18 Years
    Maximum Age & Unit of Time
    75 Years
    Accepts Healthy Volunteers
    No
    Eligibility Criteria
    Inclusion Criteria: Cancer type is adenocarcinoma; In the physician's opinion, mechanism of pain is most likely linked to an adenocarcinoma 'in proximity to' or invading a nerve or nerve plexus (i.e., 'adenocarcinopathic' pain; ACPP); Experiencing poorly controlled pain (defined as pain of 4 or higher on a 10-point visual analogue scale) despite the use of non-opioid analgesics or despite the regular use of up to 60 mg morphine equivalent daily dose (MEDD); Eastern Cooperative Oncology Group Performance Status (ECOG PS) of 0 to 2; Estimated prognosis of at least 3 months; Able to fill out questionnaires and understand procedures in English and/or French; Able to provide first person informed consent; Physician deems it appropriate to start the patient on the opioid. Exclusion Criteria: Known QTc prolongation (QTc greater than 500ms, QRS less than 120ms) or known congenital QTc prolongation syndrome; Taking at least one medication that increases risk of Torsades de Pointes (TdP): cisapride, disopyramide, dofetilide, flecainide, procainamide, propafenone, quinidine, quinine, sotalol; History of opioid abuse or dependence using Edmonton Pain Classification; Has geographic difficulties with follow-up in person; Has any of the following comorbidities: documented class 3 or 4 New York Heart Association (NYHA) heart failure, myocardial infarction in the last 3 months, unstable angina, pericardial disease, oxygen dependent pulmonary diseases, Parkinson's disease, suspected or diagnosed dementia, bipolar disorder, poorly managed major depression (current or treated) or anxiety disorder; Taking medication known to have clinically significant interactions with the CYP450 enzyme: carbamazepine, efavirenz, phenobarbital, rifampicin, azole antifungals, antiretrovirals, grapefruit juice, clarithromycin, erythromycin; Diagnosed with Child-Pugh class B and/or C cirrhosis; Has hepatic insufficiency, defined as jaundice with irreversible hyperbilirubinemia of at least 34 micromol/L despite biliary tract stents (severity criteria in Child-Pugh-Turcotte score); Received radiation or any nerve block or plexus block on the same side as the pain in the past 14 days or PLANNED within the next 14 days; PLANNED prescription for daily co-analgesia with pregabalin, gabapentin, or dexamethasone during the next 14 days (not including dexamethasone with chemotherapy); Taking medication associated with major risk of serotonin syndrome (monoamine oxidase inhibitors; MAOIs): linezolid, moclobemide, rasagiline, selegiline; Taking medication known to be an opioid agonist, antagonist, or partial agonist: naltrexone, buprenorphine, tapentadol, tramadol; Other negative characteristic as per physician discretion (e.g., reduced renal function).
    Overall Study Officials:
    First Name & Middle Initial & Last Name & Degree
    Bruno Gagnon, MD MSc
    Organizational Affiliation
    Centre de recherche du CHU de Quebec
    Official's Role
    Principal Investigator

    12. IPD Sharing Statement

    Plan to Share IPD
    No
    Citations:
    PubMed Identifier
    14701781
    Citation
    Bruera E, Palmer JL, Bosnjak S, Rico MA, Moyano J, Sweeney C, Strasser F, Willey J, Bertolino M, Mathias C, Spruyt O, Fisch MJ. Methadone versus morphine as a first-line strong opioid for cancer pain: a randomized, double-blind study. J Clin Oncol. 2004 Jan 1;22(1):185-92. doi: 10.1200/JCO.2004.03.172.
    Results Reference
    background
    PubMed Identifier
    29101087
    Citation
    Mercadante S, Bruera E. Methadone as a First-Line Opioid in Cancer Pain Management: A Systematic Review. J Pain Symptom Manage. 2018 Mar;55(3):998-1003. doi: 10.1016/j.jpainsymman.2017.10.017. Epub 2017 Nov 1.
    Results Reference
    background
    PubMed Identifier
    27494037
    Citation
    Haumann J, Geurts JW, van Kuijk SM, Kremer B, Joosten EA, van den Beuken-van Everdingen MH. Methadone is superior to fentanyl in treating neuropathic pain in patients with head-and-neck cancer. Eur J Cancer. 2016 Sep;65:121-9. doi: 10.1016/j.ejca.2016.06.025. Epub 2016 Aug 3.
    Results Reference
    background
    PubMed Identifier
    28195060
    Citation
    Leppert W, Zajaczkowska R, Wordliczek J, Dobrogowski J, Woron J, Krzakowski M. Pathophysiology and clinical characteristics of pain in most common locations in cancer patients. J Physiol Pharmacol. 2016 Dec;67(6):787-799.
    Results Reference
    background
    PubMed Identifier
    27482630
    Citation
    Slosky LM, BassiriRad NM, Symons AM, Thompson M, Doyle T, Forte BL, Staatz WD, Bui L, Neumann WL, Mantyh PW, Salvemini D, Largent-Milnes TM, Vanderah TW. The cystine/glutamate antiporter system xc- drives breast tumor cell glutamate release and cancer-induced bone pain. Pain. 2016 Nov;157(11):2605-2616. doi: 10.1097/j.pain.0000000000000681.
    Results Reference
    background
    PubMed Identifier
    14657982
    Citation
    Gagnon B, Almahrezi A, Schreier G. Methadone in the treatment of neuropathic pain. Pain Res Manag. 2003 Fall;8(3):149-54. doi: 10.1155/2003/236718.
    Results Reference
    background

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    Methadone for 'Adenocarcinopathic' Pain Treatment

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