Palliative care activists across India worked hard to obtain a source of long acting pain relief  and an alternative for short acting morphine for patients with serious health related suffering.  Methadone was approved in 2017 and was made available in January 2018.

The Indian Journal of Palliative Care dedicated an entire supplement to methadone for the Indian context.  These open access documents will provide the interested volunteer with the appropriate background. Volunteers are needed for ongoing clinical support for Indian Palliative Care clinicians who want to gain experience with methadone and would like access to advice.  While there are many methods of equianalgesic conversions, please follow this protocol for consistency.

Methadone guidelines for Homecare/ Outpatient

Indications

1. Reliable caregiver
2. Patients with Neuropathic pain, renal failure, opioid toxicities, opioid induced hyperlagesia , opioid tolerance, allergy to other opioids, adjuvant, night-time pain requiring doses in the middle of the night

Dosages

1. Patients receiving Oral Morphine Equivalent (OME) 60- 120 mg can be started on Methadone. Maximum of 5 mg BD (Adjust the dose according to OME
2. Methadone is not a first choice in pain conditions except in renal failure. In renal failure , if the patient need opioids, start with 2.5 mg BD

If the patient is at the end of life, there should be no concerns about Qtc interval.

If the portable monitor is not available, and the patient cannot come to the inpatient unit, start low dose methadone 2.5 mg BD and check the Qtc in 1 week.  No medications need to be stopped. 

Methadone Flowchart

References: 
1. Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper, Mary Lynn McPherson

Diabetes is at epidemic levels in India.  Despite Pallium’s aim to improve the quality of life in patients who are suffering from life-limiting and debilitating diseases, we find that in our patient population, due to the burden and complications of diabetes like loss of vision, cardiovascular event, lower extremity deformations and amputations, cost of medical care and poor healthcare access, there is a gap in the prevention, education and management of diabetes in our community.

Pallium India seeks to address usual palliative care issues (pain, grief, symptom management) and this condition, which has long lasting effects on whole health including heart and kidney disease, amputation and blindness.  The proposal for diabetes care at Pallium India is available on request.

Collaboration is needed for funding: 
Point of care HbA1c testing - US $410 for home testing machine

Laboratory testing: Cr, microalbumin - US $5 per test
Monofilaments for every person with diabetes - US $27 per person

Diabetes-friendly food kits (high protein) - US $15 per month per person

Collaboration is also needed for content specialists to meet with Pallium India staff to prioritize programming and review current programming.

There has been an increase in the resistance to antibiotics in India, specifically to amoxicillin, cefoperazone, and fluoroquinolones, including ciprofloxacin. Antibiotic use at Pallium India has been affected by this resistance.

In 2018, an antibiotic order form was created in order to track antibiotic use and guide staff antibiotic choices at Pallium India. Ideally it is filled out and discussed at a monthly interdisciplinary antibiotic stewardship meeting.  This form has already led to changes at Pallium India, including removal of antibiotics with high resistance (ciprofloxacin) from the formulary.

Ongoing support for this initiative could include:

Assistance with monthly antibiotic stewardship meetings.

Mentorship on antibiotic choices and choices.

Analysis of data on a quarterly basis.