Nurses Perspectives on Low-Dose Methadone for Pain in Nursing Homes: Semi-structured Interviews

Abstract

Background:

Chronic pain is prevalent in nursing homes, yet safe and effective long-acting opioid options are limited. Studies suggest that low-dose methadone (LDM) may be an ideal alternative. However, its use in nursing homes remains rare and perspectives from nursing staff on its practical benefits and challenges are underreported.

Objectives:

To explore nurses’ perspectives on LDM for pain in nursing home residents and assess potential benefits and barriers to its adoption.

Design:

A qualitative study employing semi-structured interviews and a modified phenomenological approach.

Setting/Subjects:

Nurses who administered LDM (<10 mg/day) as the primary opioid for pain in the past three years in Hawaii and British Columbia nursing homes.

Measurements:

Semi-structured interviews were conducted via Zoom™ using a standardized interview guide. Interviews were recorded, transcribed verbatim, and analyzed using a qualitative description approach. Data collection continued until thematic saturation was reached.

Results:

Of the 11 nurse participants, most reported that LDM was effective in managing pain without major side effects, even in cases where other opioids had failed, and observed improvements in resident behavior. Four key themes emerged: initial hesitancy and the role of education, effectiveness in pain control, preferable side effect profile, and pros and cons of administration. Participants noted that LDM’s long-acting nature and liquid formulation were particularly beneficial in nursing home settings. Additionally, the use of LDM appeared to alleviate their workload by improving resident cooperation and reducing the need for frequent medication administration.

Conclusions:

LDM is effective and well-tolerated for pain management in nursing home residents, with minimal side effects and added benefits for resident behavior and nurse satisfaction. These findings support the need for further studies to assess LDM’s utility in nursing home settings.

Key Message

This qualitative study explores nurses’ perspectives on low-dose methadone (LDM) for pain management in nursing homes, highlighting its effectiveness, safety, and potential benefits for improving resident behavior and reducing caregiver stress. The findings suggest that LDM could address unmet needs in managing pain in this vulnerable population.

Introduction

Chronic pain is a common issue for older adults, especially among nursing home residents, where the prevalence of chronic pain ranges from 45% to 85%.¹ Despite this, chronic pain in nursing home residents is often under-treated.^1,2 Uncontrolled pain in nursing home residents has been associated with agitation,³ depression,⁴ poor sleep,⁵ and disruptive behaviors such as refusing care and aggression toward staff.⁶ Therefore, uncontrolled pain has serious negative impacts not only on residents but also on the people who care for them.

Opioids are indicated for persistent pain when nonopioid modalities fail, with long-acting opioids preferred for consistent pain.⁷ However, available options of long-acting opioids have significant limitations for nursing home residents. Fentanyl patches risk overdose, particularly in residents requiring lower doses, and are not recommended for those on less than 60 mg/day of oral morphine equivalents.⁸ Long-acting opioid tablets are unsuitable for residents with dysphagia as they cannot be crushed, and morphine is contraindicated in renal impairment. Furthermore, the high withdrawal rate observed in a clinical trial of long-acting morphine and oxycodone in nursing home residents underscores the challenges associated with adverse effects at standard doses.⁹ Transdermal buprenorphine patches are an emerging option for nursing home residents.¹⁰ However, their high cost may limit use in many nursing homes. Additionally, even at the lowest dose (5 mcg/h), buprenorphine patches were associated with high discontinuation rates in advanced dementia due to psychiatric and neurological adverse events.¹¹ These limitations highlight the pressing need for a safer, more effective, long-acting opioid for this population.

Methadone is a synthetic opioid traditionally used as a second-line option when other opioids have failed. It is generally recommended that methadone only be used by experts and for patients who are not opioid naive given its complicated dosing, long half-life, and potential for QT prolongation.¹² However, observational studies suggest that LDM (typically <10 mg/day) is effective as a first-line opioid to improve cancer pain^13–15 and noncancer pain¹⁶ across various care settings with minimal adverse effects. LDM may be particularly beneficial for nursing home residents, who often have dysphagia and renal impairment, as methadone is available in an oral solution, has a long-acting property, and is safe for those with renal failure. Case series studies demonstrated that LDM effectively controlled pain and occasionally improved agitation in nursing home residents, with no significant adverse effects.^17,18 These findings suggest that LDM can be a desirable option for nursing home settings.

Despite its potential, LDM remains rarely used in nursing homes. In an analysis of 22,253 Medicare-enrolled nursing home residents initiated on a long-acting opioid, methadone was not prescribed in any case.¹⁹ Most previous LDM studies have focused on quantitative measures such as pain scores. However, given the complexity of pain manifestations in nursing home residents, a qualitative approach could provide valuable insights. Nurses, who spend the most time with residents and play a central role in administering medications and observing their effects, are uniquely positioned to provide these insights. To date, their perspectives on LDM use in nursing homes are absent from the literature. This study aims to explore nurses’ experiences and perspectives on LDM to better understand its potential for integration into routine pain management in nursing homes.

Methods

Study design

This is a qualitative phenomenological study using semi-structured interviews of nurses who administered LDM to residents in nursing home settings. Findings are reported in accordance with the Standards for Reporting Qualitative Research.²⁰

Researcher characteristics

T.U. and C.B. are palliative medicine physicians who have prescribed LDM to nursing home residents. T.U. worked with most of the Hawaii participants. C.B. and J.B., a palliative care outreach nurse, worked with most of the British Columbia participants. To minimize bias, the interviews were conducted by J.O., a medical student with no prior experience prescribing LDM or working with these participants. Qualitative research guidance was provided by A.K., an expert in the field.

Participant selection

Participants were initially recruited from nursing homes in Hawaii where T.U. had prescribed LDM over the past three years. However, many nurses with experience using LDM had left their positions since the COVID-19 pandemic, making recruitment challenging. Despite extensive efforts, we were unable to identify additional U.S. nursing homes where LDM was in use, underscoring its rarity in this setting. To ensure adequate participation, recruitment was expanded to three nursing homes in Vancouver, British Columbia, where C.B. and other physicians routinely used LDM. These facilities adopted LDM under the influence of Gallagher, who worked in these settings and authored the first published report on its use in nursing homes.¹⁷

Nursing homes in the United States and Canada serve comparable populations, providing care for older adults with complex medical needs under similar care practices.²¹ Importantly, neither country requires special certification for prescribing methadone for pain management beyond standard opioid prescribing requirements.^22,23 Given these similarities, expanding recruitment to Canadian nursing homes was considered appropriate for exploring nurse perspectives on LDM.

The recruitment period spanned from June 2022 to October 2023. A total of 11 participants (4 from Hawaii and 7 from British Columbia) were recruited and thematic saturation was reached. Participants, approached by email, included registered nurses and licensed practical nurses who had administered LDM for pain control to at least one resident in the past three years. For this study, LDM was defined as less than 10 mg/day as the sole long-acting opioid. Methadone used as an adjuvant analgesic to other long-acting opioids was not considered.

Data collection methods

Institutional review board approval was obtained from the pertinent institutions. Once participants consented to be in the study, in-depth semi-structured interviews were conducted via Zoom™. All interviews were conducted by J.O., who maintained a neutral position and refrained from offering any opinions on the use of LDM. Each interview lasted 30–60 minutes. The same initial open-ended questions listed in the interview guide (Supplementary Appendix) were asked to each participant. Follow-up questions were asked as needed. Key domains explored included: (1) general impressions of LDM, (2) experiences and observations, and (3) attitudes and opinions toward its use. Interviews were recorded, transcribed using Zoom™ transcription software, and de-identified for analysis, with errors corrected by J.O.

Data analysis

A qualitative description approach was used to interpret the data. J.O. and T.U. familiarized themselves with the anonymized interview transcripts and created broad lists of codes capturing key insights from participants. Lists were then compared and consolidated into a single set of agreed-upon codes, which were used to analyze and categorize the interviews. From this, J.O. and T.U. independently generated lists of common themes, which were then compared and condensed into a final list of themes and subthemes. Throughout the analysis, constant reference to the original transcripts, open discussions, and input from A.K. ensured a thorough and accurate representation of nurse perspectives.

Results

Characteristics of study participants can be seen in Table 1. Of the 11 participants, nine (81.8%) were female. The average age was 49.5 (standard deviation [SD] 12.3) years. Four participants (36.4%) worked in a nursing home in Hawaii, USA. Seven participants (63.6%) worked in one of three nursing homes in British Columbia, Canada. Participants had a range of experience in nursing home settings, with 45.5% having over 10 years of experience. The average number of residents to whom each nurse administered LDM was 6.3 (SD 8.9).

Table 1.

Characteristics of Study Participants

Characteristics	N = 11
Gender, n (%)
Female	9 (81.8)
Male	2 (18.2)
Age, year, mean ± SD	49.5 ± 12.3
Title, n (%)
Registered nurse	11 (100)
Licensed practical nurse	0
Years working in the nursing home industry, n (%)
<5	4 (36.4)
5–10	2 (18.2)
11–20	4 (36.4)
21–30	1 (9.1)
>30	0
Location of their nursing home, n (%)
Hawaii, USA	4 (36.4)
British Columbia, Canada	7 (63.6)
Number of residents treated with LDM per nurse, mean ± SD	6.3 ± 8.9

LDM, low-dose methadone; SD, standard deviation.

Analysis of the interview data identified four key themes: (1) initial hesitancy and the role of education, (2) the effectiveness of LDM in pain management, (3) its preferable side effect profile, and (4) the pros and cons of administration (Table 2).

Table 2.

Common Themes and Subthemes

Theme	Subtheme	Example quotes
Initial hesitancy and role of education	Initial hesitancy that resolved after experience	“I kind of had my doubts at the time that it was gonna work. I never saw that before. I never saw methadone used in that way before... quite honestly, I thought he was wrong, you know, in ordering it to begin with. Yeah, I said why not just give morphine?” (Participant 4)“After seeing the beneficial effect on the resident I felt more comfortable,” (Participant 1)
	The role of formal education in fostering confidence	“When it [methadone] was introduced there was multiple education sessions done for staff to understand… I feel like, you know, when residents are on methadone, it’s very safe. I mean, there is no difference, like, it’s just like a pain medication” (Participant 6)
	Uncertainty about superiority over other opioids	“I was still not completely sold on the idea of methadone... I still thought that the other medication [morphine] was also good too.” (Participant 4)
	Family reactions: support for comfort but general concerns about opioids	“Not only methadone, but overall like narcotics, or you know, opioids... sometime families think it’s like addiction... I think they’re worried... they might get addicted, you know, and then sometimes they think these are the medications... you could only give to someone when they are dying.” (Participant 6)“Most of them were comforted, knowing that their loved one is more comfortable.” (Participant 7)
Effective for pain control	Challenges in assessing pain in nursing home settings	“That resident has a lot of pain, but she cannot talk, okay, so just we gotta monitor her expression- face expressions, body gestures.” (Participant 3)“At some points, the level of consciousness is so low there’s no way to tell what the pain level is, unless it’s severe pain.” (Participant 10)
	Improvement of pain and reduction of other pain medications	“She started to improve daily. Her hydromorphone we you know, almost… the amount of PRNs were almost getting 0 by the third week… and her pregabalin has been like weaned off totally. So she’s doing much better.” (Participant 6)“Methadone works. That’s why we are not giving any PRN pain medicine. So it means resident’s pain is under control. Right?” (Participant 8)
	Improved behavior and function	“Less yelling, less calling out… I can see in the residents they’re more relaxed, more calm. Occasionally, you can see some smile on the face of the resident.” (Participant 1)“She was happy. She’s up every day, she comes out of the room. She enjoys all the activities, you know. She enjoys the food. She’s talking a lot. She’s walking around, no issue.” (Participant 6)“We’re able to care for people and not get hit.” (Participant 7)
	Effective for complex pain and pain refractory to other opioids	“I feel like sometimes, many residents from my experience only, their pain is more settled when they are on methadone than hydromorphone... In my opinion we have tried those as our first choice, but it didn’t really help them. So when we try, like, methadone, it really helped them.” (Participant 6)
	Improved workload and nurse satisfaction	“I feel very relieved that I don’t have a resident who’s yelling, I don’t have a resident who is calling out.” (Participant 1)“You feel better as a nurse when you know that you’re able to see a result in them that they’re much more comfortable.” (Participant 7)“Because resident, they are maintaining their daily life without complain of pain, right? And then they accept all the cares we provide without refusing or biting, or whatever. Yeah.” (Participant 11)
Preferable side effect profile	No major side effects	“It seems like a safe medication to use.” (Participant 10)“They didn’t really have adverse reactions” (Participant 2)
	Constipation	“When they start them on methadone, they don’t really have like constipation problems and stuff, whereas other strong pain medications could cause them to really, like, severely constipate.” (Participant 6)
	Less drowsiness compared with other analgesics	“The word ‘high’... I didn’t see that, yeah, because it’s a very low dose and it was just giving them the relief of pain, but not really making them so sedated, obtunded.” (Participant 1)
	No SOB/rpiratory suppression	“The sedation, the shortness of breath, or the decreasing like respiratory rate like it just hasn’t been as predominant as something like Dilaudid would be.” (Participant 9)
Pros and cons of administration	Liquid form well tolerated	“When she was dying and not conscious, we were still able to give it to her buccally. So it was actually quite a relief that we were able to keep her pain under control.” (Participant 7)“You just administer it under the tongue and a very low amount, so it absorbs easily and, you know, the possibility of aspiration will be less.” (Participant 1)
	Long-acting formula easier to administer	“It’s nice that it’s still like every 8 hours that we’ve been giving it. So it’s not like you’re giving it like super frequently either.” (Participant 9)
	Concerns about liquid dosing/overdose	“We need two nurses to sign for that medication. It’s just not so convenient for us.” (Participant 5)

Initial hesitancy and the role of education

Several participants were initially unfamiliar with LDM being used for pain management in nursing home settings and were only familiar with methadone in the setting of treating opioid use disorder. Several nurses reported some stigma among the care team surrounding the use of LDM for pain control because of its association with treating opioid use disorder. One nurse stated that this stigma was more prevalent among novice nurses with less education about and experience with methadone. Nurses interviewed from the Hawaii facilities, on average, expressed hesitation prior to administering LDM for the first time. This was mostly because they had never used it before for pain management. This contrasts with most nurses from the British Columbia facilities who reported no initial objections toward giving LDM. This was primarily attributed to receiving educational sessions on LDM for pain control prior to administration, training that nurses in Hawaii did not receive. According to participant 6, “when it [methadone] was introduced there were multiple education sessions done for staff to understand.” When asked about their feelings toward administering LDM, participant 6 says, “I didn’t really feel any different, you know, because it’s just like any other medication.” Some nurses expressed a desire for further education regarding the use of LDM for pain control so they would feel more comfortable administering it. Additionally, two participants (18.2%) from Hawaii were unsure what benefits methadone had over other opioids, which one participant attributed to not having enough experience with methadone, further highlighting the importance of education.

Regardless of whether or not participants expressed initial hesitation, almost all participants had overall positive opinions of LDM after use and an improved impression of LDM over time.

Most participants reported that the family members of their residents were accepting of LDM because it helped ease their loved one’s pain.

Effectiveness of LDM in pain management

Before describing the effect of methadone on their residents, many participants expressed that it is difficult to assess pain in residents with a significant cognitive impairment, which made it hard for them to assess methadone’s analgesic effect. Many participants said they used resident behaviors including agitation, yelling, and grimacing to assess pain. Furthermore, many nurses observed that mobility decreased with untreated pain. Participant 6 reports, “If they’re in pain, they like to stay in bed. They don’t even want to come out of their room.” Participants, therefore, used willingness to participate in activities as another marker of pain control.

Ten of 11 participants (90.9%) agreed that LDM was effective in reducing pain. Many nurses said they felt LDM was effective in reducing pain because they noted an improvement in the behaviors and functioning of their residents. Participant 1 noted “less yelling, less calling out” and reported “I can see in the residents they’re more relaxed, more calm. Occasionally, you can see some smile on the face of the resident.” Other participants noted improved appetite, sleep, ability to walk, and participation in group activities after starting LDM. Some participants reported a reduction in the amount of as-needed pain medications given for breakthrough pain after starting LDM. Participants reported that LDM was especially effective for chronic pain and neuropathic pain, including one resident with a severe case of trigeminal neuralgia who responded very well to LDM.

Many nurses expressed that LDM was good for residents whose pain was refractory to other opioids. Participant 7 states, “Some people, we’ve tried oxycodone, and we tried hydromorphone, and it just doesn’t seem to work for some people. So we try methadone for others.” Some nurses even felt that LDM improved pain, especially chronic pain, better than other opioids.

Some nurses reported that negative resident behaviors harmful to medical staff improved after starting LDM. Participant 4 recalled a resident who had “called me a couple of names and I was a little shocked by that.” After starting LDM, the resident “wasn’t so nasty. He was a little kinder.” Several other nurses reported decreased physical aggression toward staff because of improved pain control. Additionally, some nurses felt that residents were more willing to accept routine care when their pain was well controlled with LDM.

Many nurses reported that it was personally satisfying to see their residents’ pain controlled with LDM. Some nurses even described feelings of emotional distress at not being able to control their resident’s pain, which improved after starting LDM. Additionally, some nurses reported an improvement in their work environment when resident pain was under control with LDM. Participant 1 says, “I feel very relieved that I don’t have a resident who’s yelling, I don’t have a resident calling out.”

Preferable side effect profile

All participants agreed that there were no serious side effects of LDM and generally regarded it as a safe medication to use in nursing home populations. The most commonly reported side effect was constipation. Many nurses felt the constipation caused by LDM was no worse than constipation caused by other opioid analgesics. One nurse even reported less constipation with LDM compared with other opioids.

Some participants noted mild sedation or drowsiness after administration of LDM. However, five participants (45.5%) felt the sedating effect of LDM was less than other analgesics. Only one nurse reported more drowsiness with LDM compared with other opioids.

None of the participants noted respiratory suppression after administration of LDM. Three participants (27.3%) reported lower concern for respiratory suppression with LDM than with other narcotics.

Pros and cons of administration

There were various pros and cons noted about the administration of LDM. Participant 4 shares a sentiment expressed by most participants when they state, “it was quite easy to administer” and “it was easy for the resident to tolerate.”

One commonly cited benefit of LDM was its availability in a liquid form, which made it easy for residents to swallow. This was especially useful for residents with dysphagia or decreased consciousness because the liquid form could be given buccally or sublingually. Participant 1 states, “you just administer it under the tongue and a very low amount, so it absorbs easily and, you know, the possibility of aspiration will be less.”

Nurses also reported that the long-acting property of LDM made it easier to administer than other opioids because the nursing staff did not have to spend as much time administering subsequent doses throughout the day.

However, some participants reported concerns with the liquid form of methadone. Several nurses reported that liquid dosing is more cumbersome for them and takes more time because two nurses have to independently check that the correct dose is drawn as a safety check. The other commonly reported concern was miscalculating the dose given the liquid form comes in various concentrations. Participant 5 recalled one resident who was sent to the hospital and “the hospital misdosed her, and then she had methadone overdose.” No overdoses, however, were reported in the nursing homes where the participants worked.

Discussion

Our study highlights several important findings about the use of LDM for pain management in nursing homes. A key outcome is that over 90% of participants agreed that LDM was effective in reducing pain, even in complex cases where other opioids had been insufficient. This finding aligns with existing studies that demonstrate the effectiveness of LDM in managing pain in medically complex populations.^{13,14,16–18} However, our study also points out that pain assessment in nursing home residents remains challenging, particularly in those with cognitive impairments. Unlike other studies that used quantitative measures, such as a 1-to-10 pain scale, to assess LDM’s effects, our qualitative approach sheds light on the nuanced and multidimensional impact of LDM in this setting.

One of the notable effects of LDM was its apparent improvement in resident behavior. Uncontrolled pain is known to cause agitation and behavioral issues,⁶ and the reduction in these behaviors following LDM administration suggests that better pain control may lead to improved resident behavior, which is consistent with previous studies.^3,24 Moreover, beyond the direct effect of pain relief on behavior, the unique pharmacological properties of methadone itself may also contribute to the observed behavioral improvements. Unlike other opioids, methadone not only acts on mu-opioid receptors but also blocks NMDA receptors and increases serotonin and norepinephrine levels in the synaptic junction.²⁵ This mechanism of action could help explain the marked behavioral improvements seen in residents, as NMDA antagonists like ketamine are known to improve depression,²⁶ and serotonergic antidepressants improve behavioral issues associated with dementia.²⁷ Methadone has even been linked to improvements in mood disorders,²⁸ and a racemic isomer, esmethadone, is currently under investigation as an antidepressant.²⁹ It is, therefore, plausible that LDM may alleviate not only pain but also neuropsychiatric symptoms, leading to overall behavioral improvement. This hypothesis warrants further investigation, as it suggests methadone’s potential therapeutic benefits may extend beyond pain management alone.

Another important finding in this study is the potential for LDM to positively impact nurse satisfaction by improving pain management and resident behavior, thereby reducing stress on nursing staff. Nurses in nursing homes face a high risk of burnout due to the emotional strain and heavy workload of caring for residents with complex needs.^30,31 Although caregiver stress is rarely measured in pain management studies, it is an essential factor to consider given the high turnover rates among nursing home nurses. By improving resident behavior and simplifying care tasks, LDM can help alleviate some of this burden, contributing to a more supportive and manageable work environment.

Importantly, side effects were not a major concern for the nurses, aligning with findings from other studies on LDM. This is particularly encouraging, given that guidelines recommend methadone be prescribed only by experienced physicians due to its complex pharmacokinetics.^7,12 LDM can simplify dosing by bypassing complicated calculations, thereby reducing the risk of overdosing.¹⁸ Although this study was not specifically designed to detect side effects, the fact that nurses—many with substantial experience using LDM—reported no major adverse effects is reassuring.

Additionally, many nurses echoed that methadone was easy to administer, even to residents with significant dysphagia, thanks to its liquid form and sublingual route. Methadone’s long-acting nature, with less frequent dosing, was also seen as a major advantage, alleviating some of the burden on nurses, as medication administration occupies a substantial part of their daily workload.³² However, nurses emphasized the importance of diligence when administering methadone, given its concentrated solution. In the nursing homes we studied in British Columbia, a two-person check system was implemented before administering liquid methadone, ensuring accuracy and preventing dosing errors. This level of diligence may be beneficial in other nursing home settings to mitigate risks and promote patient safety.

As expected, some nurses were initially hesitant to administer methadone. However, this hesitation did not stem from its association with opioid use disorder, but rather from nurses’ limited experience with the drug in a pain management setting. Nurses in British Columbia who had received formal education on methadone use expressed far less hesitation, underscoring the critical role of education in building confidence among nursing staff. Many nurses also reported feeling more comfortable with LDM after observing its effectiveness in controlling pain. Additionally, family hesitancy toward methadone was not a significant concern in this study. Families were primarily focused on ensuring effective pain management for their loved ones, suggesting that clear communication about LDM’s benefits can help ease concerns.

This study has several limitations. First, the small sample size of 11 participants may limit the generalizability of the findings, although thematic saturation was achieved in our analysis. Recruitment challenges, particularly staff turnover in nursing homes post-COVID-19, limited participation. A larger sample or focus groups could have further strengthened the findings, and future research should explore these approaches to enhance generalizability. Additionally, the focus on nursing homes in Hawaii and British Columbia may not fully capture the diverse experiences of nurses in other regions. The retrospective design also introduces the potential for recall bias. We did not measure the effectiveness of analgesia or side effects in objective scales, relying instead on nurses’ attitudes and opinions. While this qualitative approach provided valuable insights into real-world experiences with LDM, prudence should be used when interpreting these findings. Future studies could integrate objective pain measures, such as the Pain Assessment in Advanced Dementia (PAINAD) scale³³ for nonverbal patients, to further evaluate its clinical effectiveness. Lastly, we did not conduct interviews with physicians, as only a few who use LDM regularly were identified, many of whom are authors of this study.

Conclusions and Implications

This study provides important insights into the use of LDM for pain management in nursing homes. The majority of nurses reported that LDM was effective in controlling pain with minimal side effects, even in complex cases where other opioids had failed. Many also noted that LDM improved resident behavior, which, in turn, helped reduce nurse stress. Additionally, LDM’s long-acting nature and ease of administration, particularly for those with dysphagia, contributed to its acceptance by nursing staff. While some nurses initially expressed hesitancy, this was largely due to inexperience rather than concerns about opioid use disorder. Education played a critical role in reducing this hesitation, with many nurses feeling more confident after observing LDM’s positive effects on residents. These findings suggest that LDM could be a valuable tool for managing pain in nursing home residents and warrant further investigation into LDM’s potential benefits and practical applications in the nursing home setting.

Brief Summary

This qualitative study explores nurses’ perspectives on LDM for pain management in nursing homes, highlighting its effectiveness, safety, and potential benefits for improving resident behavior and reducing caregiver stress. The findings suggest that LDM could address unmet needs in managing pain in this vulnerable population.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This article was supported by the Maryland Department of Health’s Cigarette Restitution Fund Program (CH-649-CR), the University of Maryland School of Medicine Program for Research Initiated by Students and Mentors, and the St Paul’s Hospital Foundation Palliative Medicine Research Fund.

Supplementary Material

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