Opioid Best Practices Still Evolving, Don’t Address Some Pain Conditions

Prescribers of opioid medication are feeling the pressure as the nation debates ways to address the opioid epidemic. The Centers for Disease Control (CDC) published a guideline for opioid prescribing practices in March 2016 to provide specific recommendations for the treatment of chronic pain, and 10 states have enacted their own guidelines and statutes about opioid prescribing practices. While development of best practices is an important process in responsible patient care, the development of dosage thresholds for prescriber action are also creating questions around patient and provider rights and responsibilities.

Dosage thresholds for opioid medications have been developed using what are known as MED (morphine equivalent dose) levels (also referred to as MME [morphine milligram equivalent] or MEQ [morphine equivalent] levels). These calculations are used to help quantify patient risk factors by creating an apples-to-apples comparison of drug potency across the broad spectrum of opioid medications.

In 2012, Washington introduced the use of an MED dosage threshold to trigger a required action by the prescriber. As of 2016, nine other states had similar prescribing policies regarding opioid dosage thresholds (California, Colorado, Indiana, Maine, New Hampshire, Ohio, Rhode Island, South Carolina and Vermont). These thresholds range from 60 to 120 MED/day and vary by state whether action is recommended or mandatory and what the action is.

The CDC’s guideline, which is nonbinding, recommends prescriptions for the lowest effective dosage possible, careful reassessment of risks and benefits if the dosage goes above 50 MED/day and careful justification of dosages above 90 MED/day. Pain practitioners point to ambiguity about how the “lowest effective dosage” should be determined and how a clinician should create a “careful justification” to go beyond 90 MED/day, which is the most restrictive dosage threshold discussed at the federal level thus far. Experts also note that the guideline is intended solely for opioid naive patients or patients moving from low-dose to high-dose opioid therapy, not for patients whose dosages already exceed such thresholds.

Another concern is that even recommendations are likely to be used by legislators and regulators as the legal standard of care. Such decisions could effectively ban higher doses, even for patients who benefit from higher doses with no significant harm and whose conditions do not respond well to other pain therapies. It is vital that prescribers and patients inform themselves about dosage thresholds in their state to advocate for the best possible outcomes.

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