Is there Maximum Daily Morphine Equivalent?

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Converting to daily morphine equivalents is not elementary.  Inaccurate opioid conversions can place patients at increased risk of underdose or overdose.  A recent petition to the Food and Drug Administration (FDA) filed in July 2012 requesting that the FDA change labeling on opioid analgesics to restrict daily dosing for non-cancer pain to a maximum of 100mg morphine or its equivalent was rejected due to lack of validated data to support a single conversion strategy.

In consideration of these issues, a survey has been created to analyze the variability among various clinician types (physicians, pharmacists, physician assistants, and nurse practitioners) in their calculations for five preselected opioids at fixed doses. The primary hypothesis is that there will be a statistically significant difference in average responses and ranges to these requested conversions. This was demonstrated on a small sample size of pharmacy interns from the Albany College of Pharmacy & Health Sciences.

We invite and encourage you to participate in this quest in which you will remain anonymous, to determine disparity and variability in opioid conversions among clinicians. Please help to dispel the myth that “all opioids are converted equally” and can easily be attributable to a “daily morphine equivalent” by clicking https://www.surveymonkey.com/s/BRTG7J7.

This project is being conducted in collaboration with the Albany College of Pharmacy & Health Sciences, University of Maryland School of Pharmacy, and Pharmacy Residents from the Stratton VA Medical Center in Albany NY.

This project is developed by Doctors Amanda Rennick (PGY1 Resident), Timothy John Atkinson (PGY2 Resident), and Nina Comino (PGY2 Resident) under the direction of Doctors Jeffrey Fudin and Mary Lynn McPherson.

 

6 thoughts on “Is there Maximum Daily Morphine Equivalent?

  1. The idiots in GOV, to include Gov MD’s have destroyed the doctor patient relationship. I recall when pain clinics did not exist. I damn sure would not volunteer for Special Forces these days and volunteer for SOG. I would not risk injury for this country as my pain from GSW’s and a back injury has been cut to almost nothing.” Opioids are not Killing Vets! It is the 250-350 MG a day of SSRI’s added to them.

  2. I need help…cut down to from an Mme of 500 to 180 in TN, 3failed back surgeries, severe nerve damage etc, been battling 30 yrs…I have now no quality of life ..bedridden… it may not be medically terminal.. but is as far as im concerned… What can I do…

  3. One factor as a cancer patient with long term chronic pain controls by 3-4 Hydrocodone tablets, is that the long term use tends to limit both any euphoric and actual pain relief efficacy… which seems not be calculated into this MME calculations.

  4. Attention all Hoosiers:

    Here are the sections in the “Emergency” Indiana pain regulations, pertaining to morphine equivalent dosing. These regulations go into effect on December 15, 2013.

    The entire document can be accessed at: http://www.in.gov/pla/2832.htm

    Thanks Jeff for all that you do. This saga has many more chapters to be written.

    @jamespmurphymd

    SECTION 2.

    (d) “Morphine Equivalent Dose” means a conversion of various opioids to a standardized dose of morphine by the use of accepted conversion tables.

    SECTION 3
    (c) The requirements in the SECTIONS identified in subsection (a) only apply if a patient has been prescribed:
    (1) more than sixty (60) opioid-containing pills a month; or
    (2) a morphine equivalent dose of more than fifteen (15) milligrams per day; for more than three (3) consecutive months.

    SECTION 9. When a patient’s opioid dose reaches a morphine equivalent dose of more than sixty (60) milligrams per day, a face-to-face review of the treatment plan and patient evaluation must be scheduled, including consideration of referral to a specialist. If the physician elects to continue providing opioid therapy at a morphine equivalent dose of more than sixty (60) milligrams per day, the physician must develop a revised assessment and plan for ongoing treatment. The revised assessment and plan must be documented in the patient’s chart, including an assessment of increased risk for adverse outcomes, including death, if the physician elects to provide ongoing opioid treatment.

    1. Thank you for this information Pat. It is quite interesting how different states have different cut-offs for what constitutes “high” or “moderate” dose morphine equivalents; based on those cut-offs there are variable directives for what needs to happen next (pain consult, face-to-face with PCP, etc.); most sates do not provide an equivalency chart, but those that do are not universally accepted buy any medical community. I do believe that in most instances the state regulatory agencies are trying to do the right thing for patient safety, however without a consensus that validates these restrictions, it is as, or more problematic than the drugs themselves. You are indeed correct, “This saga has many more chapters to be written.”

  5. Too many “regulations” rely on the ethereal “morphine equivalent” when mandating parameters. This can be dangerous. In the first decade of this century the U.S. saw a disproportionate rise in methadone related deaths. This was in in large part due to faulty conversion tables:

    “A chief reason, the panel concluded, is that conversion tables — used by physicians to transition patients from one opioid to another — recommend too much methadone for most patients.”

    ref: http://www.medscape.com/viewarticle/716603

    Thank you for your important work on this problem.

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