Morphine Equivalence: Med + MEDD ≠ Cred

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My shortest blogs ever.  The reason?  I want you to read The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development, a short commentary hot off the press.

To blame deaths on prescribed opioids with ubiquitous emphasis on MEDD is like blaming the ground for a faulty parachute.

Nevertheless, scientists and policy makers have become sheep mindlessly walking off a cliff to the anti-opioid abyss based on the fictitious morphine equivalent daily dose (MEDD), also known to many as morphine equivalent dose (MEQ) or oral morphine equivalent (OMEQ). But alas, a poppy by any other name would smell as sour.

I don’t blame the majority of clinicians who are doing their best to follow [questionable] guidelines while trying to avoid liability and care for patients.  I do blame universities that have largely ignored their obligation to teach pain management to new and seasoned clinicians. I also blame politicians and journalistic sensationalists that respectively are interested in the grandiloquence and ferment surrounding opioid abuse without addressing the real problem. 

What is the real problem? Clinicians simply are ill-prepared and lack the time, energy, and expertise to carefully assess patients for chronic opioid use prior to, during, and following opioid initiation. 

Simply put, federal agencies, scientists, and lawmakers are grasping at straws to assign blame for opioid mishaps and the easiest most convenient scapegoat is the MEDD.  For all those that profess MEDD is the culprit, we have news for you! 

Please read the commentary HERE that I’ve co-authored with Drs. Jacqueline Pratt Cleary and Michael Schatman. I promise you’re in for a treat with NO-HOLDS-BARRED!

And as always, PLEASE share your comments and thoughts here for the world to see after you’ve read it!

 

 

18 thoughts on “Morphine Equivalence: Med + MEDD ≠ Cred

  1. Nice site,
    I have severe pain and has been said by a pain Dr. That it was equal to bone cancer pain, I know a lot of people that had cancer and had very little pain.
    the CDC really has most there ideas completely wrong.
    I wonder how many of these deaths are severe pain patients, my self I know there is 30 days in a month, and if on the 15 th I had extra pain, I will not take one of the balance of my prescription as I know that down the road I will need them, I think most severe pain people do not screw with there meds, it is the ones that are getting it from Dr,s that need these patients for there cash flow, I know a DO that keeps his office open with pushing pain pills, if the dea was doing there job they would pick up on this, but to make it easy for them selves with out a plan , just saying no is there easy way out. If we all could just say no to our responsible so wouldn’t we be in trouble.

  2. If I hadnot routinely traced that burning/ itching allergy to
    skin yeast, I might have gotten into the doctor in-time
    to not be unable to acquire an anti viral that could
    have minimized my suffering.

  3. And….Howard Hoffberg’s commentary/ synopsis should make it into the mainstream. Let’s keep educating clinicians. CDC (March 2016) Guidelines do not mandate dosages but suggest what literature says about them. It is up to US to publish what we know as clinical specialists and make it at least into the contextual database that the CDC cites.
    Deborah Matteliano PhD RN
    Certified Pain Management Specialist

    1. This should make it into the mainstream, Deb….although the media is not particularly interested in the truth, as the truth doesn’t sell press. Perhaps the Constitutions provision of freedom of the press needs to be amended to preclude bias….

      1. Agreed Michael. The press has very little incentive to publish this side of the story because it doesn’t interest politicians or most lay people. Money, deaths, opioid-associated blame, sex, drugs, and r & r is where it’s at.

  4. Jeff – please keep it up! We need rational minds and comments right now. Everyone will be the losers in this crazy battle.

  5. Another GEM from Dr. Fudin! Pain patients are now at the mercy of the zealots and those who are acting unethically and immorally by falsifying the real data.

    One example of patient specific variation that defies explanation by MEDD that I have seen in 2 specific patients over the years when I was in practice. Each person was on high dose traditional opioids but was able to transition to a much lower dose of Darvon (propoxyphene) when it was available. The transition to the lower MEDD was accomplished easily, with no “withdrawal” and with improved pain control and increased participation in daily activities.
    Just saying, it is a complex PATIENT SPECIFIC process.

    1. While it should be a PATIENT SPECIFIC process, Doc, guideline committees have no tolerance (or concern) for outliers. A good example would be the study in the J Women’s Health last year that determined that only 20% of women with chronic pain did well with opioids….and therefore opioids are “bad” medications. What about the 20% who DO benefit!!! No one is suggesting that opioids should be considered a first-line treatment for chronic pain. However, the guideline committees want to strip them from physicians’ armamentaria altogether. John Adams referred to this as tyranny of the majority – and this is what physicians – and of course their patients – are faced at present. Combine that with the invalid science of which Jeff, Jaqueline, and I wrote, it’s not surprising that American pain medicine is deeply embedded in the toilet….

      1. I am just a Pain patient/Advocate for pain meds. Here is my specific issue Fibromyalgia is now and has been for several years at least a decade been described as a wide-spread pain all over the body. So you go through all the intials right getting diagnosed with Fibromyalgia. The day comes after average 2 years later. Our country the United States has pain medication I have not even heard of nor do I want. But I will tell everybody whether you are a Dr. or Pain management specialist, whatever you have been taught in a book great, whatever you have been taught about cancer from real up depth up close, your own first case of cancer and how you treated it according to the book., and now you are face to face with a patient who has Fibromyalgia. Even better a patient who admits being told they have Fibromyalgia and you are there seventh Doctor in 2 years they have scene. Now think back to your cancer patient, did they tell you they saw 7 Doctor’s? No maybe one then you. Most Fibromyalgia patients are given anti-depressants and if like me told for 5 long painful years “it is all in my head” “I’m just depressed”. Here is my take on the whole thing if it is described as a painful disease then why is it up to us to ask you for pain medication that you would give your cancer patient? Is it because it is written for end of life cancer or to get you through cancer? How is the pain I am feeling all over my body different, it’s painful, it is described as painful and who is to be the judge of my pain? I will be honest regular doses do not work for Fibromyalgia patients because it is nerve pain although it is my overall everything, your worst flu day or two has turned into my Ground Hog Day over and over. I am in my 12 year yes I have taken opiates, been off for a couple years now with clonodine and trammadol. Point is I want the hydromorphone 8mgx6 a day that works for me and allows for me to work and provide for my family. I am barely making it through my days, I do and it starts all over, I would take happily the term of an addict if that is what it takes to make me feel useful again. This term Fibromyalgia has only brought me more pain because you won’t say I took an oath to life, you can give me mine back, if I am an addict for a while, so be it, if I should die from an overdose then I do, My reason is simple if I have to keep going on feeling as bad as I do with barely any medication, then please take a knife out and end it, I am not living, I am existing and you can help and you won’t I would rather be an addict to the hydromorphone until there is a pill with the cure, at least an addict can be healed. Please the next time you can be a difference in the life of someone with Fibromyalgia, Would you feel better knowing you could of helped but didn’t, or would you feel better knowing you helped them until they figure out what the disease is. You wanted to be a Doctor to help people who are sick or prevent death as best you could. Please don’t be the last hope to someone in pain, the cancer patient gets medicine to help with pain opiods, Fibromyalgia is a pain disease millions are suffering unnecessarily, and if there is a Lawyer that is ready to go to the Supreme Court if necessary for Opiods to be acessible for patients in pain in doses they know works here is my email brorobbrit@live.com please be determined and any Doctor be a Dr. House, we are counting on you to help us. I’ll go to studies or tests whatever just find a cure or a common ailmant and provide pain relief in double doses for your patients afflicted. How many letters will I get?

    2. AT last, a common sense and ethical approach to a physician treating the patient. Most of the opioid overdoses the politicians and new media hype are not actual patient driven overdoses. They are drug addicts using the doctors with vague complaints of pain, and the historical treatment has been, prescribe some type of opiate pain medicine. BUT because of these types individuals the patients whom depend on needed relief from pain are now suffering as the CDC and our government really do not want to do the research necessary to find a solution, nor do they want to loose the dollars in funding from all the special interests groups that have popped up overnight in their pockets. I am a lung cancer patient, married to a Vietnam Veteran that has numerous conditions, so yes, we know a bit about pain. And yes, believe me the VA is fighting him tooth and nail over his pain medication suddenly. No, he does not drink, doesn’t take any depression medications that would be considered a risk with his 1 opioid medication that he has used for the pain from a crushed lower spine during his service. Has NEVER failed a drug test, either urine nor veinous. Matter of fact, if actually broken down his levels often would not even test at dose equivalent trough levels as he sometimes forgets to change his patch until the day after it is due and his pain worsens to the point of nearly non bearable. My thought process is we need to address mental health in a more prominent light in this country, treat the bigger disease first, then we can REALLY see a reduction in overdose deaths from ALL sources. Thank you for your remarkable contribution to the research and the scary revelation in the flaws of the use of conversion methods.

  6. There is great variability in a person’s response to specific opioid medication based on many factors including their dynamic pain fluctuations, which makes it difficult to measure a human subjective experience for MEDD. The MEDD dose to elicit a reduction of 50% from a pain rating of 10 to 5 may be a different dose for the same patient to elicit a 50% reduction from 6 to 3. If a patient perceives almost complete pain relief with his opioid regimen, then he rapidly may develop opioid induced narcosis, resulting in a “slippery slope” of respiratory suppression, sedation and drug overdose. Therefore, the goal is to provide analgesia for a goal of 30-50% pain reduction, so the respiratory drive remains intact. “Therapeutic opioid tolerance” (defined by Dr. Tennant as prevention of respiratory depression due to CNS dynamic changes in u-opioid binding) may be variable based on gender, habitus, age, genetics, neuroendocrine bias and co-morbidities, and may correlate with the duration of a “steady state” dose (although serum opioid levels do not necessary correlate with analgesic effect). This effect may also vary by the lipophilicity and duration of the actual binding of each unique opioid molecule to the mu, kappa, delta, sigma opioid receptors (some of which are stimulatory) of the brainstem. There are dynamic interactions with all of these opioid receptors in the brain, which allows for theraputic tolerance. The clinical analgesic effect can be a combination of all CNS binding (with other receptors in the spinal cord and cerebral regions) as well as peripheral binding sites (with up-regulation of peripheral receptors with acute noxious stimulation).

    I believe the greatest risk of respiratory depression is actually in those who are currently opioid naive individuals (who have predisposing factors to make them at a higher relative risk for opioid induced respiratory depression) with acute pain that have over-estimated their body’s resiliency and rapidly titrated their regimen, particularly when combined with other sedating medications. Another group of risky patients includes those who are currently opioid “naive” (even for a few days), but had recently been taking higher doses of opioids (they may have actually escalated their dose, and now they have prematurely used up their supply of prescribed medications). They then recieve a refill, and resume their opioids at a their prior “baseline” dose, or with a rapid titration, without waiting for an acclimation effect. These patients may be inadvertently characterized as “opioid tolerant” based on the pharmacy utilization profiles, and they will generally not admit that there was actually a lapse in their use of opioids to explain the circumstances of their “unintentional” opioid overdose.

    1. Yes this is true but what about a locking devise where another pill wont come out for 6 hours say lower side of 3-4 hours would be 3 etc. I have been addicted, I have been called crazy, I think I have been in many situations over the last 12 years and I am pushing my limitations as far as I can and educating others, We still deserve the right for our pain to be treated my scale without any meds is by far a 15 with the non-opiod comes down to a 12 with opiods and double what most require and its been that way my whole life not just since Fibromyalgia. My double dose opiods brings it down to 7 I can function with a bad headache. I really do realize that for some a very small percentage it may cause issues and yes sometimes run out early only because our pain is not always terrible it’s alot of days I don’t want to live anymore and no one is following the worst of it!

  7. Great blog, Dr. Fudiin. Short, sweet, and to the point. There is nothing as painful to the zealots as the truth!!!!!!!!!!!!!!!!!!

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