I like Ohio, especially Cincinnati, Columbus, and Cleveland, the “C’s”. I’m counting on Ohioan public health enthusiasts, patient care advocates, and the academic presence in Ohio to step forward and answer a burning question; Was the Columbus Dispatch article by Alan Johnson specifically intended to be Deceptive, Deceitful, and Dishonest, or in a single word, Duplicitous? In any case, the journal earned a “D” for media sensationalism, withholding or misleading facts, and potentially adversely affecting legitimate patient constituents from receiving opioid therapy by caring, but frightened, clinicians in cases where these drugs are appropriate and safe when prescribed appropriately with proper monitoring. Even patients in pain are often frightened away from these medications and choose pain and punishment over comfort.
In the article entitled Dangerous prescriptions fell in Ohio in 2013, reports show by title alone is deceptive. “Dangerous” drugs include many such as warfarin (blood thinner), anti-inflammatories (NSAIDs such as ibuprofen), anti-cancer drugs (antineoplastics such as the platinols, vincas, anthracyclines. etc.), and many, many more. I will admit that certainly opioids are dangerous if not prescribed carefully and correctly or taken as prescribed, but let’s face it; there are many intentional and unintentional overdose deaths from acetaminophen and antidepressants too.
The article states “There’s fresh evidence that opiate painkillers are slowly losing their stranglehold on Ohio” [Johnson] as though Ohioan’s are winning a war of sorts, and gaining ground against the enemy. It is reminiscent of the famous Franklin D. Roosevelt quote, “We have nothing to fear but fear itself”. Even if the author’s statement were true and there was a war to be won on reducing the number of prescribed opioids; how many battles are lost to uncontrolled pain-related suicides, broken marriages from unbearable pain, psychological demise from depression and inability to work, and endocarditis (infection of the heart) or hepatitis C or death from Ohio’s heroin renaissance? While Ohio lawmakers are smiling and patting themselves on the back, perhaps even more Ohioans are suffering now because of a real “stranglehold” from burgeoning heroin use and synthetic cannabinoids (Spice), Kratom Alkaloids (Mitragynines) or Cathinones (Mephedrone, Methylenedioxypyrovalerone, (MDPV), and Methylone) which have become more popularized as prescription opioids have become less attainable for legitimate and illegitimate purposes. But in general, the public does not keep track of these things, nor are they interested in this less familiar territory or the science behind the street chemistry. “Territory” is the operative word because heroin, Spice, Kratom, and Cathinones have in fact established a less told “stranglehold”. But, these dangerous Schedule I drugs don’t make such sexy media when one considers that 100 million Americans at any given time have chronic pain and most have in fact at least used opioids one time or another for short-term acute injuries or dental/surgical-related pain. The familiarity with opioids is what helps sell these stories.
The Ohio Automated Rx Reporting System, as with other state prescription monitoring systems can be a wonderful much-needed commodity, but it certainly is not the panacea to “…a clear understanding of how vulnerable their patients are to an overdose situation” [Johnson]. What it does do however is to help monitor total opioid dosing and ensure, at least within state boarders, that subversive patients are not doctor-shopping from physician-dealers and multiple pharmacies.
“An Ohioan died every five hours from a drug overdose in 2011, the most-recent year for which statistics are available, according to the Ohio Department of Health. The majority were pill deaths.” [Johnson] What we’re not told here is that more deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. (Centers for Disease Control and Prevention. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Morbidity and Mortality Weekly Report 2008;57(45):1226–8. AND McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of American Medical Association 1993;270:2207–12.) Taking away tobacco won’t likely be a popular political move and would cost this county billions in revenue.
“Key to the new reports is the Morphine Equivalent Daily Dose. If that number is 80 milligrams or higher, which is the equivalent of 11, 5-milligram oxycodone pills per day, it is a red flag that the patient could be at risk for overdose or developing a dangerous addiction to painkillers. The MED Dose represents what the patient is receiving from all medical sources — doctors, dentists and other clinicians.”[Johnson]
Truth be told, morphine is about 30-33% less potent than oxycodone. Why not journalistically be less misleading and say 80mg of a single oral morphine capsule, it is about equivalent to 60mg of a single oxycodone tablet or why not say about 6 oxycodone 10mg tablets daily is equivalent to about 6 morphine 15mg tablets daily. These are more easily comprehendible truths, and put it more in perspective for the reader, but instead [Johnson] chooses to compare a daily morphine dose bundled together against several oxycodone tablets at small milligram strengths. I suspect that has a professional journalist, Johnson knows this better than me.
“In the past, physicians could figure the MED Dose themselves by taking what could be a long list of drugs prescribed to a patient, calculating the morphine equivalent of each, and adding the total to see if the patient was at risk.”[Johnson] Can they Mr. Johnson? Let’s examine that…
Your statement assumes that the morphine equivalent dose (MED) is accurate and the sole reason for opioid risk and death. The truth is that there are no standard acceptable MED’s on which to base Ohio’s or anybody else’s MED. This was one of the FDA stated reasons for denying the recent citizen petition that requested a maximum 100mg per day MED for noncancer pain. In fact, Quantifying Opioid Equivalence Disparities, on this website outlines a study to ascertain the calculation variability among several healthcare providers (including some identified from Ohio) when attempting to convert five different opioids to an equivalent dose of morphine. These preliminary results were presented in a POSTER at the 2013 ASHP Midyear Clinical Meeting in Orlando FL.
A summary of findings include:
- Based on average responses and standard deviations alone, there appears to be signiﬁcant variation in opioid conversions within each professional type
- Comparisons of average morphine equivalent doses between professions appears similar, with the exception of those identifying multiple professions and outliers
- No ofﬁcial method exists that allows each of the ﬁve studied opioids to be accurately converted to another opioid, i.e. morphine
And, an earlier post of preliminary data, The Answer is Morphine 100mg Equivalent – Morphine Jeopardy, showed the same outcomes with a smaller group with huge disparities in MED based on various readily available resourcses. Also, according to Webster and Fine, “Recent evidence suggests that the use of dose conversion ratios published in equianalgesic tables may lead to fatal or near-fatal opioid overdoses.” (Webster L, Fine P. Review and Critique of Opioid Rotation. Pain Medicine 2012; 13: 562-570.)
“This is an example of how powerful a tool this has become for clinicians to take care of their patients,” said Kyle Parker, executive director of the Ohio Board of Pharmacy. He said while some doctors have complained about the reporting process, “it’s hard for them to ignore the bigger issue.”[Johnson] Well, he got that right and Kyle Parker is correct…HARD TO IGNORE THE BIGGER ISSUE! The bigger issue is outlined in yet another recent blog, Opioids, Media Deception, & Heroin: Are We Happy Now?
As always, comments are welcome and encouraged!