Bulletin: Heroin and Fentanyl Dealers are Ignoring Morphine Sulfate Equivalent (MSE) Limits and Offering Ultra High Dose Unit Opioids in the Sale of Their Products
For some, this week is a time of self-reflection and repentance for sins or mistakes one has made over the past year. In the spirit of this reflection, Dr. Morty Fein and I teamed up to bring you this blog post. The general theme here reflects on MSE, because at its core, the concept is flawed and we are hurting honest people by employing policies based on pseudoscience and flawed data.
The hurt caused to chronic pain patients requiring long-term opioids is something upon which PROPagandists, lawmakers and third payer policy makers should reflect. The glaring imperfections of MSEs are outlined in the Academy of Integrative Pain Management’s White Paper posted on their website just this month, entitled Opioid Dosing Policy:Pharmacological Considerations Regarding Equianalgesic Dosing.
And now, PROPaganda is taking a page from former NY mayor Mike Bloomberg’s roundly criticized policy attempting to place limits on the size of soft drinks, a policy that got everyone riled up about the “nanny state.” Heaven forbid anyone try to help people limit their self-destructive behavior this way. They will all just buy multiple drinks people argued. And how dare Bloomberg tell me how much sugar I can ingest at one sitting, through one straw, from one barrel?
The anti-opioid lobby have defined a new target – ultra high dose unit opioids (UHDUOs) – and they have petitioned FDA for the removal from the market. MSE limits, “pill” limits, duration limits are not enough for them. Their next PROPosterous PROPosal is for people with cancer or those being treated for severe pain by a pain expert (and therein not allegedly subject to CDC guidelines and other artificial and unscientific limits imposed by the payors and some states) to take mouthfuls of tablets or capsules from their oversized prescription bottles that have even more dose units for sale or use by their kids. The Bloomberg analogy breaks down here because those patients who need higher strength dose units are not being self-destructive they are simply taking their medicine. With upwards of a quarter of people with pain in one survey endorsing problems with swallowing their medicine, this seems cruel and unusual to make them take twice as many and more pills or capsules.
Limit upon limit upon limit upon limit. They are a broken record. Prescribing is down 15-20% and yet the death toll keeps rising. And everyone acknowledges that the abusers have moved on to heroin and illicit fentanyl in any case which is why our policies are failing. But let’s keep searching for our lost keys on the side of the block where the light is better even though we lost them on the dark side of the street.
WAIT. I HAVE A BRILLIANT IDEA.
Let’s subject heroin and illicit fentanyl dealers to MSE limits. And let’s eliminate their UHDUOs. We can have a campaign, Kudos for the elimination of your UHDUOs. While we nickel and dime people with pain, heroin dealers are offering the world limitless access and you don’t even need to deal with some insurance company bureaucrat to get what you need. You do need to pay cash though and break the law and take your life in your hands but hey that’s not as bad as a prior auth. Or being humiliated at your pharmacy or dealing with your burned out, surly healthcare provider.
We can’t even calculate the MSE limits for the average illicit fentanyl product laced with impurities such as bootleg carfentanil and we know that doses of carfentanil alone must exceed limits because they can be used to thwart a Chechen terroist attack. Heroin on the other hand we can calculate, because pure heroin (unlaced) is diacetyl-morphine which in essence is two morphine molecules on either side of a 2-carbon chain (an acetyl group). That acetyl group is similar to what we all know as vinegar. A typical snorted or injected dose of heroin ranges from 5-20mgs and injectors use on average about 4 times per day. A habit of 5-20mgs four times daily means a total daily dose of 20-80mgs per day for an MSE of 40mgs to 160mgs MSEs. Thereby, many not even very heavy users are able to use at a dose that exceeds the top of most states’ MSE levels but of course your friendly neighborhood dealer won’t stop there.
It is time to move towards clinically sound solutions to prescription opioid abuse, diversion and overdose that don’t continue to attempt to solve the problem of heroin and illicit fentanyl abuse by further penalizing if not torturing law abiding citizens with chronic pain. More adequate reimbursement for clinician time and the use of reimbursed tools such as urine drug monitoring and the time it takes to understand trends and results of prescription drug monitoring program (PDMP), and sensible policies that allow safer and faster access to the potentially safest products and even the removal of MSE ceilings for drugs to which they don’t apply, would be a start.
But it sure would be nice to get focused on the problem as it exists now as compared to a few years ago. Bloomberg was just trying to protect us from ourselves; pain patients don’t need PROP to be their nanny.
As always, comments are welcome!
References (for heroin):
- Kaiko RF, Wallenstein SL, Rogers A, et al. Relative analgesic potency of intramuscular heroin and morphine in cancer patients with postoperative pain and chronic pain due to cancer. NIDA Res Monogr. 1981 Feb;34:213-9.
- Reichele CW, Smith GM, Gravenstein JS, et al. Comparative analgesic potency of heroin and morphine in postoperative patients. J Pharmacol Exp Ther. 1962 Apr;136:43-6. N Engl J Med. 1981 Jun 18;304(25):1501-5.
- Kaiko RF, Wallenstein SL, Rogers AG, et al. Analgesic and mood effects of heroin and morphine in cancer patients with postoperative pain. N Engl J Med. 1981 Jun 18;304(25):1501-5.