Monday, June 4, 2012

Do You Know Your MEDs? A Powerful Metric for Opioid Management

MED stands for morphine equivalent dosage.  And you should immediately start using it (if you're not already) to identify and mitigate the potentially harmful effects of chronic opioid use. 

Different formulations of opioids can be compared to one another (and the real extent of opioid therapy can be established) by converting each drug to its morphine equivalent dosage.  Each opioid has an "MED conversion factor" and there are simple calculators available online (the State of Washington's is particularly useful:

The Official Disability Guidelines chapter on pain has a helpful overview for how to interpret the data and keep claimants safe:
"Recommend that dosing not exceed 120 mg oral morphine equivalents per day. Opioids may be recommended as a 2nd or 3rd line treatment at doses ≤ 120 mg daily oral morphine equivalent dose (MED). Risk benefit of use should be evaluated, including that of substance abuse and death. An accurate diagnosis should be established and it is strongly recommended that a psychological evaluation occur before starting this class of drugs. Escalation of doses greater that 120 mg (MED) should be done with caution, and generally under the care of pain specialists, and in certain cases, addiction specialists, with the understanding that many patients who progress to chronic opioid therapy have underlying psychiatric disease and substance abuse issues."

Take a patient on 30 mg of oxycondone, twice a day (60 mg total) and Exalgo (hydromorphone ER) 16 mg twice a day (32 mg total).  The morphine equivalent of the oxycodone is 90 mg per day (MED conversion factor of 1.5) and the morphine equivalent of the hydromorphone is 128 mg per day (MED converstion factor of 4.0).  This leads to a total morphine equivalent dosage of 218 mg per day.  This is a major problem. 

There is significant evidence that suggests the 120 mg MED threshold should be taken very seriously.  One of the clearest pieces of evidence comes from a paper published last December by Gary Franklin and colleagues from Washington State Labor and Industries.  After the introduction of opioid dosing guidelines in 2007, Dr. Franklin and his team measured the impact: "Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses ≥120 md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths."

Pay attention to MEDs and be prepared to identify and intervene on the claimant's behalf if the 120 mg threshold is breached.

On Twitter @PRIUM1

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