Letters to The Editor
Opioid Calculator Validation
Has your opioid calculator tool been validated in any published peer reviewed journals? I would like to reference it as being utilized by researchers in their study.
Thank you for this important inquiry. There is a considerable amount of literature that discusses disparities in opioid conversion calculations, but to my knowledge, nothing that has “validated” any conversion schematic. The advantages of the Practical Pain Management (PPM) Opioid Conversion calculator compared to others were published in PPM’s journal.1 Shaw and Fudin studied the differences among several online opioid conversion calculators and compared the variability in opioid conversions among them.2 This publication did include the PPM calculator. Of important note to your inquiry, the PPM calculator does base most of the calculations on generally acceptable opioid equivalence tables that have been adopted as American Pain Society guidelines.3,4 The exceptions are for single conversions for opioid-naïve patients and the methadone conversions which rely on the Fudin Factor.5 The reasons for these exceptions are outlined in the Shaw study.2
It would be difficult to validate and quantify any particular opioid conversion schematic using any conversion tables or opioid conversions calculators because there is no universally accepted conversion; however, most pain clinicians do agree on a range of equivalents. There is an ongoing project to help quantify the disparity among various clinicians in making these conversions, and I would encourage our readers to participate so that we can ultimately learn which equivalents are most universally employed among practicing clinicians and ascertain to what extent quantitative differences exist.6 To participate, please go to PracticalPainManagement.com and follow the instructions.
—Jeffrey Fudin, BS, PharmD, FCCP
DEA Practicing Medicine
I found the letter from Dr. Postnikoff interesting and unfortunately true.7 Just recently I received a call from a pharmacist who had just had a visit from the Drug Enforcement Agency (DEA). Two issues came up that were scary. One was the DEA’s position on methadone. They said that I should not be prescribing more than 80 mg per day of methadone for chronic pain. Second, all chronic pain patients, once stable, then need to be weaned down on their daily regimen no matter how they are doing.
Since when did the DEA get a license to practice medicine? I thought the DEA was supposed to be concerned with the illegitimate use of opiates, not how they are used if the patient has a legitimate need for the medication. After my initial anger began to wane, I began to think about how our relationship with the DEA is an antagonistic one instead of a partnership. I would like to know what other pain practitioners think about this concept.
Dear Dr. April,
At this time in history, there are certainly some animosities between some physicians and DEA. This is understandable when one realizes that the DEA is responsible for monitoring the flow of controlled substances and deciding whether to issue or revoke registrations from, or even recommend the prosecution of, clinicians who prescribe these drugs. True criminal conduct by a prescriber is fairly easy to spot. He or she does not evaluate and prescribe in good faith, in a manner that reflects real medical practice with documentation of bona fide relationships with patients, pharmacists, and other clinicians. For the most part, DEA personnel lack medical training and only know what they learn in a conference or from the clinicians the agency uses as experts.When physicians like you hear comments about “methadone limitations” and “all patients need to be weaned down,” a certain amount of confusion and fear is natural. DEA has made clear that its role is not to tell clinicians how to practice medicine and does not have any policy on dosage or chronicity of prescribing for controlled substances. Thus, if a DEA agent truly made these comments in his/her official capacity, then he/she is acting inappropriately and this conduct may be reported to DEA officials.
I would encourage you to speak or write a "Dear DEA letter" about any concerns you have regarding the comments made to you by the pharmacist about the methadone and patient weaning issues.
We know that many physician groups around the country meet on a fairly regular basis with local DEA representatives, and this is progress. It is as important for us to help DEA minimize the potential for abuse and diversion as it is for DEA to minimize the potential for interfering with rightful access to medications. In the end, we all need to commit to speaking a common language.
I also believe that a physician who is going to regularly prescribe Schedule II opioids needs to be ready to justify his or her practice.
and Jennifer Bolen, JD