Patients Who Require Ultra-high Opioid Doses
Great controversy exists about chronic non-cancer pain patients who seemingly require very high opioid dosages. Persons and parties who surround these individuals may label them as “addicts” or “abusers,” and some may resent the high cost of high dose opioid treatment.
To compound the controversy, some observers have claimed there is no evidence that opioid doses over 200mg morphine equivalents are effective for non-cancer pain. Recent guidelines have attempted to establish morphine equivalent dosages over 200mg a day as being “high.”1 Such guidelines, however, are not supported by any high-quality published clinical trials but, rather, represent the opinion of their authors.
Despite such claims and guidelines, pain practitioners routinely observe that some chronic pain patients require morphine equivalent doses well above 200mg and may range from 1000mg to as much as 2000mg, or even more, per day. The necessity of high opioid doses has been accepted for years in the treatment of some cancer patients but is considered controversial for non-cancer pain.
This article classifies these patients as users of “ultra-high” opioid doses and makes recommendations on their man-agement. The impetus for this paper is driven not only by clinical needs of the patient but also to clearly and succinctly bring to light these cases so that all concerned parties can better identify, treat, accept and understand the reality of these patients.
Classification of the Patient Who Requires Ultra-high Opioid Doses
Pain specialists understand that there is no maximal safe dose of opioids and that there is wide variation in the dose required to achieve maximal comfort and function in the patient without causing sedation or physical impairment. Dosage can vary 40-fold for the same clinical condition.2 A small minority of patients require massive doses of opioids for chronic pain. We propose classifying opioid doses as follows: A dose of less than 200mg/day of morphine equivalents is a standard or low dose; 201-1,000mg/day is a high dose and over 1,000mg/day of morphine equivalent constitutes an ultra-high dose (see Table 1). Those physicians who choose to treat the ultra-high dose opioid patient should at least recognize that the patient qualifies for this classification and label. In addition, we recommend that all parties use the “ultra-high dose” label to impart to all concerned parties that this is a special patient who requires special management, concerns and understanding. Patients taking ultra-high doses require extra care in ongoing assessment of needs, benefits and monitoring of adherence and safety.
Calculation of Morphine Equivalents
Since many patients are treated with opioids other than morphine and more that one opioid, it’s useful to be able to convert the patient’s medication regimen to its equivalent in milligrams of morphine. Table 2 is provided to simplify the calculation from other opioids to morphine. Be advised that methadone does not have a linear equivalence to morphine and the equivalence table should not be used to convert patients from one opioid to another.
Who Requires Ultra-High Opioid Dosages?
Fundamentally, this is a chronic pain patient who has attempted considerable trials with low and high opioid dosages and continues to have significant pain and diminished quality of life as demonstrated by a bed- or house-bound state and failure to work, eat, sleep, and socially interact—among other activities of daily living. They may also demonstrate some biologic indicators such as elevated pulse and blood pressure related to undertreated pain.3 The physician who treats the patient who requires ultra-high doses of opioids must clearly document in the patient’s chart that trials with low and high dosages have not been adequate to control pain and promote function.
|Class||Criteria by daily
|Low or standard||0 to 200mg|
|High||200 to 1000mg|
In addition to documentation that low and high opioid doses have not been successful, an attempt should be made to determine the presence of some physical, x-ray and/or biochemical evidence that is commonly associated with severe chronic pain.4
Case 1: Patient who was stable on ultra-high doses. Mr. M, aged 67, was referred for ongoing care when he moved from another state. He was born with myelomeningocele and spina bifida and, in young adulthood, twice had surgery because of pain related to a tethered spinal cord. Nonetheless, he had been employed until he suffered a work-related back injury 19 years prior to the first visit. He was seen at several pain clinics and it was determined that additional surgery would not help, so he was begun on opioids. At the time of his first visit, he was on sustained-release morphine, 1200mg/day plus hydromorphone 8mg up to 6 per day for breakthrough pain (total of 1392mg morphine equivalents/ day). He walked using a brace and cane, but did not drive. Mr. M was continued on exactly the same regimen for the 23 months that he was seen at the clinic. His pain varied but was often as low as 4/10. He was compliant and there were no abuse or misuse issues.
Case 2: Patient who required several dosage increases. Mr. D was 47-years-old when he was first seen at this clinic for chronic back pain related to a motor vehicle accident he experienced at age 15. He had recently been seen at a university pain clinic, which recommended that his current medication regimen be continued. This consisted of sustained-release oxycodone (OxyContin®) 320mg tid (equivalent to 1440mg of morphine/day), along with temazepam 30mg qhs for insomnia, celecoxib 400mg/day for pain and inflammation, baclofen 10mg qid for muscle spasm, and fluoxetine 40mg/day for depression. He had already received several courses of epidural and facet injections. He was ambulatory and drove his car. He had recently been accepted for Social Security Disability after a career as a school administrator. He was a divorced single father who was raising his two small children. The patient was continued on the same dose of OxyContin, 960mg/day for the entire time he saw the lead author—83 months (6.9 years)—but, because of increasing pain, he was subsequently also prescribed methadone, as well as hydromorphone for breakthrough pain. During his last 20 months of care at this clinic, he was on a combination of 960mg/day OxyContin, methadone 180mg/day, plus Dilaudid 96mg/day (total of 2004 morphine equivalents/day). He continued to have significant pain, but obtained sufficient relief that he could function. On his last visit, he was still driving and he was still raising his two children. Mr. D was compliant throughout, with no abuse or misuse issues.