Rationale for Medical Management
In the last half decade, the field of pain management has been under tremendous pressure to re-evaluate best practices when it comes to prescribing opioid medications. First came a call to arms to recognize pain as the fifth vital sign and to tackle the under-treatment of pain.1 With improvements in pain management, however, came a rise in a number of adverse effects and outcomes, including unintentional overdose deaths, especially among women.2,3 Studies have shown that the higher the dose of opioid prescribed, the greater the risk of morbidity and mortality associated with the drug regimen.4-6 More recently, many people have come to believe that Medicare’s patient satisfaction surveys may significantly impact opioid abuse. The reimbursement model is based on patient pain scores—an issue that at times seems to overshadow withholding opioids in certain patients that have an elevated medical or mental health risk.7
Many states have established guidelines using daily opioid dosages to “trigger” certain events, such as a referral to a specialist or to revisit the treatment plan in detail. These opioid dosages are usually described in morphine equivalents (MEQ). These doses are also referred to as Morphine Milligram Equivalents (MME; nyc.gov), Morphine Equivalent Daily Dose (MEDD; palliative.org), MED (CMS), or Oral Morphine Equivalent (OME; cpsa.ab.ca) The “trigger” dosage usually ranges from 80 to 120 mg, or in some cases up to 200 mg of morphine equivalents.8
Although the public health benefit of these exact trigger levels may be debatable, they are now a growing reality facing clinicians, pain patients, and pharmacists alike. Washington State was one of the first states to build dosing triggers into their guidelines, and to call for doctors to refer to pain management specialists when daily doses reaches 120 mg MEQ.9 According to the Washington State guidelines, “The hallmark of the guideline is a recommendation to not prescribe more than an average daily MEQ of 120 mg without either the patient demonstrating improvement in function and pain or first obtaining a consultation from a pain management expert.”
The Ohio State Medical Board has also issued new guidelines with a cut-off of 80 mg/d.10 These guidelines use 80 mg MEQ as a “trigger threshold,” requiring the clinician to “press pause” and re-evaluate how to optimize therapy and ensure patient safety. Ohio took this approach in part because the odds of an overdose are significantly higher above that dose. The state also believes that the “pause offers a good opportunity for the prescriber to consider potential adverse effects of long-term opioid therapy.”10
This article offers basic rationale for clinicians when prescribing opioid analgesics above the trigger MEQ.
Rationale for Dosing
There are a number of reasons that patients may require higher doses of analgesics, including disease progression, increased activity, comorbid psychiatric disease, failure of conservative and non-opioid therapy, and under-dosing of opioids. Most experts agree that what drives higher doses in the chronic pain patient is inadequate pain relief and poor functioning. Therefore, the core rationale for opioid dosage escalation above the standard level is based on improving the patient’s pain, quality of life, and functionality while minimizing the adverse effects and clinical manifestations of uncontrolled pain.
Often missing in the debate over opioids is the negative consequences of uncontrolled pain. Uncontrolled pain is detrimental from both a physical and mental standpoint. It impairs many basic and instinctive physiologic functions including sleep, metabolism, intellectual processing, and hormonal balance. It impairs muscular movement, which additionally interferes with activities of daily living. This may be manifested by immobility, reclusiveness, and inability to dress, work, or care for family. Each of these adverse effects should be queried or elicited during a comprehensive patient history.
Uncontrolled pain causes hyperarousal of the sympathetic nervous and endocrine systems, which may lead to hypertension, tachycardia, hyperhidrosis, vasoconstriction, and the metabolic consequences of excessive cortisol release. In the author’s experience (FT), uncontrolled pain may elevate (and can later deplete) serum hormone levels such as corticotropin (ACTH), cortisol, and pregnenolone.11
A patient who requires higher doses of opioids may have been seen by multiple physicians and have undergone a battery of tests. Unfortunately, it is these authors’ experience that all too often patients will describe their experience with these clinicians as suboptimal, with little to no physical examination performed (“…they never even touched me…”). However, a physical, hands-on examination cannot be skipped.
The physical examination of patients with intractable pain will usually reveal abnormalities consistent with neurological or musculoskeletal dysfunction. Included in this hands-on examination should be an assessment for muscle guarding or muscular spasms, joint contractions, and especially for neurological deficits including sensory (thermal or pinprick) hypo- or hyperesthesia, motor/muscle weakness, hyperreflexia (including assessment for positive clonus and Hoffman’s reflux), fine motor coordination, memory and even cranial nerve function.
Chronic, non-operable, spinal pain disorders are probably the most common conditions that require high-dose opioids.12 Arthritic and myofascial conditions, neuropathic pain, and headaches are other common causes. These conditions are almost always associated with inflammation and neurologic impairment. From a musculoskeletal standpoint, contractures and hypertrophy of joints may occur with potential physical deformities, asymmetry of musculature, leaning, scoliosis, impaired gait, and limitations of limb extension. Other than hyperalgesia, some central pain conditions such as fibromyalgia, migraine, phantom limb pain, and traumatic brain injury may show few, if any, physical signs except those caused by excess sympathetic discharge.
Clinicians should document in the medical record the trials and exact causes of failure or contraindication of non-opioid therapies (tolerability, adverse events, comorbid hepatic/renal issues, bleeding risk, etc), especially in the face of progressively escalating doses of opioids.
Unfortunately, even our greatest scientists have not developed an objective pain assessment tool (ie, a “painometer”). Diagnostic testing may not have a direct correlation with pain severity, but can help support a rationale for using higher daily opioid dosages. X-ray, MRI, and electro-diagnostic assessments establish that a pathologic disease process is present and potentially the cause of severe pain. Inflammatory markers, such as the erythrocyte sedimentation rate and C-reactive protein, document that an inflammatory process is present.13