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Justification of Morphine Equivalent Opioid Dosage Above 90 mg

One team’s rationale for justifying prescribing higher dosages of opioids.
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It is recognized that some patients with severe chronic pain require opioid dosages over 90 morphine milligram equivalents (MME) a day.1 The Centers for Disease Control and Prevention (CDC) has stated in its opioid prescribing guidelines that physicians should evaluate and carefully justify the rationale for prescribing above this level.2 California, where we practice, also has written guidelines that require justification for a daily opioid dosage above 80 MME.

The CDC guidelines relate to adults with noncancer pain and those who are not receiving palliative or end-of-life care. The guidelines are intended for use by clinicians evaluating new “opioid-naïve” patients and for non-pain specialists using chronic opioid therapy to treat patients in pain, including those who already take an opioid dosage above the 90 MME. The CDC defines chronic pain as 3 months or more of persistent pain or pain past the time of normal healing in an outpatient setting.

We are independent medical practitioners who dedicate a portion of our time to the management of intractable pain patients. We have formed a network of physicians and regularly meet to review cases and improve our procedures and protocols to better care for these difficult patients. At this time, we have not found any instructions from federal or state agencies on how a physician should justify a daily opioid dosage above 80 to 90 MME, so we have developed an evaluation protocol to provide such justification. This article provides details about our protocol.

Editor’s Note: the protocol presented here represents the authors’ opinions, and not necessarily those of PPM or the publisher. No prospective study has been carried out to evaluate the risk of patients who are screened using this tool. Future investigation, therefore, is warranted.

Protocol

Patients evaluated using our protocol are patients with intractable pain who have failed multiple nonopioid measures and have been titrated up to an opioid dosage greater than 90 MME prior to referral to our practice (Table 1).

The basics of the evaluation consist of history, physical examination, determination of family involvement (defined here as a close family member(s) who is knowledgeable and participating in the ongoing care process), serum testing for inflammatory markers and hormone abnormalities, and review of medical records and diagnostic tests, including magnetic resonance imaging (MRI), x-rays, etc. Some initial risk assessment for abuse of opioids and other medications is recommended. We use the Opioid Risk Tool (ORT), CAGE questionnaire on alcohol use, and SOAPP (Screener and Opioid Assessment for Patients with Pain) scales.

We consider there to be selected pain patients who can’t be treated with opioids, regardless of dosage. These include people with opioid-use disorder, patients who can’t or won’t provide medical records that document past treatments, and patients who have psychiatric disease, including anxiety, depression, and bipolar disorder, who are unable to mentally process medical instruction, safely protect medication, and provide self-care. We do not consider mental impairments to be an absolute contradiction to opioid therapy, but we do require a caretaker, such as a nurse or trusted family member, to control, protect, and administer medication in such cases.

Intrinsic to our evaluation is the determination of medical necessity for high-dose opioids to prevent the complications of severe, undertreated pain. In addition, communication between clinicians and patients is vital, especially to convey information about the risks and benefits of opioid therapy and ensure an understanding of the goals of therapy—including improving the patient’s quality of life and functioning.

Patient Record

We recommend that a summary form be used to compile the reasons supporting the decision to exceed 90 MME (Table 2). The reasons and rationale for exceeding 90 MME are multiple, and they should be compiled as a compendium that can be placed in the patient’s chart and submitted to concerned parties, including regulators and third-party payors, as needed. Every component listed on our example summary form need not be present to justify a 90 MME.

Physical Examination

All the major underlying causes of pain severe enough to require a high dosage of opioids will exhibit some physical signs. Diseases such as arachnoiditis, reflex sympathetic dystrophy/chronic regional pain syndrome, and genetic connective tissue disease will show structural anatomic damage and/or physiologic impairment of nerves, muscle, bones, tendons, or joints.3

MRI is necessary to diagnose adhesive arachnoiditis in the lumbar spine.4 MRIs also will show a variety of other pathologic painful abnormalities that may be present in and around the spine. Plain x-rays still may be useful, particularly for joint and spine abnormalities in genetic and metabolic diseases such as kyphoscoliosis, sickle cell anemia, Ehlers-Danlos, and Marfan syndrome. Intestinal x-rays may be necessary to diagnose painful abdominal and pelvic conditions such as Crohn’s disease, intestinal obstruction, and abdominal or pelvic adhesions. A variety of electrodiagnostic tests are available to complement the electroencephalogram and electromyogram.5 These provide evidence of abnormal nerve conduction due to injury or disease.

Severe, chronic, painful diseases also may manifest in abnormal reflexes, posture, balance, ambulation, and extremity range of motion. If structural damage is grossly evident, we recommend taking a photograph for the patient’s record.

Since the patient is on an opioid and most likely other medications, an assessment of alertness, vision, speech, and mental acuity is necessary to document drug tolerance and ability to safely ambulate and, perhaps, operate a motor vehicle. Mental capability must be assessed as part of the physical examination.

If a patient’s pain is not adequately controlled, he or she will likely show some evidence of excess sympathetic discharge. Physical signs of excess sympathetic discharge include hypertension, tachycardia, mydriasis, hyperhidrosis, hyperreflexia, and cold hands and feet due to vasoconstriction.

Last updated on: August 16, 2017
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