Opioid Pain Medication: How much is too much? (part 1)
December 17, 2020How much is too much?
When it comes to opioid pain medication, that is a great question. More importantly, the answer to this question isn’t so black and white. The short answer is that it depends, and truthfully, there is no one size fits all approach. There are things we know and things we don’t about the use of opioid pain medication in the treatment of chronic non cancer pain.
In 2016, the Centers for Disease Control (CDC) looked at the use of opioid pain medication in the treatment of chronic non cancer pain. The CDC had 50 experts looking at nearly 500 scientific articles on the topic. Why was the CDC concerned in the first place? Well, nearly 100 million Americans say they live with chronic non cancer pain everyday. That is nearly 40% of the adult American population. It was thought that 20 million people relied upon opioid pain medication to treat their chronic pain; by contrast, 34 million Americans suffer from diabetes mellitus. The use of opioid pain medication is not trivial especially when you consider that the long term use of this medication often results in tolerance (i.e., increasing ineffectiveness of the medication) and rising doses over time (i.e., dependence). To understand the big picture better, the United States was the most prolific consumer of opioid pain medication in the world by a wide margin, yet we had the most unhealthiest population in the world as measured by the number of citizens suffering with chronic pain. In fact, there was even a greater concern and that was the burgeoning opioid crisis. It was reasonable to think that all of this opioid pain medication was not helping people, but in fact it was actually hurting people who saw their lives destroyed by this medication as they went on to develop opioid use disorder (i.e., addiction).
So in essence what was the CDC studying? It was wondering if all this opioid pain medication was actually doing any good at all. But before we get to that answer, we must first understand the concept of a morphine equivalent. What is a morphine equivalent? All opioid pain medications are compared to morphine, which serves as a standard. So if you are a patient taking hydrocodone 30mg/ day, then your morphine equivalent is 30mg of morphine/ day; it is a 1 to 1 conversion. If you are taking oxycodone 30mg/ day, we use a conversion of 1.5 and get 45 morpines/ day. The concept of morphine equivalents allows one to compare different opioid pain medications (i.e., apples to apples).
So let’s get back to the CDC, and see how they used the morphine equivalent.
According to the CDC guidelines, when doses of opioid medication exceed 50 morphine equivalents/ day but less than 90, there is 2-3 fold increased risk overdose, death and use disorder. For most patients in our practice, they are below that “line in the sand” of 50 morphine equivalents/ day. That is good. Of course, having a patient on a regimen of opioid pain medication that is less than 50 morphine equivalents/ day does not mean we should ignore our risk assessments and monitoring. There are many factors including age, other medications, and other medical conditions that can make the use of opioid pain medication in the treatment of chronic pain fraught with issues. At Specialists in Pain Care, we are not against the use of opioid pain medication in the treatment of chronic pain. To the contrary, we believe there needs to be experts like ourselves who can properly assess, monitor and administer these medications to our patients suffering with chronic pain.
In part 2 of this series, we will further explore the question of “How much is too much?”.
To learn more: go to our OPIOID RISK ASSESSMENT TOOL!
