PHARMACIST STEVE

All the alphabetic federal entities that are coming after the chronic pain community…  Backin the mid-80s – thru mid90’s our community pharmacy did a fair number of opiate IV on end stage cancer pts at home.  What is now known as MME’s were around, but I don’t remember them being referred to a MME, but everyone knew that they were not workable – black & white conversions. Back then, there was no computer to calculate them for you…

‘back in the day” the rule of thumb rotating a pt from one opiate to another… was take the mgs using the opiate conversion answer and CUT IT IN HALF and then titrate the pts meds up or down to optimize their pain management..

The entire CDC guidelines and just about anything dealing with pain management is built on the FOUNDATION OF MME’s.

To the best of my knowledge, the MME’s were determined by naive people with mechanically induced pain (heat or cold) and given a SINGLE DOSE of a particular opiate.  This was before our DNA had been mapped and years before the liver CYP-450 was even “discovered” and no one could even believe to create a accurate MME’s without knowing the pt’s CYP-450 liver enzyme metabolism rate and those didn’t come around until the late 90’s or early 2000’s.

Here is one of those MME conversion program that use as a reference on occasion  https://globalrph.com/medcalcs/opioid-pain-management-converter-advanced/ and here are the footnotes on this same program:

1. 1. Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. 
   2. Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids.
   3. The amount of residual drug in the patient’s system must be accounted for. Example: fentanyl will continue to be released from the skin 12 to 36 hours after removal of the patch. Residual effects from discontinued long-acting formulations should also be assessed before converting a patient to a new opioid.
   4. Review the concept of incomplete cross-tolerance: D. McAuley:   “Incomplete cross-tolerance relates to tolerance to a currently administered opiate that does not extend completely to other opioids. This will tend to lower the required dose of the second opioid. This incomplete cross-tolerance exists between all of the opioids and the estimated difference between any two opiates could vary widely. This points out the inherent dangers of using an equianalgesic table and the importance of viewing the tabulated data as approximations. Many experts recommend – depending on age and prior side effects – reducing the dose of the new opiate by 33 to 50 percent to account for this incomplete cross-tolerance. (Example: a patient is receiving 200mg of oral morphine daily (chronic dosing), however, because of side effects a switch is made to oral hydromorphone 25 – 35mg daily – (this represents a 33 to 50 percent reduction in dose compared to the calculated 50mg conversion dose produced via the equianalgesic calculator). This new regimen can then be re-titrated to patient response. In all cases, repeated comprehensive assessments of pain are necessary in order to successfully control the pain while minimizing side-effects.”

      5. The use of high but ineffective doses of a previous opioid may result in overestimation of the converted opioid. 

      6. Ideally, methadone conversions (especially patients who were previously receiving high doses of an opioid) should only be attempted in cooperation with a pain specialist or a specialist in palliative medicine. 

The authors make no claims of the accuracy of the information contained herein; and these suggested doses and/or guidelines are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this document shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user’s use of or reliance upon this material.    PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.  

I have tried to find some information about the person(s) or studies behind the MME’s concept, but have come up empty handed.  What would happen if the community could raise some money and challenge the CDC in court to produce the documentation of the studies behind the MME conversion ratios?  Might be able to get it with a simple FOIA ( Freedom of Information Act) request.

What would happen if the CDC could not produce a quality study to support the conversion ratios in all of opiates that they have used in the 2016 guidelines and the proposed 2022 guidelines. Could the validity of those very guidelines be put in jeopardy. Could the CDC be forced to rescind those guidelines..  Could that also mean that any other rules/regulations/policies and procedures would have to be made null & void.. until someone did a good quality study to develop workable MME conversions.

Could all those docs who have been put in prison for prescribing above a certain MME that the DEA considers above a certain limit and considers being without valid medical necessity be appealed and most likely overturned and they could be set free?

I am only posting this here on my blog, feel free to share….  just don’t try to share a hyperlink to anywhere on FAKE BOOK…  they have labeled my blog as a SPAMMER. 

 

Filed under: General Problems