Dr. Ziegler: States have tried to respond to the opioid overdose epidemic, and one of the more recent innovations has been a focus on dosage thresholds and subsequent triggers. Once a chronic pain patient, for example, reaches 120 mg morphine equivalency per day, it triggers a particular action or recommendation. The concern about these models is that they’ve not been evaluated and that they are very much focused on this idea of preventing overdose, while at the same time there’s another huge epidemic, that of undertreated pain.
Dr. Fudin: It’s been said that patients who are on higher doses of morphine equivalence per day are at higher risk of opiate induced respiratory depression and death. But the truth is that patients who are on very high doses of opioids may be very much sicker and they may be at a higher risk of death for other reasons. It’s really very important that the prescribing is tailored to individual patients. In my mind, to have dose thresholds is maddening because there are no uniformly accepted guidelines to what constitutes morphine equivalent. Also, some patients may be ultra-rapid metabolizers of a drug, some may be poor metabolizers, others are in between. And if we could account for that variability, there still the problem of drug interactions. All these factors are largely, if not completely, ignored by all the states who have these dosing thresholds.
Dr. Ziegler: When it comes to science and politics oftentimes politics trumps science. So when we’re dealing with dosage threshold policies, instead of making mandatory rules, they should be at least advisory guidelines until these models can be evaluated for their efficacy and their impact on pain patients.
Dr. Fudin: Prescribers and pharmacists really should be working together to combat the overdose crisis, For example with respect to in-home naloxone kits, if their state does not allow them to dispense it, pharmacists should notify a physician prescriber that ‘gee, you know your patient has a pretty high risk. I can give them naloxone if you allow me a telephone order to do that.’ And it would be helpful for physicians to get blood levels of some of these opioids that they’re prescribing. In an overdose case, when you’re presented with a toxicology report from a medical examiner, you need to know how that blood level measures up to what the blood level was anti-mortem. One patient may be able to tolerate a level that another can’t, but if you don’t have blood levels to compare against when the patient was alive, that’s a difficult call in court.