An Appeal for a Universal Opioid Metric
Primum non nocere—first, do no harm—is an aphorism attributed to the physicians’ Hippocratic oath. Arguably we as physicians have been harming our patients through our liberal use of opioids to treat non-cancerous pain. The practice of utilizing opioids as a mainstay of chronic pain therapy has many untoward downstream societal effects, which have been well described. As physicians, we have a responsibility to our patients and society to help solve our opioid problem. The Morphine Milligram Equivalents (MME)/day conversion metric is a validated opioid metric utilized in research. The widespread adoption of such a metric in clinical care will help frontline clinicians provide better care and enhance our quality and safety efforts regarding opioid use.
We are in the midst of an unprecedented opioid crisis. More people died from drug overdoses in 2014 than in any year on record. On an average day in the United States according to the Centers for Disease Control and Prevention (CDC), 78 people die from an opioid-related overdose, and 650,000 opioid prescriptions are dispensed. In his letter introducing the Department of Health and Human Service’s “Turn the Tide” campaign, Surgeon General Dr. Vivek Murthy suggests that clinicians “have the unique power to help end this epidemic.” A great first step may be to demand clarity: to define and describe the problem by using a universally agreed-upon metric which objectively records opioid consumption. If “big data in healthcare” is our new mantra than maybe opioid consumption, as rendered by an (MME)/day conversion, is one of our most valuable data points.
The distractions and obligations of computerized data entry, production pressure, and patient satisfaction scores may cause us to lose sight of the poly-opioid therapy that many of our patients receive. I frequently care for patients on more than one opioid medication, varying regimens, and different formulations. I have to ask, “Is that the patch or the pill? 5 mg or 10 mg per tablet? How many times a day?” You get the idea. Frequently these patients have multiple chronic conditions including morbid obesity. Unfortunately, obesity and opioid use can be a deadly combination. We seem so focused on acetaminophen and liver failure when opioid-induced hypopnea/apnea poses a much more immediate threat to life. With the myriad options and formulations of opioid therapy, how can we recognize when a dangerous dose threshold has been exceeded? Should our electronic health record (EHR) help us with clinical decision support? Perhaps there is a body mass index (BMI) x (MME)/day value that should warrant closer observation (e.g., capnography and pulse oximetry)?
Opioid dose conversion tables have been well described and validated in our literature for years.[2,3] Even the Centers for Medicare and Medicaid Services (CMS) produces an Opioid Morphine Equivalent Conversion Factor table. There are over 10 opioid conversion calculators available on the iTunes Application store. Our EHR technologies should be able to automate this conversion based on dispensed medication or patient-reported use and facilitate regular reporting and analyses of trends. For example, our EHR should help us to identify which multimodal strategies are truly “opioid-sparing” and provide an added safety measure by alerting clinicians when opioid use or prescription amounts are excessive.
A universal opioid metric in clinical care creates many new opportunities for research and quality improvement activities. Simply measuring and reporting this metric may provide insight and clarity where none previously existed. This may meet the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Merit-Based Incentive Payment System (MIPS) criteria under “Clinical Practice Improvement Activities.” In addition, for anesthesiologists, this may qualify as engaging in “practice improvement activities” for our Maintenance of Certification in Anesthesiology.
Our engineering friends would tell us that it is hard to define a problem unless you measure it. As physicians on the front lines of our opioid epidemic, can we agree to demand a better way to measure and track opioid use? The good news is that we already have one.
- Quinones, Sam. Dreamland: The True Tale of America's Opiate Epidemic.
- Patanwala AE, Duby J, Waters D, Erstad BL. Opioid conversions in acute care. Ann Pharmacother. 2007 Feb;41(2):255-66.
- Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage. 2009 Sep;38(3):409-17.