• Morphine Equivalent Dose: Ohio’s New Tool against Prescription Drug Abuse
  • November 13, 2013 | Author: Daniel S. Zinsmaster
  • Law Firm: Dinsmore & Shohl LLP - Columbus Office
  • The Ohio Boards of Medicine, Pharmacy, Dentistry, and Nursing have adopted new guidelines pertaining to prescribing opioid medication. The guidelines are part of Ohio’s continuing effort to combat and reduce prescription drug abuse and diversion, and intended to further caution health care practitioners when prescribing high levels of painkillers for long-term use. Based on this objective, these agencies will be encouraging Ohio physicians and health practitioners to utilize Morphine Equivalent Dosing (“MED”) to evaluate or reevaluate the efficacy and safety of a patient’s treatment plan when it involves opioids.

    MED is a system to equate different opioids and their varying potencies into a standard morphine equivalent value by way of a conversion chart created by the Centers for Disease Control (“CDC”). Under the notion that a patient’s odds of overdosing or abuse increase dramatically when a patient reaches a daily level of 80 milligrams MED, these guidelines establish that when a patient reaches such a level the prescriber should “press pause” and reevaluate the effectiveness and safety of the patient’s pain management plan.

    The guidelines are designed to complement the medical judgment of the health care practitioner. Thus, there is an important distinction to highlight between the MED guidelines and the State Medical Board of Ohio’s rules regarding the treatment of intractable pain (Ohio Administrative Code 4731-21). The administrative rules create compulsory practice standards for managing a patient’s non-curable and persistent pain with prescription drugs when the course of treatment exceeds of twelve (12) continuous weeks. Even when a proper diagnosis of chronic and/or intractable pain has been established, providers should first consider non-pharmacologic and non-opioid therapies.

    How does it work? Using the CDC conversion chart, each active opiate prescription will have a daily MED value, which is then combined with other prescribed opioids into one cumulative value. Opioids, like all controlled substances, are reported to Ohio’s Automated RX Reporting System, or OARRS, which is operated and maintained by the Ohio Board of Pharmacy. The MED data is available on OARRS patient prescription profiles, including a section for “Active Cumulative Morphine Equivalent.” The Active Cumulative Morphine Equivalent corresponds to the amount of opiate prescription medications, converted to a common unit based on the CDC’s conversion formula, which the patient currently has access to based on the prescriptions that have been reported to OARRS at the time the OARRS report was run. Further, there is an “Active” column on OARRS reports, displaying which prescriptions are currently active and therefore included in the calculation of the Active Cumulative Morphine Equivalent.

    The State Medical Board of Ohio has provided instruction to physicians treating chronic pain patients with opioids at a level of 80 mg MED or greater for three months:

    • Reestablish informed consent with the patient so that the patient understands the potential adverse effects of long-term therapy with opioids.

    • Review and document improvements to the patient’s functional status, including what the Medical Board has coined the “4 A’s” of chronic pain treatment:

      • Activities of daily living;

      • Adverse effects;

      • Analgesia; and

      • Aberrant behavior.

    • Review and document progress toward treatment goals and objectives, which should be individualized for each and every patient.

    • Review OARRS data for patient compliance and/or indications of aberrant behavior. Please note Medical Board rules require an annual review of OARRS when a patient is receiving controlled substances for a period in excess of twelve (12) consecutive weeks.

    • Consider a pain treatment contract or modification of an existing agreement where appropriate.

    • Reassess whether to refer the patient to a specialist for further examination of the area, system, or organ of the body seeming to be the source of the patient’s pain.

    The guidelines do not preclude or prohibit a physician from issuing or filling prescriptions for opioids if a patient’s MED value is greater than 80. Rather, the guidelines serve as a strong reminder that Ohio physicians must practice in accordance with standards of care, which includes appropriate prescribing practices.