Not everything that can be counted counts, and not everything that counts can be counted.
~ Albert Einstein (attributed)
In medicine we like to measure.
For example, physicians often ask patients to rate their pain on a scale from zero to ten – despite our knowledge that pain is so uniquely personal that it cannot accurately be measured nor honestly compared to another person’s pain.
In contrast, an opioid pain drug’s strength (potency) can be measured and considered in determining how much of that opioid a patient might safely use.
There are numerous opioid medications (“apples and oranges”) on the market. And comparisons between opioids can become complicated and difficult. Thus for simplicity’s sake, experts recommend comparing all opioid drugs to a standard, i.e., morphine.
Calculating the amount of morphine that would equal the dosage of a patient’s opioid medication allows us to compare “apples to apples.” Furthermore, calculating the amount of morphine needed to equal a patient’s TOTAL daily dose of opioid gives us a value called the “Morphine Equivalent Daily Dose,” or MEDD.
Note: For the sake of this discussion, MEDD will refer to the sum total of opioid medication taken orally in a 24 hour day.
Here’s how it works…
If a patient takes 30 mg of MORPHINE each day, the patient’s Morphine Equivalent Daily Dose (MEDD) would be 30 mg.
Similarly, if a patient takes 30 mg of HYDROCODONE each day, the MEDD would still be 30 mg, because hydrocodone and morphine are generally considered to have equal potency.
Now consider OXYCODONE (which is about one and one-half times more potent than morphine). In this case a mere 20 mg of oxycodone equates to a MEDD of 30 mg.
20 mg x 1.5 = 30 mg
In other words, the patient would need to take 30 mg of morphine to offer the same relief as 20 mg of oxycodone.
There are many formulas, calculations, and tables available online and in texts to help in determining the MEDD such as this one featured in Practical Pain Management:
And to paraphrase Paul Harvey…
You know what the MEDD is.
Now you’re going to hear the rest of the story.
Benefits of high-dose opioids for chronic pain are NOT established.
– Centers for Disease Control and Prevention 03.15.2016
On March 15, 2016 the Centers for Disease Control released its much-anticipated Guideline for Prescribing Opioids for Chronic Pain, drawing heavily upon the MEDD concept (Note: The CDC called it: morphine milligram equivalents per day.).
Below are some major points regarding the MEDD as featured in the CDC Guidelines:
<50 …likely reduces risks
≥50 …increases overdose risk without necessarily adding benefits
If ≥50 …(a) implement additional precautions, (b) increase frequency of follow-up, and (c) consider offering naloxone & overdose prevention education
≥90 …should not be prescribed without careful justification.
If ≥90 and no improvement in pain and function …(a) discuss other approaches to pain management, (b) consider tapering to a lower dosage and/or discontinue, and (c) consider consulting a pain specialist.
>100 …associated with significant risks
According to the CDC and many other experts, the benefits of high-dose opioids for chronic pain are not established. They say that high MEDD is associated with increased risks for serious harms such as: motor vehicle injury, opioid use disorder, and overdose. The CDC advises that despite the anxiety it might produce, patients should be given the opportunity to re-evaluate their use of opioids at high MEDD. However, because of physical and psychological dependence, tapering can be challenging and may need to be done very slowly.
Determining an opioid’s potency and its true Morphine Equivalent Daily Dose is not an exact science. Each person’s body reacts to a drug in a unique way. In medicine we call this “pharmacokinetics and pharmacodynamics.” Nevertheless, more and more experts believe that utilizing a standardized MEDD is a necessary part of the strategy to minimize risks associated with chronic opioid therapy for pain.
The miserable have no other medicine but only hope.
~ William Shakespeare, Measure for Measure
Counterpoint: “The Myth of Morphine Equivalent Daily Dosage”
As a very experienced pain specialist, as well as an addiction specialist, if a patient is finding they are able to do the things they were previously unable to accomplish due to pain, as a result of being on a dose > 90 MEDD, is it your thinking this patient should be titrated down?
This is counterintuitive to me. I don’t know YOUR answer, but am aware of CDC Guidelines and those recommendations as pointed out in this article. If the patient is gaining function, losing weight, and stable on the higher dose, what’s the up side? The patient shows no signs of abusive behavior. No dirty labs, INSPECT report has no inconsistencies, and there’s no history of attempts at early refills nor discrepancies during random pill counts.
Thank you for your advocacy and honesty in the Confluential Truth blog.
Kim, there’s hope! It’s not quite so draconian as one would think. Look at this passage that I copied directly from the CDC guide. By saying “For patients who agree…” the CDC is clearly leaving the option open for maintaining a patient on high dose opioids:
“For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan.”
I think the decision to stay on high dose opioids is complex and requires trust and collaboration between the patient and the prescriber. And it’s also true that sometimes the old adage “If it ain’t broke, don’t fix it” can be the best course of action.
Thank you for your reply, Dr. Murphy. I appreciate your view and am glad to have great doctors still around to see pain patients. Without practices such as yours, many would have no quality of life to speak of.