Community Oriented Primary Care
Policy Number: 16.XX
4/16/2011
Mechanism of annual review: Doses of opioids exceeding 400
mg per day of morphine equivalents or methadone exceeding
100 mg per day in the treatment of chronic non-malignant pain
1.
Purpose:
The purpose of this policy and procedure is to define minimum standards
for monitoring, responding to and documenting high doses of opioids used
in the setting of chronic non-malignant pain management with controlled
substances in the Community Health Network (CHN) Community Oriented
Primary Care (COPC) clinics.
2.
Statement of Policy:
It is the policy of the COPC that all providers/clinics follow a uniform
approach to monitoring for and responding to high doses of opioids used
in the setting of chronic non-malignant pain management with controlled
substances.
3.
Rationale
A. Background and Purpose
There is growing concern both locally and across the country about
increasing morbidity and mortality due to overdose from prescription
opioids. The COPC PCQI Pain Task Force was asked to address whether
there should be specific primary care policy that addresses the risk for
overdose from prescribed opioids. More specifically, given some evidence
that suggests a link between high doses of opioids and overdose deaths,
the group was asked to make a recommendation about whether there
should be an actual opioid dosage “cap” within primary care for the
treatment of chronic, non-malignant pain.
The risks and benefits of high dose opioids are not well studied. Upon
review of the available literature and discussion with local experts, the
Task Force does not recommend an across the board opioid dosage cap.
B. Required Procedure
Each COPC health center is required to perform a documented annual
review by the medical director/designee, provider peer, or treatment team
whenever a patient is prescribed more than a total dose 400 mg of
morphine equivalents per day for chronic, nonmalignant pain. This total
should exclude any methadone dose used as part of opioid replacement
therapy.
4.
Definitions:
Annual review is required when either of the following conditions are met:
a. Patient is prescribed greater than 400 mg per day of morphine sulfate
or an equivalent dose of other opioids or combination of opioids whose
daily sum is > 400 mg of morphine or its equivalent.
b. Patient is prescribed greater than 100 mg per day used for to treat
chronic non-malignant pain. The calculation should not include the dose of
methadone used as part of opioid replacement therapy such as in a
methadone maintenance program.
5.
Conversion Factors and how to use them:
For the purposes of this policy we are focusing on morphine, oxycodone,
and hydromorphone. Equivalent doses vary depending on the reference
used. For this policy we used the Pharmacist Letter (July 2010) and The
Medical Letter (April 2010).
PLEASE NOTE: The conversion factors listed below are to be used
solely for the calculation of morphine equivalent dose for the
purpose of deciding whether a case meets threshold for review.
They should NOT be used for calculating doses of opioids when
converting from one opoid to another in the course of clinical care.
Morphine 30 mg = oxycodone 20 mg = hydromorphone 7.5 mg
OR
Morphine dose = 1.5X oxycodone dose = 4X hydromorphone dose
6.
Sample Calculations:
a. Patient A is prescribed morphine sustained release 100 mg three times
a day and oxycodone immediate release 30 mg every eight hours as
needed.
Calculation:
morphine daily dose = 300 mg morphine equivalent
oxycodone daily dose = 90 mg X 1.5 = 135 mg of daily morphine
equivalents
Total daily morphine equivalent dose = 300 mg + 135 mg = 435 mg
This patient would require annual review for high dose opioid therapy.
b. Patient B takes oxycontin 80 mg three times a day and hydromorphone
2 mg four times a day as needed.
Calculation:
oxycodone daily dose = 240 mg X 1.5 = 360 mg of daily morphine
equivalents
hydromorphone daily dose = 8 mg X 4 = 32 mg of daily morphine
equivalents
Total morphine equivalent dose = 360 mg + 32 mg = 392 mg
This patient would not need an annual review for high dose opioid
therapy.
7.
Mechanism of annual review
Every health center is required to have a mechanism to perform a
documented annual review by the medical director/designee, provider
peer or treatment team whenever the daily dose of morphine or equivalent
exceeds 400 mg a day or 100 mg of methadone (excluding methadone
prescribed as part of opioid replacement therapy) prescribed in the
treatment of chronic non-malignant pain.
This policy is in addition to existing policies and procedures in this area.
All other CHN chronic pain policies continue to be in effect.
Addendum:
Pharmacist Letter (July 2010)
The Medical Letter (April 2010)