When Equal Isn’t Really Equal

When Equal Isn’t Really Equal

By Steven R. Ariens, P.D. R.Ph.
We are now starting the second year of the CDC opiate dosing guidelines being in place. We have seen these so called “guidelines” that do not carry the weight of law being adopted by many healthcare organizations as their standard of care and best practices.

Steve Ariens

Many have pointed out the poor quality of studies/data that the CDC committee used to develop these guidelines and ignored other and often better studies/data that contradicted what was used.

Many healthcare entities are slicing and dicing the guidelines, implementing certain sections and ignoring/discarding other whole sections.

The one section of the guidelines that EVERYONE seems to include in their policies and procedures is the daily Morphine mgs Equivalent limits.

If one looks at these opiate conversion tables you will find warning like these:

http://clincalc.com/opioids/

Equianalgesic conversions used in this calculator are based on the American Pain Society guidelines and critical review papers regarding equianalgesic dosing.4,5,6,7 When possible, chronic-dosing studies have been used, including bidirectional and dose-dependent conversions.

There is an overall lack of data regarding most equianalgesic conversions, and there is a significant degree of interpatient variability. For this reason, reasonable clinical judgment, breakthrough (rescue) opioid regimens, and dose titration are of paramount importance.

reasonable clinical judgment, breakthrough (rescue) opioid regimens, and dose titration are of paramount importance

As a clinician, it is important to note that there are significant limitations to equianalgesic conversions and tables. While these equianalgesic tables are current the “best” solution, their limitations should be emphasized:

Single-dose studies: Early studies determining equianalgesia were based on single doses, not chronic administration. Due to drug accumulation, half-life, tolerance, and active metabolites, subsequent chronic administration studies often vary greatly from the original single-dose data.

Bidirectional conversions: When converting between certain opioids, the direction of conversion (eg, morphine to hydromorphone versus hydromorphone to morphine) will produce a different conversion ratio. These bidirectional differences are not captured in a traditional equianalgesic table.5,7

Dose-dependent conversions: The conversion ratio of certain opioids can be dependent on the dose of the original opioid. In the case of converting morphine to methadone, methadone has a relative potency of 4:1 at lower morphine doses, but becomes much more potent (12:1) in patients converting from very high morphine doses.5,7

Cross-tolerance: Many references recommend a cross-tolerance reduction between 25-50% when converting between unlike opioids.9 In patients with very high opioid requirements, the difference between 25% and 50% can be a very significant discrepancy.

Equianalgesic Discrepancies: There are significant discrepancies in equianalgesic dosing tables, with even FDA-approved drug labels not demonstrating agreement. These discrepancies are a factor of both references using old data (single-dose studies) and an overall paucity of data in chronic dosing studies.

Patient-specific factors: No equianalgesic table is able to take into account patient-specific factors — primarily hepatic function, renal function, and age. Opioid metabolism and excretion do differ among the opioids; therefore, alterations in drug disposition will alter the relative potencies of different opioids.

To put it in “layman’s terms”.. These opiate conversion tables are made up of “fuzzy math” with the exception of Methadone conversion, which is “FUZZIER MATH”.

The second variable that is ignored by the CDC guidelines is the variable of a pt’s Cytochrome P450 enzyme system. Which 20%-30% of the population has “defective” metabolism of opiates. Requiring higher and/or more frequent dosing to achieve adequate pain management.  http://www.medscape.com/viewarticle/771480

There are more than 57 genes in the CYP450 liver enzyme system that are used by the body to metabolize different medications but only three are primarily involved with opiate metabolism – except Methadone.

So we have two major variables that can dramatically affect the pt’s overall pain management and they are not on anyone’s “radar”.  So many healthcare professionals and healthcare entities just blindly following guidelines that were set up by a committee that intentionally or unintentionally set up guidelines that does not take a individual pt’s variable needs into consideration.

Steve Ariens is a pharmacy advocate, blogger, and National Public Relations Director for The Pharmacy Alliance.

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There are 16 comments for this article
  1. connie at 9:47 am

    To Jean Price, the problem is that our founding fathers said that our constitution was written for a godly country and we have sadly become anything but godly! I fear for not only the CPP but for the entire country.

  2. becky at 6:02 am

    Steve you are compassion. You are hope. You are knowledge. Thank you for caring about us. From jus yet another Chronic pain patient….
    I appreciate your work.

  3. Jean Price at 8:53 pm

    How could anyone expect ONE size OF ANYTHING to FIT everyone…especially when we were made so uniquely that no two of us even have the same fingerprints?! Doesn’t make sense, does it?! But then, NONE of this whole opioid craziness has made sense! That’s why it so darn hard to fight or to get anyone to listen! You can’t fight nonsense with sense…OR reality or with science or even with TRUTHFUL information! Beside, who with the power to change any of this CARES anyway?!? JUST ONE MORE NATIONAL SHAME! Like the VA has been for ages, like our political parties have become, like our schools are, like our government ethics have become, like our many disrespectful protests are, and the list goes on and on, I’m afraid! We have asked God to bless this country for centuries! Well, now maybe it’s time to ask Him for His HELP!!

  4. I. Hollis at 5:37 pm

    Excellent article Steve!!!
    Science was ignored.
    Genetics were completely left out in this CDC fuzzy math debacle! So much for the roughly 30% who are different.
    Cookie cutter medicine doesn’t work for everyone.
    Thanks for speaking about this very important issue!
    Knowledge is power.

  5. Connie at 1:39 am

    Sadly it isn’t always a problem in the home or in the parenting that makes an addict. Sometimes it just that person who chooses to look for a thrill or an escape from themselves. No matter what makes an addict it’s wrong to blame anyone or anything other than the person who made that choice. When they od it’s wrong for the family to look for a scapegoat when it was the choice of their loved one to use drugs improperly and illegally! Heaven forbid that anyone be held responsible for their own actions!

  6. Carol at 6:15 pm

    I lost my pain doctor late last year (he took a better/bigger position in Northern California. I tried to find a pain doctor in Los Angeles. I thought I found one. He knew of my previous doctor; I brought all my records, xrays, etc. ‘No problem’ he said. He wrote my same prescriptions. The following month I go in and he does a ‘180’ on me. Cut my meds by 65% in one day after taking these meds and being stable on them for over 8 years. Whammo! Within 2 days, I thought I was going to die. He had the nerve to tell me since I don’t have HIV or cancer, I shouldn’t be getting any pain meds. Maybe I should file a complaint with the State? California has a Patients’ Bill of Rights that is supposed to guarantee pain medications to those with chronic, intractable pain but I guess he forgot to read it. Now I can’t find any doctor that will prescribe my meds – all they want to do is more injections which probably caused most of my pain in the first place!!! This is inhumane and outrageous!

  7. Michael Wagner at 4:29 pm

    Steve
    Your better off being on hydromorphone as if they checked and you were only taking 32 mg of hydromorphone you would slide right on by.
    That’s how smart they are

  8. Lynda at 4:13 pm

    Until someone of importance of great wealth or is very popular is tortured to death kills themselves none of our lives matter none of our suffering in unimaginable pain means anything to them. They aren’t in pain so it doesn’t bother them. They have a scapegoat for the countries junkies the families can blame chronically ill people for needing opioid pain relief medications was the cause of their family member becoming a drug addict that lies & stole their families heirlooms to get a fix is all the pain patients fault & not some failing in their in home or parenting. The perfect people to blame once you take the only medication that made life worth living away that patient is too ill in too much pain or killing themselves to do much about it. Besides no one wants to hear from those they are torturing with no longer relieved pain because then they couldn’t torture the pain patients they wrongly allowed & helped to be labeled as addicts so they and their loved ones don’t have to take responsibility for any of it. Not to count those that are benefiting financial don’t want us heard from because they are wanting that government & other profits to keep rolling in. It is sad disgusting when so many are willing to deliberately let people be tortured by pain & just not care about an innocent person suffering so much or that their families are suffering or that they have lost their loved one to death or worse suicide a suicide that would never have happened a death that would never had happened if they wouldn’t have had their pain relief medications taken away they would have never been left suffering & crippled by pain causing their deaths but because of them using the excuse of what others have done &/or because it was profitable people will continue to suffer so severely the deaths & suicides will continue so senselessly so avoidable.

  9. Rebecca Belcher at 4:39 pm

    Completely correct. I took a test for metabolizing certain chemicals and I deplete quickly. We do not all metabolize equally. It was like when I asked the doctor why I had to drink as much water as a 6′ foot male for my colonoscopy. I’m 5′ tall. Was coming out of my nose! : )
    They are understanding that not all cancer is the same. They are individually treating patients now. I’m sure at a might higher cost for these customized treatments.

    Who are we “treating here” with the sudden downsizing of opiates.
    Ok folks, Fentanyl is coming in from China etc. mixing with Heroin. I’ve yet to be prescribed Heroin for pain relief. Opioid problem is coming from outside the US, folks. How are they cracking down on these “imports”?

    Yes. Big Pharma is still making money too!
    I’m a post failed fusion Xs 3.

    Surgeons do not perform the massive fusions of spines like they did in the 90s. Germany had already stopped. But, fusions were big money makers here in the good ‘ol USA! Paid for lots of doctor mortgages and additions to hospitals.

    Guess what is one of the major causes of pain & disability today?
    ???? Fusions! Bingo!!

    Concerned over litigation now?
    Remember that oath you were required to take all those years back? But, you’re SO concerned about my welfare NOW? Hello?

    Some of us are relatively intelligent out here, folks. You caused a lot of pain here too. Those surgeries would not be done today.

    Have a new pain doctor now. At first he wanted to “burn those pain nerves”! He neglected to think about heating up about 1.5 pounds of Titanium just left in me from failed fusions. Practicing medicine, people. He needs to do SOMETHING to make money!
    Now it’s an internal pump.

    Oh yeah, I want a 4th surgery to insert more crap.
    I wish I had NEVER let a surgeon touch me spine. Now you want to leave me in psi that you created?
    Plus a C8 nerve – oops- accidentally nicked?

    Take some responsibility here folks. You created a lot of disabilities with surgeries. And pain.

    Plus target the right audience here.
    Pain patients?

    I’ve lost 10 years plus of my life due to medical misadventures.
    So quick to cut levels. Why?

    Why do I keep thinking $$$$$?
    Medical malpractice?
    Or is it truly your concern over your patients?

    Addicts have been around for a century. You will not change them by decreasing supply. They will find it. Someone will supply it.
    Supply/Demand.

    Wake up please! Your job is to not do more harm than good. So far, the medical community has failed me.
    Now you want to leave me in pain too for botched surgeries?

    Want some real lawsuits? It’s unethical and inhumane.
    But, we are becoming numbers to you. I cant find a GP. They are leaving in droves.

    Think Think Think
    You owe that to us!
    Thank you!

    You cannot undo what you do but you can stop needless suffering.
    I hate taking pain meds but not writhing in pain and wanting to die is not a great alternative.

    It’s SO easy for you to
    Generalize
    Pass Judgment
    I wish you all 3 failed fusions and a walk in your patient’s shoes.
    Humility! I do not enjoy visiting you, paying you, being dependent on you for my pain management.
    You caused my pain. This won’t be resolved this way. Over -reacting
    Look abroad folks!!!
    Where are the drugs coming from?
    Hmmmmmm?

    Thank you

    Be responsible and ethical or get out of the profession. Please !
    You are not doing us any favors.

    Do a study on the number of fusions done in the 80s and 90s!!!!

    You have far to go yet!

  10. Steven at 2:25 pm

    These stories of personal suffering infuriate me. Doctors have an oath to be compationate in their care of patients. How can all these doctors suddenly stop a person’s meds simply because of a misguided attempt by the CDC to dictate what is best for patients that have proven over many years that their normal regimen of meds prescribed by their physician’s is what’s best. I am going through the same misguided process of medicine elimination after many years of proper treatment that worked well for me. Now I’m in pain every day and still have to cut my med’s even more in May and again after that, I’m sure. I wont live for long in this amount of pain. I am certain of it.

  11. JoDawn at 11:31 am

    Thank you!
    Extremely informative and I didn’t need a doctorate to understand it!
    I appreciate it!

  12. Maureen at 11:10 am

    Hi Steve, thank you for yet another very informative post! Your explanations are excellent, especially that of the liver enzyme system. I learned some of this when I had the DNA tests done 4 yrs ago by my awesome pain management doctor when I lived in CT.
    I found out why I had severe reactions to some of the previous meds we had tried me on, and why my body does best with a specific dose of Hydrocodone, only,
    but not with other pain meds. I found it fascinating to get those answers about my body. When I moved to Florida (dumb idea) and my 1st Doctor here changed my meds, which infuriated me, and I had horrible reactions.
    I told him about those test results and he had no idea what I was talking about… Yet, he refused to put me back on my original meds. I became very ill form the meds, and took myself off of them after 4 maths, which only put me in even more suffering with pain. It was all a nightmare, to say the least.
    Fast forward, It has taken me 2 yrs and ‘4’ docs later to finally be put back on what I call ‘my safe meds’… Gralise and hydrocodone. My pain levels wanted higher doses but my liver won’t accept them.
    Pain management Doctors ought to be educated by someone such a you!
    As always, thank you for all that you do on our behalf. God bless you!

  13. Kara at 10:55 am

    Isn’t this basic chem. knowledge? I mean, how the heck can all these docs justify leaving patients under the bus?

    And what about bioavailability? Pills offer what? Roughly 25 to 35% of the medicine in the tablet?

    Crazy. This is so inhumane.

  14. Michael G Langley, MD at 10:32 am

    Seems very sad that science means so little to the people making the decisions on our pain care. I would dare say they are not ignoring the better studies when it comes to cancer treatment! In the end, are we not just a pain in the side to most doctors who don’t give a darn about us. We only represent danger to their practice and not a clinical challenge that goes unmet! When politics and society guide our care, it is only giving us less than optimal care. But, We are just pains in their backsides! Our suffering does not matter! Doctors are not responsible for taking care of suffering?! They seem to be practicing a different type of medicine than compassionate doctors do!

  15. connie at 9:58 am

    Your preaching to the choir Steve. As CPP we know that the guidelines are a total mess to use clean language, there are four letter words that are much better! I am attempting to pack my house after fifteen years in one place and doing so with about 90% reduction in meds its pure torture!

  16. Ellen Falvey at 8:52 am

    An excellent article, which the CDC and legislators should read and understand. In Rhode Island, thanks to legislation passed in 2016 and 2017, it is nearly impossible to get medications to manage pain. I have trigeminal neuralgia, a chronic, incurable pain disease. I have tried all the medications and was deemed refractory. I’ve had two gamma knife radiosurgeries, tried all the alternative pain remedies (acupuncture, etc.) and in desperation had another unsuccessful brain surgery in November, 2016. A 1-1/2 hour procedure turned into a 6-1/2 hour full craniotomy, 6 weeks in a coma, 2 months in a rehab hospital and another 2 months of VNA services. The sharp shooting electric pain is still there and often times worse. Oxycodone allowed me to function and care for my elderly mother. That is no more, I haven’t found a doctor who will prescribe it. I spend most days in tears of pain. I am off to another “pain specialist” this afternoon, who only does “injections”. I’ve tried them before unsuccessfully, but maybe there is something new. Thank you for your advocacy and clearly showing the flaws in the CDC guidelines.