MME's may be an illusory pharmacological concept

[drusso]

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Inches, Centimeters, and Yards : The Clinical Journal of Pain

Objective:Morphine-standardized doses are used in clinical practice and research to account for molecular potency. Ninety milligrams of morphine...

journals.lww.com

"The overlooked inconsistency among daily MME definitions revealed by our study calls into question the clinical validity of a single numerical risk threshold. When measuring with inches, centimeters, and yards, the absolute number of units is arbitrary. The mix of clinical and research metrics used to calculate the 90 MME threshold is similarly convoluted. As providers, we struggle to do what we feel is right for our patients in the midst of increasing outside pressure with serious ramifications. Our findings call into question state laws and third-party payer MME threshold mandates. Without harmonization, the scientific basis for these mandates may need to be revisited. As the CDC Guideline is revised, and clinical decision tools are developed, it is critically important to reassess the evidence base in light of this previously unknown MME definitional variability."

Equations for Calculating MMEs | Opioid Research

www.opioiddata.org

 

[Ducttape]

why start them at all, except in very rare circumstances?

 

[lobelsteve]

Building a haystack to surround your pre selected needle.

 

[Doctodd]

New ARNP's love to talk MEQ's for inpatients. It makes them sound knowledgeable.

 

[drusso]

why start them at all, except in very rare circumstances?

What are alternatives are you thinking?

 

[painfree23]

What are alternatives are you thinking?

Show me the study that shows opiates are good? They aren’t long term solutions. Don’t need an alternative…do no harm.

 

[drusso]

why start them at all, except in very rare circumstances?

Pain

. 2021 Jul 12.
doi: 10.1097/j.pain.0000000000002331. Online ahead of print.

Evaluating the stability of opioid efficacy over 12 months in patients with chronic noncancer pain who initially demonstrate benefit from extended-release oxycodone or hydrocodone: harmonization of Food and Drug Administration patient-level drug safety study data​

John T Farrar 1, Warren B Bilker, Philip T Cochetti, Charles E Argoff, Jennifer Haythornthwaite, Nathaniel P Katz, Ian Gilron
Affiliations expand

• PMID: 34261978
• DOI: 10.1097/j.pain.0000000000002331

Abstract​

Opioids relieve acute pain, but there is little evidence to support the stability of the benefit over long-term treatment of chronic noncancer pain. Previous systematic reviews consider only group level published data which did not provide adequate detail. Our goal was to use patient-level data to explore the stability of pain, opioid dose, and either physical function or pain interference in patients treated for 12 months with abuse deterrent formulations of oxycodone and hydrocodone. All available studies in the Food and Drug Administration Document Archiving, Reporting, and Regulatory Tracking System were included. Patient-level demographics, baseline data, exposure, and outcomes were harmonized. Individual patient slopes were calculated from a linear model of pain, physical function, and pain interference to determine response over time. Opioid dose was summarized by change between baseline and the final month of observation. Patients with stable or less pain, stable or lower opioid dose, and stable or better physical function (where available) met our prespecified criteria for maintaining long-term benefit from chronic opioids. Of the complete data set of 3192 patients, 1422 (44.5%) maintained their pain level and opioid dose. In a secondary analysis of 985 patients with a measured physical function, 338 (34.3%) maintained their physical function in addition to pain and opioid dose. Of 2040 patients with pain interference measured, 788 (38.6%) met criteria in addition. In a carefully controlled environment, about one-third of patients successfully titrated on opioids to treat chronic noncancer pain demonstrated continued benefit for up to 12 months.
Copyright © 2021 International Association for the Study of Pain.

 

[kstarm]

Pain

. 2021 Jul 12.
doi: 10.1097/j.pain.0000000000002331. Online ahead of print.

Evaluating the stability of opioid efficacy over 12 months in patients with chronic noncancer pain who initially demonstrate benefit from extended-release oxycodone or hydrocodone: harmonization of Food and Drug Administration patient-level drug safety study data​

John T Farrar 1, Warren B Bilker, Philip T Cochetti, Charles E Argoff, Jennifer Haythornthwaite, Nathaniel P Katz, Ian Gilron
Affiliations expand

• PMID: 34261978
• DOI: 10.1097/j.pain.0000000000002331

Abstract​

Opioids relieve acute pain, but there is little evidence to support the stability of the benefit over long-term treatment of chronic noncancer pain. Previous systematic reviews consider only group level published data which did not provide adequate detail. Our goal was to use patient-level data to explore the stability of pain, opioid dose, and either physical function or pain interference in patients treated for 12 months with abuse deterrent formulations of oxycodone and hydrocodone. All available studies in the Food and Drug Administration Document Archiving, Reporting, and Regulatory Tracking System were included. Patient-level demographics, baseline data, exposure, and outcomes were harmonized. Individual patient slopes were calculated from a linear model of pain, physical function, and pain interference to determine response over time. Opioid dose was summarized by change between baseline and the final month of observation. Patients with stable or less pain, stable or lower opioid dose, and stable or better physical function (where available) met our prespecified criteria for maintaining long-term benefit from chronic opioids. Of the complete data set of 3192 patients, 1422 (44.5%) maintained their pain level and opioid dose. In a secondary analysis of 985 patients with a measured physical function, 338 (34.3%) maintained their physical function in addition to pain and opioid dose. Of 2040 patients with pain interference measured, 788 (38.6%) met criteria in addition. In a carefully controlled environment, about one-third of patients successfully titrated on opioids to treat chronic noncancer pain demonstrated continued benefit for up to 12 months.
Copyright © 2021 International Association for the Study of Pain.

and 2/3s of the people didn't get benefit? Also they included patients on less opioids in their inclusion criteria. We know that tapering improves pain for many patients. I am going to need a lot more evidence to consider changing my practice especially in light of the many, many articles about risk and harm with these medications.

I do think MMEs do not have a great scientific basis.

 

[Ducttape]

tell me:
1. deceptive study. on patients who were able to be put on chronic opioid therapy, 1/3 were able to be maintained.

what percentage of patients ever got to this point? ie by default, the % of people who are started on opioids but are able to be maintained long term would be less than 30%.
2. do you have a carefully controlled environment?
3. at least one of the authors is renowned for espousing chronic opioid use.
4. the way the article is written, they were preselecting a group of individuals that were favorable to their outcome. im not so comfortable with that - you are looking for a positive result by screening out the negative. see post 1.

Patients with stable or less pain, stable or lower opioid dose, and stable or better physical function (where available) met our prespecified criteria for maintaining long-term benefit from chronic opioids.

if you had a procedure that you knew had only a 38% chance of benefit but had probably 95% chance of significant risk, would you offer that treatment to a patient? (95% chance is based on the knowledge that at least that percentage develops significant constipation. factor other risks including 50%+ hypogonadism, 40% nausea, high risk tolerance and dose dependence...)

 

[drusso]

tell me:
1. deceptive study. on patients who were able to be put on chronic opioid therapy, 1/3 were able to be maintained.

what percentage of patients ever got to this point? ie by default, the % of people who are started on opioids but are able to be maintained long term would be less than 30%.
2. do you have a carefully controlled environment?
3. at least one of the authors is renowned for espousing chronic opioid use.
4. the way the article is written, they were preselecting a group of individuals that were favorable to their outcome. im not so comfortable with that - you are looking for a positive result by screening out the negative. see post 1.




if you had a procedure that you knew had only a 38% chance of benefit but had probably 95% chance of significant risk, would you offer that treatment to a patient? (95% chance is based on the knowledge that at least that percentage develops significant constipation. factor other risks including 50%+ hypogonadism, 40% nausea, high risk tolerance and dose dependence...)

F *c k the data, right?

 

[Ducttape]

F *c k the data, right?

absolutely not.

but read the data and ask - what questions did they ask, and what did they answer?

they asked - of those ppl we put on long term opioids, how many were able to do well long term.



so my question - why put them on long term opioids, especially since only 1/3rd do well.

see above:

why start them at all, except in very rare circumstances?

 

[drusso]

absolutely not.

but read the data and ask - what questions did they ask, and what did they answer?

they asked - of those ppl we put on long term opioids, how many were able to do well long term.



so my question - why put them on long term opioids, especially since only 1/3rd do well.

see above:

If I were one of the patients inappropriately denied, I'd be pissed...I don't want my doctors rolling dice.

 

[Gnarvin]

Plus that study only went out to 12 months…most of the patients I see on chronic opioids seem to think they should be on them for the rest of their lives.

 

[drusso]

Plus that study only went out to 12 months…most of the patients I see on chronic opioids seem to think they should be on them for the rest of their lives.

Who cares how long? Even if the study went out 36 months, I say F*ck'em.

 

[Ducttape]

law of diminishing returns. if only 1/3 is getting benefit after 12 months, how many are getting benefit after 36?

and how many suffer from withdrawal symptoms when they are stopped?

If I were one of the patients inappropriately denied, I'd be pissed...I don't want my doctors rolling dice.

this paper suggests you are more likely to have a patient inappropriately started...