MORPHINE MILLIGRAM EQUIVALENTS (MMEs) Elisabeth Fowlie Mock, MD, MPH, FAAFP Maine Quality Counts Caring For ME Webinar 11/8/2016

Transcription

1 MORPHINE MILLIGRAM EQUIVALENTS (MMEs) Elisabeth Fowlie Mock, MD, MPH, FAAFP Maine Quality Counts Caring For ME Webinar 11/8/2016

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3 Objectives By the conclusion of this webinar, the learner will have: Identified & be prepared to use a MME calculator Understood how PMP can assist in improving quality and safety of patient care Strategized to create patient registries for opioid use

4 Acknowledgements Lisa Letourneau, Quality Counts Noah Nesin, PCHC Eric Haram, MidCoast Hospital ARC Faculty & Participants, QC Chronic Pain Collaboratives Bangor Area Controlled Substance Workgroup Karyn Wheeler & Chris Beaudette, QC

5 Disclosure EFM was a paid Peer Consultant for Maine Quality Counts Chronic Pain Collaboratives 1&2, funded by an unrestricted grant from Pfizer Independent Grants for Learning and Change (IGL&C) group. MICIS does not receive any direct pharmaceutical support.

6 Big Questions Which MME calculator to use? How will MMEs be handled by Maine s Prescription Monitoring Program? How can providers keep track of changes in patients daily MME dosage? How can practices use EMRs to record providers opioid prescribing by MME?

7 PROBLEM

8 National Response March 2016 Reversing the epidemic requires changing the way opioids are prescribed CDC s Injury Center developed evidencebased guidelines for opioid prescribing

9 THE HEALTHCARE FORCE AWAKENS

10 if you only read 1 thing on opioids, read these 3 pages!

11 THE TRUTH ABOUT OPIOIDS We know of no other medication routinely used for a nonfatal condition that kills patients so frequently. Freiden. NEJM: 374;16:

12 Opioids go beyond NNT & NNH: NUMBER NEEDED TO KILL All comers on opioids: NNK=550 Doses >200 MME: NNK=32 Median time from first opioid rx to death: 2.6 years Freiden. NEJM: 374;16:1501-4

13 Maine Chapter 488 (LD 1646) July 2016 Limits on script duration (7/30d) Mandatory PMP check (opioids/bzdp) 100 MME daily limit Required CME E-prescribing (Schedule II)

14 Maine worse than most: 1.5% of adult population on >100 MMEs

15 DIFFERENT NAMES FOR THE SAME THING MME=morphine milligram equivalent MED=morphine equivalent dose

16 THE INROF OPIOID PRESCRIBING

17 Calculating MMEs Recommended calculator: r/dosecalculator.htm BEWARE METHADONE PMP will include an calculator soon

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19 Table 2 CDC Guidelines

20 METHADONE PHARMACOKINETICS Brennan, Practical Pain Management, March 2012.

21 Detailed version from CDC se/pdf/calculatin g_total_daily_do se-a.pdf

22 Calculator Options

23 Opioid Risks: Risk of Overdose Increases with Dose ALOSA Foundation materials.

24 Relative Risk Continues to Rise from 100 to 200 Gomes. Arch Intern Med 2011;171:

25 OUD RISK RISES WITH MME Donell. MMWR 2016;65(1):9.

26 There is no completely safe opioid dose

27 UNDERAPPRECIATED CONTRIBUTION Benzodiazepines thought to be associated with nearly 80% of opioid overdose deaths Gudin. Postgrad Med 2013; 125(4):

28 High-risk Regimens Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to 90 MME/day or carefully justify a decision to titrate dosage to 90 MME/day. CDC Guidelines, April 2016.

29 Monitoring Frequency Published guidelines recommend reevaluation (face-to-face appointment) by prescriber every 90d for patients receiving >50 MMEs every 30d for patients receiving >120 MMEs CDC 2016 Guidelines; WA State Medical Directors

30 Bangor Area Controlled Substance Workgroup (BACSG) Collaborative effort among EMHS, St. Joseph s, PCHC, Acadia, CHCS and multiple other entities Developed standard INFORMED CONSENT and Prescribing Guidelines for OPIOIDS, BENZOS, STIMULANTS

31 Chronic Pain Playbook Mainequalitycounts.org/ controlledmedication playbook

32 Harm reduction Hardwire naloxone protocols into your practice Ideally rx to all patients on opioids Highest risk: co-rx d BZDP, EtOH use, respiratory compromise, MME>50

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34 Washington State: Agency Medical Director s Group

35 Creating a Registry Methods: EMR generated list triggered by ICD codes, problem list or prescriptions Manually compiled list from individual provider s PMP lists (suggest 3 month window) Prospectively generated list from refill requests

36 Using the registry Some practices are able to actively engage a list through the EMR Many others end up creating a spreadsheet and managing manually (time/labor intensive but decreases as weanings progress)

37 PATIENT X, early 2016 HYPERTENSION PROBLEM LIST OBSTRUCTIVE SLEEP APNEA, INTOLERANT OF CPAP CHRONIC BACK PAIN ON CHRONIC OPIOIDS, MME=220 CHRONIC KIDNEY DISEASE STAGE 3 DEPRESSION PTSD

38 HYPERTENSION PATIENT X, late 2016 PROBLEM LIST OBSTRUCTIVE SLEEP APNEA, INTOLERANT OF CPAP CHRONIC BACK PAIN ON CHRONIC OPIOIDS, MME=120, actively tapering CHRONIC KIDNEY DISEASE STAGE 3 DEPRESSION PTSD

39 PATIENT X, 2017 PROBLEM LIST HYPERTENSION OBSTRUCTIVE SLEEP APNEA, INTOLERANT OF CPAP CHRONIC BACK PAIN, OPIOIDS DISCONTINUED CHRONIC KIDNEY DISEASE STAGE 3 DEPRESSION PTSD

40 THINK LOCAL For local resources regarding utilizing EMRs for chronic pain and opioid management, contact these Maine practices who participated in month learning collaboratives: Local experts Early adopters Ready to spread best practices

41 CPC1 Participants Bucksport Regional Health Center CMMC Family Medicine Residency, Lewiston DFD Russell Medical Center, Leeds EMMC Center for Family Medicine (Residency), Bangor Harrington Family Health Center Sacopee Valley Health Center (ECHO only), Porter Scarborough Family Medicine St. Joseph Internal Medicine, Bangor

42 CPC2 Participants Brewer Medical Center (PCHC) CMMC Family Medicine Residency, Lewiston EMMC Husson Family Medicine, Bangor Dover Foxcroft Family Medicine Inland Family Care, Unity Maliseet Health and Wellness Center, Littleton Mark Braun, MD, Scarborough MMP Family Medicine Portland/Falmouth St. Joseph Internal Medicine, Bangor Sheepscot Valley Health Center, Coopers Mills Swift River Family Medicine, Rumford Westbrook Primary Care Winterport Community Health Center

43 Under CPC1 section on QC website

44 Big Questions Which MME calculator to use? How will MMEs be handled by Maine s Prescription Monitoring Program? How can providers keep track of changes in patients daily MME dosage? How can practices use EMRs to record providers opioid prescribing by MME?

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