MORPHINE MILLIGRAM

EQUIVALENTS (MMEs)

Elisabeth Fowlie Mock, MD, MPH, FAAFPMaine Quality Counts

Caring For ME Webinar

11/8/2016

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

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

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.

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?

PROBLEM

National Response—March 2016

� Reversing the epidemic

requires changing the

way opioids are

prescribed

� CDC’s Injury Center

developed evidence-

based guidelines for

opioid prescribing

THE HEALTHCARE FORCE AWAKENS

if you only read 1 thing on opioids,

read these 3 pages!

THE TRUTH ABOUT OPIOIDS

“We know of no other

medication routinely used

for a nonfatal condition that

kills patients so frequently.”

Freiden. NEJM: 374;16:1501-4.

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

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)

Maine worse than most: 1.5% of

adult population on >100 MMEs

DIFFERENT NAMES FOR THE SAME THING

� MME=morphine milligram equivalent

� MED=morphine equivalent dose

THE INR OF OPIOID PRESCRIBING

Calculating MMEs

Recommended calculator:

http://agencymeddirectors.wa.gov/Calculato

r/DoseCalculator.htm

�BEWARE METHADONE

�PMP will include an calculator “soon”

Table 2 CDC Guidelines

METHADONE

PHARMACOKINETICS

Brennan, Practical Pain Management, March 2012.

Detailed version from CDC

� https://www.cdc

.gov/drugoverdo

se/pdf/calculatin

g_total_daily_do

se-a.pdf

Calculator Options

Opioid Risks: Risk of Overdose Increases with Dose

ALOSA Foundation materials.

Relative Risk Continues to Rise

from 100 to 200

Gomes. Arch Intern Med 2011;171:686-91.

OUD RISK RISES WITH MME

Donell. MMWR 2016;65(1):9.

“There is no completely

safe opioid dose”http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

“UNDERAPPRECIATED

CONTRIBUTION”

Benzodiazepines thought to be associated

with nearly 80% of opioid overdose deaths

Gudin. Postgrad Med 2013; 125(4):115-130.

“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.

Monitoring Frequency

� Published guidelines recommend re-

evaluation (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

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

Chronic Pain

Playbook

� Mainequalitycounts.org/

controlledmedication

playbook

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>50https://www.mainemed.com/MICIS

Washington State: Agency

Medical Director’s Group

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

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)

PATIENT X, early 2016

PROBLEM LIST

� HYPERTENSION

� OBSTRUCTIVE SLEEP APNEA, INTOLERANT

OF CPAP

� CHRONIC BACK PAIN ON CHRONIC OPIOIDS,

MME=220

� CHRONIC KIDNEY DISEASE STAGE 3

� DEPRESSION

� PTSD

PATIENT X, late 2016

PROBLEM LIST

� HYPERTENSION

� OBSTRUCTIVE SLEEP APNEA, INTOLERANT

OF CPAP

� CHRONIC BACK PAIN ON CHRONIC OPIOIDS,

MME=120, actively tapering

� CHRONIC KIDNEY DISEASE STAGE 3

� DEPRESSION

� PTSD

PATIENT X, 2017 PROBLEM LIST

� HYPERTENSION

� OBSTRUCTIVE SLEEP APNEA, INTOLERANT

OF CPAP

� CHRONIC BACK PAIN, OPIOIDS

DISCONTINUED

� CHRONIC KIDNEY DISEASE STAGE 3

� DEPRESSION

� PTSD

THINK LOCAL

� For local resources regarding utilizing EMRs

for chronic pain and opioid management,

contact these Maine practices who

participated in 12-18 month learning

collaboratives:

– Local experts

– Early adopters

– Ready to spread best practices

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

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

Under CPC1 section

on QC website

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?