Frederick Douglas:
‘..If there is no struggle, there is no progress. Those who profess to favor freedom and yet deprecate agitation are men who want crops without plowing the ground. They want rain without thunder and lightning. They want the ocean without the roar of its mighty waters..’
“..Find out just what a people will submit to, and you have found out the exact amount of injustice and wrong which will be imposed upon them, and these will continue till they are resisted with either words or blows or with both. The limits of tyrants are prescribed by the endurance of those whom they oppress..”
NORMAN J CLEMENT RPH., DDS, NORMAN L. CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., INC.T. SPIRIT OF REV. IN THE SPIRIT OF WALTER R. CLEMENT BS., MS, MBA. HARVEY JENKINS MD, PH.D., IN THE SPIRIT OF C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., IN THE SPIRIT OF THE HON. PATRICE LUMUMBA, IN THE SPIRIT OF ERLIN CLEMENT SR., EVELYN J. CLEMENT, WALTER F. WRENN III., MD., JULIE KILLINGSWORTH, RENEE BLARE, RPH, DR. TERENCE SASAKI, MD LESLY POMPY MD., CHRISTOPHER RUSSO, MD., NANCY SEEFELDT, WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., NEIL ARNAND, MD., RICHARD KAUL, MD., IN THE SPIRIT OF LEROY BAYLOR, JAY K. JOSHI MD., MBA, AISHA GARDNER, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NJOKU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS
DR.NABARUN DASGUPTA:
“..The Non-Standard Metric: Understanding Daily Opioid Morphine Milligram Equivalents..”
Today’s Lecture: Dr. Dasgupta presents the findings of his team’s research, revealing the variability in daily MMe calculation and its implications for research, policy, and clinical practice.
This source is a transcript of a lecture given by Dr. Nabarun Dasgupta, focusing on the critical issue of how daily morphine milligram equivalents (MME) are calculated in research, clinical practice, and policy.
Dr. Dasgupta reveals that despite its widespread use and incorporation into law, daily MME is not a standardized metric, as there are at least four distinct methods of calculation that yield significantly different results from the same data.
The lecture meticulously demonstrates how these overlooked definitional differences can lead to inconsistent identification of high-dose opioid patients and disparate conclusions in policy evaluations.
Ultimately, the purpose is to highlight this fundamental flaw in a seemingly straightforward metric, urging for greater transparency in MME calculations and a move away from rigid thresholds in favor of more nuanced, continuous assessments of opioid dosing.
Stanford Pain Relief Innovations Lab Speaker Series NABARUN DASGUPTA CLICK HERE
Dr. Nabarun Dasgupta’s lecture from the Stanford Pain Relief Innovations Lab Speaker Series addresses the significant inconsistencies in how daily morphine milligram equivalents (MME) are calculated.
He reveals that despite its widespread use and integration into law, there are at least four distinct, often overlooked, methods for calculating daily MME.
This variation in calculation, stemming primarily from different interpretations of “day” in the metric, leads to substantial discrepancies in identifying high-dose opioid users, impacting research, policy, and clinical practice. Dasgupta demonstrates how these different definitions yield conflicting results when analyzing the same patient data and comparing opioid prescribing patterns across states.
He argues that the lack of standardization undermines the validity of MME as a clinical metric and calls for greater transparency in reporting the specific calculation method used.
Dr. Dasgupata’s lecture ultimately emphasizes that subtle methodological choices in calculating MME have significant and often unacknowledged consequences for understanding and addressing opioid prescribing and potential overdose risks.
Timeline of Main Events Covered in the Source:
Decades Ago: MME conversion tables were devised based on analgesic effect in small randomized hospital trials converting patients between opioid analgesics, not on pharmacology.
Interceding Decades: The concept of equal analgesic effect used for Mme conversion was adopted to represent the toxicological phenomenon of higher doses, despite its origin in pain management.
Around 16 Years Prior to the Lecture: Dr. Dasgupta has been using MMEs in research and struggling to convince colleagues about the significant impact of subtle calculation choices.
Years Ago (Prior Study): Dr. Dasgupta’s team conducted a study on street prices of prescription drugs, finding that street price-based relative potencies were close to equianalgesic conversion tables, suggesting some face validity for MMEs.
Time of CDC Guideline Development: Eighteen studies using daily Mme were cited to justify the 90 Mme per day threshold. Analysis of these studies revealed they silently used four different definitions of daily Mme, centered around the interpretation of “day.”
Recent Research Project (Leading to the Lecture): Dr. Dasgupta’s team initiated research to investigate the overlooked differences in how daily Mme is calculated. They identified four distinct definitions used in the literature and the CDC guidelines.
Study on Four Analysts: Four analysts, given the same patient data and conversion factors, identified different sets of “high-dose” opioid patients based on the 90 Mme/day threshold, highlighting variability beyond pharmacology.
Analysis of CDC Guideline Citations: Reverse engineering of the equations in the 18 cited studies revealed the silent use of four different definitions for daily Mme.
Controlled Experiment (California and Florida): Using PDMP data from California and Florida (Q3 2018), the researchers compared the percentage of “high-dose” patients and average opioid doses using the four different Mme definitions. This demonstrated significant discrepancies in results based solely on the definition used.
Analysis of Texas PDMP Data: Similar patterns of disagreement across the four Mme definitions were observed in preliminary data from Texas (Q1 2020).
Analysis of Overlapping Scripts: Approximately 42% of prescriptions in the sample overlapped, affecting one in four patients, highlighting the significant impact of overlapping day supplies on Mme calculations.
Analysis of the 90 Mme Threshold: Shifting the high-dose threshold slightly (from 90.9 to 90) resulted in a 15% increase in the number of patients classified as high-dose, indicating a large number of patients near this arbitrary boundary.
Current Research (Ongoing): Dr. Dasgupta’s team is currently working on a paper addressing two often unaddressed assumptions in studies linking opioid prescribing and overdose mortality: the specificity of the overdose substance to the prescribed opioid and the assumption of continuous exposure between dispensing and overdose. They are also conducting simulation studies on the longitudinal impact of different Mme definitions in the US.
Arkansas Medicaid Policy: An example of a policy requiring taper for patients above 250 Mme/day, highlighting the real-world impact of Mme definitions on patient care.
Dr. Tiji’s and Pain Patient’s Quotes: These illustrate the tangible effects of how Mme is calculated and the restrictions imposed based on it on both prescribers and patients.
Chris Delcher’s Point: Highlights the potential for using PDMP data positively for patient care by understanding and addressing the issues with Mme calculation.
MISREPRESENTATION OF STUDIES AND OPIOID EQUIVALENCIES AS THE STATE OF ILLINOIS OUTLAWS THIS GUIDELINE FOR PRESCRIBING NARCOTIC ANALGESICS FOR PAIN
Through the persistent advocacy of Bob Sheerin, Nancy Seefedlt, Pharmacist Steve Ariens, and Atty Kat Hatz of The American Diability Foundation, the State ofIllinois has signed into law a Ban on the usage of Morphine Milligram Equivalent (MME).
MEDICAL SCIENCE vs BARRY MEIER OF MISGUIDED MEDIA ARMED WITH A PULITZER PRIZE
A YouTube transcript from Democracy Now! explores the unintended negative consequences of federal opioid prescribing guidelines on chronic pain patients.
Doctors and researchers have voiced concerns that revised CDC guidelines, initially aimed at preventing addiction, are causing under-prescription and reduced access to necessary pain relief for individuals with conditions like cancer and lupus.
This has reportedly led to worsened pain and quality of life, with some patients even considering suicide.
The discussion highlights the complexity of pain management, contrasting the need to combat opioid over-prescription with the suffering of patients who legitimately rely on these medications.
Cast of Characters:
This timeline and cast of characters summarize the key information and individuals discussed in the provided excerpt.
- Terry Lewis: A social scientist, rehabilitation practitioner, and clinical educator. She is currently running a national survey of patients and physicians to understand the impacts of changes in chronic pain treatment. Her work focuses on the experiences of patients with chronic pain and the unintended consequences of opioid prescribing guidelines on this population.
- Barry Meier: Author of “Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic.” He is an expert on the history and impact of the opioid crisis. He acknowledges the need for appropriate pain treatment but emphasizes the dangers of over-prescribing opioids and the potential of alternative pain management strategies. He also highlights the role of pharmaceutical companies in the opioid crisis.
- Jeff Sessions: Former Attorney General of the United States. During his tenure, he spoke publicly about the opioid crisis and advocated for reducing opioid prescriptions, suggesting that some pain could be managed with non-opioid alternatives. His remarks reflect a perspective focused on curbing addiction by limiting opioid availability.
- General Kelly (mentioned by Jeff Sessions): A former Marine (implied to be John F. Kelly, though not explicitly stated). Sessions uses an anecdote about Kelly supposedly refusing pain medication after surgery to illustrate his belief that individuals can often manage pain without opioids.
- M Goodman (likely Amy Goodman): The host of Democracy Now, who facilitates the discussion between Terry Lewis and Barry Meier.
THE MYTH OF MORPHINE MILLIGRAM EQUIVALENT DAILY DOSE
A YouTube video transcript critiques the concept of Morphine Equivalent Daily Dose (MEDD). The speaker argues that using MEDD as a research variable is flawed due to individual differences in drug response.
This invalidates research relying on MEDD, hindering the development of effective pain management practices. The transcript further criticizes opioid guideline committees for their excessive focus on lowering MEDD, neglecting crucial factors like individual patient needs.
The speaker suggests this emphasis, driven by an invalid metric, negatively impacts primary care physicians and could worsen the existing shortage.
Ultimately, the video contends that focusing on arbitrary dosage limits, rather than personalized care, is detrimental and potentially more harmful than the perceived opioid crisis.
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REFERENCE:
Briefing Document: The Myth of Morphine Equivalent Daily Dose (MEDD)
Source: Excerpts from “The Myth of Morphine Equivalent Daily Dose” (speaker unnamed in provided excerpt)
Date: Likely recent, given the discussion of the CDC guidelines and impending physician shortages.
Overview:
This briefing document summarizes the key arguments presented in the provided excerpt concerning the Morphine Equivalent Daily Dose (MEDD). The speaker argues that MEDD is a flawed and invalid concept, particularly when used as a dependent variable in research and as the primary focus of opioid prescribing guidelines. This invalidity has significant negative consequences for research, clinical practice, and the healthcare system as a whole.
Main Themes and Key Ideas:
- MEDD is Fundamentally Flawed and Inconsistent:
- The central argument is that a specific dose of morphine (e.g., 10mg) does not produce the same effect in all individuals due to various factors, including pharmacogenomic differences.
- The speaker states, “my 10 milligrams of morphine is not necessarily the same as your 10 milligrams of morphine due to a variety of differences including the pharmacogenomic differences.“
- Consequently, the tables used by doctors to calculate MEDD are described as “a mess” and “very inconsistent.“
- Invalid Use of MEDD in Research:
- The speaker strongly criticizes the use of MEDD as a dependent variable in research studies related to opioid use.
- The core of this criticism is that if the dependent variable (MEDD) is inherently invalid, then any research findings relying on it are also invalid.
- The speaker emphasizes the importance of this research in informing clinical practices and laments that this is not happening due to the invalidity of MEDD: “if the dependent variable has been empirically established as invalid then all the re research that uses it is invalid and this research of course is very important in that it is going to ideally inform our attendees practices and that’s just not happening because of the invalidity.“
- Problematic Focus on MEDD in Opioid Prescribing Guidelines:
- The speaker is highly critical of opioid guideline writing committees, particularly their focus on reducing MEDD levels.
- They argue that these guidelines are disingenuous and prioritize lowering the quantity of opioids prescribed over more crucial considerations, such as individual patient needs and characteristics.
- The speaker highlights the emphasis on “how much is prescribed rather than more importantly to whom are we prescribing.” This echoes concerns previously raised by Dr. Darnell and the speaker.
- The CDC guideline is specifically labeled as “really terrible” and criticized for not addressing important individualized factors like genetic makeup.
- The speaker believes these guidelines are “agenda based rather than empirically based,” making them inherently problematic.
- Negative Consequences for Primary Care Physicians and the Healthcare System:
- The MEDD-focused guidelines are creating a “chilling effect” on primary care physicians, who are often the primary prescribers of opioids.
- This is particularly concerning given the projected shortage of primary care physicians in the US. The speaker warns that these guidelines could further dissuade individuals from entering primary care fields like family practice and internal medicine.
- The speaker predicts that this worsening of the “primary care crisis” could “result in a lot more deaths than does the so-called opioid crisis.” This suggests a belief that restricting appropriate opioid access through flawed guidelines will have severe unintended consequences on overall patient care.
- Call to Action for Primary Care Physicians:
- The speaker urges primary care physicians to actively voice their concerns about MEDD-based guidelines.
- Specific actions suggested include:
- Writing op-ed pieces for local newspapers.
- Speaking to State Medical Societies.
- Organizing collectively.
- The rationale behind this call to action is that the potential for a disgruntled primary care physician workforce, coupled with the existing shortage, presents a significant challenge that individual states cannot afford to ignore.
Important Quotes:
- “my 10 milligrams of morphine is not necessarily the same as your 10 milligrams of morphine due to a variety of differences including the pharmacogenomic differences”
- “accordingly the tables that doctors rely upon um are a mess um there’s they’re very inconsistent”
- “if the dependent variable has been empirically established as invalid then all the re research that uses it is invalid”
- “most of my time today lecturing was spent discussing the disingenuous opioid guideline writing committees um use of Meed focusing on everything or on nothing actually other than getting that Meed down when it’s an invalid concept”
- “so much emphasis on how much is prescribed rather than more importantly to whom are we prescribing”
- “the CDC guideline is really terrible um um and it doesn’t address important questions and focuses on you know how much you ought to be prescribing without taking individualized um genetic makeup and other factors into account”
- “an invalid guideline that’s agenda based rather than empirically based is certainly problematic”
- “Primary Care docs who are subject to the chilling effects of these Meed based guidelines write oped pieces to their local papers they speak to their um State Medical societies uh that they try to organize”
- “if this ends up pushing people away from family practice where most of the prescribing is done then the family practice and Internal Medicine we call the primary care crisis is only going to worsen and I think that that is going to result in a lot more deaths than does the so-called opioid crisis”
Conclusion:
