Washington State weighs limiting narcotic doses

January 8, 2007

Deaths associated with opioid use have been on the rise in Washington State. In Seattle and surrounding King County, for example, opioid-related deaths increased by 40% between 2003 and 2004, according to Caleb Banta-Green, MPH, MSW, a research scientist for the Alcohol & Drug Abuse Institute at the University of Washington. Banta-Green reported that the increase in opioid-related deaths coincided with an increased rate of opioid prescriptions for the treatment of chronic pain.

The Washington Department of Labor and Industries also observed an alarming number of opioid-related deaths among its beneficiaries. After examining its data, it discovered that as the number of Rxs for opioid drugs has increased, so have the prescribed doses of opioids. The average dose of morphine (or its equivalent) for chronic pain management rose steadily from 83 mg per day in 1996 to 132 mg per day in 2002. The department has since worked with the state departments of Health, Corrections, Health Care Authority, and Social and Health Services. Together, this working group-the Interagency Workgroup on Practice Guidelines-prepared the "Draft Guidelines for Opioids for Non-Cancer Pain." Representatives from other commissions and boards, including the board of pharmacy, provided input as well.

In the guidelines, the Interagency Workgroup panel recommends a total maximum daily dose of 120 mg of morphine or its equivalent. If a prescriber feels higher doses are needed, the workgroup recommends getting a second opinion from a physician specializing in pain management. "One hundred twenty milligrams of morphine equivalent is not a maximum daily dose but rather a threshold at which to seek consultation," explained Jaymie Mai, Pharm.D., pharmacy manager for the office of the medical director at the Washington Department of Labor and Industries.

Patient safety is very important, agreed Jeremy Holt, R.Ph., staff pharmacist at Kelley-Ross Pharmacy in Seattle. But he objected to the dose limit set by the guidelines. "We have a high population of HIV patients," he said. Many of his patients with peripheral neuropathy may require higher doses of pain medications, including opioids. Controlled-release oxycodone, at 80 mg twice daily, is not an uncommon dose; it would be equivalent to 120 mg of morphine, he said, leaving no room for an opioid prescription for breakthrough pain.

If the opioid guidelines were to be implemented into state programs, many patients receiving such benefits could be required to see pain specialists before receiving their opioid Rxs. Holt is concerned about how long the process would take and whether his patients would receive adequate medication. Without knowing how the guidelines would be implemented, Holt said his pharmacy might not support them.

While scientific data may be clear, the interpretation of the findings is not, said Banta-Green. Opioid Rxs may be increasing, but experts disagree as to whether this is a public health hazard or an indication that chronic pain management is improving. Policymakers must therefore be very careful in developing policies based on interpretations of data, Banta-Green said. "We want to make sure any interventions to prevent problematic use don't adversely affect the vast majority who are appropriately using their medications."

The workgroup plans to publish the opioid guidelines early this year. The guidelines will be educational only for a year or so, within which time the workgroup will seek feedback from physicians, pharmacists, and other healthcare professionals. "We are particularly interested in seeing research that demonstrates the safety and effectiveness of dosages above 120 mg morphine equivalents per day," it stated.

If the agencies involved are satisfied with the educational outcomes of the guidelines, Washington pharmacists could be seeing the results in the not-so-distant future.

The author is a clinical writer based in the Seattle area.