Morphine Regulations Increase, While Marijuana Restrictions Wane

Monday, April 3, 2017

Marsha K. Millonig, MBA, BPharm

It would be extremely difficult to find a pharmacist today who isn’t looking a little more closely at every opioid prescription he or she receives, especially those for morphine and morphine-related products. Although this is an issue we discuss frequently, it seemed appropriate to take another look at current and developing solutions.

The CDC guidelines published in 2016 made several recommendations, including one related to risk assessments:

“8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.”

The amount of morphine milligram equivalents (MME) a patient is taking on a daily basis is a key indicator that prescribers and pharmacists should be monitoring. Leveraging resources such as the medication record you maintain for the patient and your state’s Prescription Drug Monitoring Program (PDMP) are both valuable ways to assess the patient’s current daily MME. A quick Google search of “MME calculator” returned over 300,000 results, so clearly there are tools available, if not already embedded in your systems or as part of the drug information suite on your mobile device, to assist.

According to ”Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline” by Thomas R. Frieden, MD, MPH, and Debra Houry, MD, MPH, “Overdose risk increases in a dose-response manner, at least doubling at 50 to 99 morphine milligram equivalents (MME) per day and increasing by a factor of up to 9 at 100 or more MME per day, as compared with doses of less than 20 MME per day.”

New state laws may attempt to address the amount of medication prescribed, often with exemptions for certain situations, such as oncology or terminally ill patients. Some, like New Jersey, do so via a day supply limit. Others, like Washington, include a MME, or in their terms, MED (morphine equivalency per day) that when reached, may trigger additional action on the part of the prescriber. These actions could include a consultation with another provider, such as a pain management specialist.

Another legislative or regulatory solution that is being pursued is that of allowing pharmacists to partially dispense an opioid prescription. Allowing pharmacists this option, in consultation with their patients, provides another opportunity for a care professional to speak with patients about their opioid use, including the amount of morphine they may be consuming each day. This also allows for prescribing efficiency: Ordering smaller amounts could lead to increased calls for refills, whereas if a subset of the original prescription is dispensed, the pharmacy still has a valid prescription on file to complete dispensing, if the patient desires.

It is yet to be seen if the rules and guidelines being implemented are having the desired effect. In Colorado, when the state’s guidelines were first released in 2014, the death rate from opioids was 6.1 people for every 100,000 residents. In 2015, the rate was 5.8, according to a report from the Colorado Department of Public Health and Environment. However, patients who suffer from chronic, often intractable, pain who have been successfully managed via opioids are now struggling. Prescribers are concerned about writing outside the guidelines, and insurers are being asked to apply limits to what they will cover, which can also inadvertently lead to patient suffering.

Marijuana Moves in the Opposite Direction

It is fascinating to note that as constraining legislative activity related to opioids increases, the use of marijuana is being legalized in many states. Twenty-eight states and the District of Columbia allow the use of marijuana for specific medical purposes. The forms of marijuana allowed vary; some states allow liquid extract products, others allow more natural forms. Eight states also permit the recreational use of marijuana.

Nonetheless, the use of marijuana is still prohibited federally, which has impacted the amount of research that has been done on the effects and interactions of cannabis with other products.

As a pharmacist, knowing about any product my patients are using benefits my ability to provide care. Whether prescription, over-the-counter, or herbal, there is always a risk of side effects or more severe adverse events, including interactions. Electronic health record systems, including pharmacy management systems, should be modified to allow for the documentation of patient use of marijuana, especially in states where its use has been legalized. Research is needed so that patients can be safely and effectively counseled about any potential risks associated with their prescriptions and their marijuana use.

Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.

Want to learn more about related topics? Check out these RxPerts Academy features on morphine and marijuana:

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