Is the opiate conversion tables putting prescribers at risk of malpractice claims ?

Below is the “warnings” from one of the many opiate conversion tables that are available to calculate MME’s… they all have – or should have – the same or similar warning to those who are expected to be using them to stay within the CDC and other daily opiate guidelines and/or state laws.  I am also including 4 statements from the CDC guidelines that provides the prescriber with latitude in providing a pt’s doses above the CDC daily MME limits.  Also a link to a published article by Dr Tennant concerning the importance of the CYP-450 enzyme deficiencies testing and opiate dosing for individual pts.

IMO… these three issues pretty much establish what is – or should be – a standard of care and best practices in treating chronic pain pts.

If a pt is being forced to reduce their opiate dosing and it is important for the pt to inquire as to which formula/table the prescriber is using to calculate these MME equivalents. The one below is just one of many out there, but… they all come up with the same/similar conversion figures and NONE OF THEM… are 100% accurate for each and every pt, may not be accurate for ANY PT ?

I am sure that no prescriber would use a piece of equipment that is known to be less than accurate and base the pt’s therapy on the results from that equipment, but isn’t that exactly what these prescribers are doing by blindly following these opiate conversion tables and ignoring the warning that comes with these conversion tables as to their accuracy and reliability ?

While I am not an attorney, I would think that any prescriber that is blindly using these opiate conversion tables maybe setting themselves up for some legal issues… maybe malpractice, maybe pt abuse, maybe unprofessional conduct, maybe failing to meet best practices and standard of care.  Only time will tell as things progress.

Before using this application, please review these important points:
bullet Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. 

bullet Factors that must be addressed during the conversion process include: Age of the patient or presence of coexisting conditions. Use additional caution with elderly patients (65 years and older), and in patients with liver, renal, or pulmonary disease. 

bullet Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids.

bullet The amount of residual drug in the patient’s system must be accounted for. Example: fentanyl will continue to be released from the skin 12 to 36 hours after removal of the patch. Residual effects from discontinued long-acting formulations should also be assessed before converting a patient to a new opioid.

bullet The use of high but ineffective doses of a previous opioid may result in overestimation of the converted opioid. 

bullet Ideally, methadone conversions (especially patients who were previously receiving high doses of an opioid) should only be attempted in cooperation with a pain specialist or a specialist in palliative medicine. 

bullet Meperidine should be used for acute dosing only and not used for chronic pain management (meperidine has a short half-life and a toxic metabolite: normeperidine). Its use should also be avoided in patients with renal insufficiency, CHF, hepatic insufficiency, and the elderly because of the potential for toxicity due to accumulation of the metabolite normeperidine. Seizures, confusion, tremors, or mood alterations may be seen. In patients with normal renal function, total daily doses should not exceed 600mg/24hrs. 

Here is four quotes from the CDC opiates guidelines:

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

“Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

Severe, chronic pain patients who seek opioid dosages above normal standards should now be tested for genetic cytochrome P450 deficiencies.

One Response

  1. How can I be treated for suboxon for opiate addiction after a lifetime over 20 years I have no health insurance no funds nothing due to identity theft and being denied thank You

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