Friday, October 4, 2019

Part 3 - Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

by Drew Rosielle (@drosielle)

A Series of Observations on Opioids By a Palliative Doc Who Prescribes A Lot of Opioids But Also Has Questions.

This is the 3rd post in a series about opioid, with a focus on how my thinking about opioids has changed over the years. See also:

Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.

Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses





This is Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

I believed, and was taught, opioids had no intrinsic ceiling effect, and didn't think there was much difference between someone being on 100 mg of morphine a day or 1000 mg. I wish this was the case, but the number of patients I can recall the last 20 years who were on very high opioid doses who were doing 'great' (had excellent pain relief leading to important functional improvements and minimal side effects) is minimal (but not zero, mind you). Like, less than 5% of patients I’ve placed on very high doses. (I’ll be the first to admit I don’t have an exact definition of what that is, I don’t think that’s possible, but generally I’m talking about many hundreds of morphine milligram equivalents a day.) Most patients remained in terrible pain and had significant, ongoing disability despite the high doses (and undoubtedly for some of them because of the high doses). I’d increase someone’s dose, they’d report they’d feel better, but within a few weeks or months they’d continue to report daily, severe pain, and function would not have improved. I saw this pattern again and again. They weren’t overdosing, most of them were fine from a safety standpoint, they just weren’t helped by me pushing their doses into the very high range. As I look back on this, it’s bizarre to me I didn’t see more clearly in the past just how poorly most of my patients on high doses were doing. How I ignored that little voice inside of me which said, “Drew, they’re already on many hundreds of milligrams a day, they continue to report daily, severe pain…opioids are not helping them anymore.”

So much so that I’ve mostly stopped prescribing opioids, long-term, in those ranges, outside of patients who are dying and the care goals are really centered around alleviating suffering in those final days/weeks. (I use those doses short term during hospitalizations for pain crises.)

I should note here that I don’t think it’s helpful to calculate ‘morphine equivalents’ for someone on methadone for pain. I know people do it, but I don’t, and I personally think it’s a folly, it’s too much comparing apples and oranges, and the fact we know how to convert someone from methadone to a ‘typical’ opioid without killing them is a different thing than being able to speak confidently along the lines of “40 mg a day of oral methadone is equivalent to X mg a day of oral morphine.” Like, does anyone think they’ve got a good grip on that (if you do, please comment)? That’s not a question I’ve asked myself for years now because I don’t think it has an answer, and I think it’s a different question than “what is a safe and reasonable dose of oral morphine to convert someone to a day who is on 40 mg of methadone daily.” Part of this is because I think a lot of what’s pernicious about commonly used non-methadone opioids really comes out at higher doses (see my next post in this series), and I think those pernicious phenomena are really muted for methadone, and as I think about patients I have different categories in my head for patients on, saying, hundreds of milligrams of morphine a day who’s doing poorly (not getting good pain relief), and someone who’s on quite a high dose of methadone who’s not getting good pain relief. To me, those are different situations, whereas there’s not much of a difference in my brain’s way of categorizing the world between someone doing poorly on very high dose morphine and oxycodone, for instance.



So, I believe patients absolutely have a therapeutic ceiling effect with opioids, and at doses that are lower than I realized years ago, although everyone’s ceiling is different, but that should not be much of a surprise.

Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.
Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses
Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

For more Pallimed posts about opioids.
For more Pallimed posts by Dr. Rosielle click here.

Drew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.

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