COMMENTARY

The Myth of Morphine Equivalent Daily Dosage

Michael E. Schatman, PhD; Jeffrey Fudin, PharmD

Disclosures

May 24, 2016

Implications in the Clinic

Clinically, prescribers need to use this information regarding the flawed MEDD concept to begin practicing dosage-switching and opioid rotation in a more thoughtful and scientific manner. Thus, even if the charts suggest that 1 mg of oxycodone is the "equivalent" of 1.5 mg of morphine, the practice of opioid rotation based on the concept of pharmacogentic homogeneity needs to be seriously reconsidered.

Furthermore, the evidence supporting pharmacogenomic differences among patients is mounting[5,6] and needs to be carefully weighed before labeling a patient who requires 30 mg of morphine rather than the prescriber's "standard" of 10 mg in order to achieve adequate analgesia as an "addict." Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.

Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.

Although we emphatically agree that opioid analgesia should not be the first-line treatment for chronic noncancer pain, when other nonopioid treatments have either failed, are contraindicated medically or owing to behavioral and emotional factors, or are inaccessible because of the health insurance industry's refusal to cover them (irrespective of their established evidence-bases), opioids should be considered. Guidelines that contain language suggesting that alternative treatments are regularly available when this is not the case are shortsighted and troubling.

Recently, we published an article in the Journal of Pain Research titled "The MEDD Myth: The Impact of Pseudoscience on Pain Research and Prescribing-Guideline Development,"[10] with Dr Jacqueline Pratt Cleary as our coauthor. This article goes into considerably more detail regarding the clinical and ethical imbroglio that we address in the current brief article, and as an open-access publication, the Journal of Pain Research encourages readers to access the full text at no cost here. We feel that the healthcare community must learn more about the need to work toward a paradigmatic revision in the consideration of opioids in research, clinical practice, and prescribing guideline development.

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