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Prescription Opiates: How Much is Too Much?

One of the biggest challenges facing the doctors and other prescribers who order prescription opiates for their patients in pain is choosing the right dose. Despite heightened awareness of the dangers of prescription pain pills, many doctors continue to write for them because they simply don’t want their patients to go about in pain.

The Substance Abuse and Mental Health Services Administration (SAMHSA) agrees with other federal agencies and physicians’ professional organizations like the American Medical Association (AMA) that physicians require more education about pain management. If you’ve had difficulty understanding why a doctor would need that extra training, this will help you understand why education about prescription opiates is so important.

Amy Bohnert, Ph.D., writing with others in the journal Medical Care, described a group of veterans in need of pain control treated with prescription opiates and then compared with a second group of veterans. The first group received medications from their doctors no higher than 100 morphine equivalent mgs (MEMs), a dosage level that was believed to be sufficient but not excessive for managing a person with a diagnosis of a condition including chronic pain.

The patients in group one were then compared to a previous group of patients identified as group two, patients whose doctors had previously prescribed them prescription opiates at a dosage that they believed would be sufficient to manage their patients’ pain. In group two, the doctors had chosen much higher doses 71 percent of the time than the dose received by group one.

The patients in group one were accepted into the study if they were receiving prescription opiates within the timeframe of the study and also if they had not filled any other pain pill prescriptions in the two years prior to the study. This standard was set to eliminate patients who were doctor-shopping or who were actively seeking prescription opiates from their family doctor, dentist, or other prescribing specialist.

So what was the big difference between the group one and group two patients? The 221 veterans in group 2 were deceased. They had received a dose of prescription opiates that ultimately contributed to death by overdose. The doctors had overprescribed in an attempt to relieve their chronic pain, with catastrophic results.

Comparing Prescription Opiates to Morphine

Before you read on, you are undoubtedly wondering just how much hydrocodone, oxycodone, or other drugs make up 100 MEMs. It’s not something we can discuss on a website that promotes opiate addiction recovery. All of the major medications vary in their comparison to 100 morphine millequivalent milligrams, and so it’s not safe to guess, and it’s not safe to believe that the information out there on the internet is even accurate.

You must also remember that the average person cannot accurately calculate how many MEMs they are getting, because some drugs are more bioavailable than others. For example, morphine taken orally has a low bioavailability compared to injected morphine, and so the dose that a doctor might prescribe to be taken orally would kill a person if they tried to inject it.

Suffice it to say that most people who develop an addiction to prescription opiates, even if they start out with a prescription from the family doctor, generally escalate their dose on their own because of the tolerance that they develop to the medication. Many individuals with addictions to prescription opiates are reported to take up to or in excess of 100 MEMs.

The New Guidelines

Dr. Bohnert’s interest in the problem grew from her participation in a group of research experts assembled by the Centers for Disease Control (CDC) who were asked to draft guidelines for educating physicians and other prescribers. When the CDC gave the assignment to the research experts, they cited these numbers that should be of concern to anyone who is battling an addiction to prescription opiates:

  • Prescribers write 259 million prescriptions for pain pills per year, which is enough to provide every American with their very own bottle of prescription pain pills.
  • Researchers identified the number of times that Americans complained of pain in 1999 and in 2012, and the level of pain in Americans remained the same. However, the sale of prescription opiates rose by 300 percent between those same years.
  • In 2013, over 2 million Americans—age 12 or older—were either dependent on or had at least misused prescription opiates.
  • Between 1999 and 2013, the number of Americans who died specifically from prescription opiates increased by 400 percent.

The new guidelines will teach prescribers to consider non-opiate medications as the first line of treatment for pain. If they do utilize prescription opiates, they should provide special precautions to patients whose doses exceed 50 MEMs, and they should have to justify any prescription that exceeds 90 MEMs.

They also need to discuss additional risks with patients. For instance, the combination of alcohol taken with pain pills is deadly. Additionally, if a patient is taking benzodiazepines prescribed by another physician, that constitutes yet another deadly combination. Patients who take prescription opiates should participate in regular urine drug screens so the doctor remains aware of everything the patient is taking and also to ensure that they aren’t doctor-shopping.

Doctors should think carefully about how long they will keep their patients on prescription opiates before they look at other treatment options. In fact, treatment options such as physical therapy, or adjunct therapies such as acupuncture or hypnosis, may be desirable before treatment with opiates.

People who have been treated for opiate addiction should never again receive prescription opiates. The stimulation of the brain’s mu receptors, even if they haven’t abused opiates in a long time, will take them back immediately to a state of relapse. The methadone programs that provide treatment for addiction to prescription opiates and heroin usually provide patients with medic-alert cards. If the patient goes to an emergency department or another physician, the card can be shown so that the prescribers know to avoid opiates. Methadone programs also have a list of medications that should not be taken, ever, by a person suffering from opiate addiction.

Are you worried that your current dose of prescription opiates could cause you to overdose? Do you ever obsess about what you would do if you did not have access to your pain pills or have you increased the amount you take over time? If that sounds like you, or someone you know, reach out for help at your local methadone treatment program now.



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