Opioids Complications are Related to the Dose

Do you know what a safe opioid dose is?

A slightly different version of this post was posted on Psychology Today on April 2, 2018

Most agree that there is no proven benefit from the chronic use of opioids (Vicodin, Oxycontin, Fentanyl) for non-cancer pain. From the Centers for Disease Control and Prevention, studies show nothing more than minimal, if any, short-term improvement for the chronic pain patient. There has never been even a suggestion of long-term benefits from these drugs. Right there, that’s enough reason not to use them. They don’t work.

Let’s review many more reasons not to use them: the many harmful effects opioids create for patients—and non-patients—who take them.

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Intensive Care Unit

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Here is what to me is really scary. Narcotics alter the actual structure and function of your brain, rapidly and perhaps permanently. Using magnetic resonance imaging (MRI), Younger and colleagues spent a month following patients with chronic low back pain who were receiving morphine. They found worrisome changes in areas of the brain relating to the reward- and emotion-processing pathways—and these changes occurred early and persisted after the opioid was discontinued. Controls taking a placebo showed no similar changes. This finding raises the concern that using opioids is damaging our brains in areas critical to our social interactions.

Everyone knows that taking opioids can be highly risky, for example, leading to addiction and overdoses. Less discussed is that some serious adverse events stemming from chronic opioid use are fractures, cardiovascular complications, bowel obstruction (“narcotic bowel syndrome” with severe constipation), sedation (and work/driving complications), poor concentration and memory, hormonal dysfunctions altering sexual interest and function, nausea, vomiting, dry mouth, and poor coping skills.

Further, opioids cause depression, which in turn, magnifies the pain. This is just one way opioids actually make pain worse. There’s another way, too. It’s called opioid hyperalgesia. An extensive review by Lee and colleagues describes opioid hyperalgesia as pain not relieved by a dose that was formerly effective. Understandably, the patient wants the dose increased only to find the pain worsens as the dose is increased. Not well understood, chronic opioid use somehow sensitizes brain receptors to pain and has an opposite effect from its intended use.

Because the adverse changes increase with the doses of the opioid, I’m going to get technical for just a bit, so that you can understand when someone is most at risk. From a widely varying literature and relying mostly on a report from the Centers for Disease Control and Prevention, we have guidelines for “safe” doses and “dangerous” doses.

We first must calculate doses in morphine milligram equivalents (MME). This means that the dose of each opioid preparation is converted to the equivalent amount of morphine. In some cases the number of milligrams of an agent like hydrocodone (Vicodin, Narco) is the same as morphine, while many others are more potent on a milligram basis and need to be converted by a multiplier to morphine equivalents. For example, oxycodone (Oxycontin) is 1.5 times as strong as morphine on a milligram basis. This means that 20 milligrams of oxycodone is equal to 30 MME, that is, it’s the same as 30 mg of morphine. Similarly, hydromorphone (Dilaudid) is four times as strong, so we multiply by 4 to get MME. Here are some other opioids and their multipliers: multiply mg of oxymorphone (Opana) by 3; codeine (Tylenol 3 or 4) is much less potent than morphine, so its multiplier is only 0.15; similarly, for tramadol (Ultram), you multiply by only 0.1. Fentanyl skin patches are somewhat different. Instead of mg per day, you multiply by the micrograms per hour and the multiplier is 4 times. For example, a fentanyl skin patch at 25 micrograms per hour is multiplied by 4 to equal 100 MME per day. Using the multipliers, you can easily calculate the MME you or someone you know might be taking. I know this is a bit complicated, but it’s important to know if you are taking a dangerous dose.

Let’s calculate one patient’s daily MME. For his chronic back pain, Marvin was taking 10 mg of Oxycontin four times daily. This is a total of 40 mg of Oxycontin per day. Now, multiply this by 1.5 which is 60 MME. He also took 4 mg of Dilaudid four times daily. This is a total of 16 mg of Dilaudid per day. Multiplying by 4 gives 64 MME. Adding 60 MME and 64 MME, he is taking a total of 124 MME daily.

This is a dangerous level. A reasonably safe dose is defined as 50 MME or less, borderline safe doses

are up to 90 MME. Beyond that the risk of death and other complications skyrockets in direct proportion to MME doses. So, is anyone you know at risk? I’ve commonly seen patients taking in the range of 200-400 MME. I hope you’re not in the danger range but, if you are, you need to beware. While some patients find it impossible to stop opioids completely, they will want at least to get down to 90 MME, hopefully to 50 MME.

The bottom line is, if your physician is prescribing a high dose of opioids to you or someone you care about, that physician may not be aware of how dangerous that dose is. Lacking training in mental health care and addiction medicine, physicians all too often unwittingly put their patients at risk.

Copyright Robert C. Smith 2018

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