What are opioids and what’s the opioid epidemic?

Opioids are a class of drugs that act on pain receptors of nerve cells in the brain and other parts of the body. They are often prescribed to treat pain caused by an injury, surgical procedure or serious condition. Opioids include the drugs:

  • Codeine
  • Fentanyl
  • Heroin
  • Hydrocodone
  • Morphine
  • Oxycodone

Opioids not only dull pain, but cause a feeling of euphoria. They can be addictive when used for long periods of time, in high doses, or in ways that do not follow the prescription instructions.

There are two types of pain typically treated with prescription opioids. Acute pain is pain that lasts for a short span of time and comes from a clear cause. This kind of pain can be caused by an injury, surgery or other specific reason. Chronic pain lasts over a long period of time and can come from a less-specified cause. There are also medical conditions linked with chronic pain. Prescription opioids can be used to treat pain in those with advanced cancer, in palliative care or for end-of-life care. Long-term use of prescription opioids for chronic pain can increase the risk of addiction.

The opioid epidemic stems from the 1990s when the quantity of prescription opioids greatly increased and prescription practices were greatly relaxed. Over the last few years, it has become clear that these drugs have negative consequences that include opioid misuse, abuse, diversion and death. Because of this, prescribing practices have changed to shorter lengths and smaller doses.

What are the new prescribing rules?

New rules for prescribing opioids have been implemented in a stair-step method by the Ohio State Medical Board. They include rules that took effect in August 2017. The rules impact opioid prescribing for those with acute pain in the outpatient setting. The specifics of the rules include:

  • Considering non-opioid treatments before an opioid is prescribed
  • Prescribing the lowest strength of an opioid for a patient
  • Telling the patient (or the guardian if the patient is under age) of all the risks of being on a prescription opioid
  • Documenting the choice to use an opioid and the information passed on to the patient
  • Not prescribing an extended-release or long-acting opioid analgesic for acute pain

If an analgesic opioid (also known as a prescription opioid) is prescribed for acute pain, the prescription cannot last more than seven days for adults and five days for minors. Refills will not be allowed.

Additional rules were implemented in December 2018 for patients receiving chronic opioids who have a dose escalation (going up) and define the maximum opioid morphine equivalent daily dose (MED) that a physician (not palliative medicine or pain medicine certified) can prescribe without consulting a “specialist.” These rules include:

  • At MED > 50, a healthcare provider must document that a consultation with a specialist was considered.
  • At Med > 80, a healthcare provider must obtain a consultation with a specialist.

What is MED and what does that mean for a prescription?

The morphine equivalent daily dose (MED) is a way to measure the dosage of a prescribed opioid that is converted to equal amount of morphine. For example, 4 tablets per day of Oxycodone at 5 mg each is equal to 30 MED.

In the new rule, the MED cannot be more than 30 MED per day. See the chart below for MED conversions.

What is equal to 30 morphine equivalents daily?

  • Opioid: Oxycodone 5 mg
    • Quantity equal to 30 MED: 4 tablets per day
  • Opioid: Oxycodone 10 mg
    • Quantity equal to 30 MED: 2 tablets per day
  • Opioid: Hydrocodone: 5 mg
    • Quantity equal to 30 MED: 6 tablets per day
  • Opioid: Hydrocodone 7.5 mg
    • Quantity equal to 30 MED: 4 tablets per day
  • Opioid: Hydrocodone 10 mg
    • Quantity equal to 30 MED: 3 tablets per day
  • Opioid: Hydromorphone 2 mg
    • Quantity equal to 30 MED: 3 tablets per day
  • Opioid: Hydromorphone 4 mg
    • Quantity equal to 30 MED: 1 tablet per day
  • Opioid: Tramadol 50 mg
    • Quantity equal to 30 MED: 6 tablets per day
  • Opioid: Tapentadol 50 mg
    • Quantity equal to 30 MED: 1 tablet per day
  • Opioid: Morphine IR 15 mg
    • Quantity equal to 30 MED: 2 tablets per day
  • Opioid: Codeine 30 mg
    • Quantity equal to 30 MED: 6 tablets per day
  • Opioid: Codeine 60 mg
    • Quantity equal to 30 MED: 3 tablets per day
  • Opioid: Oxymorphone 5 mg
    • Quantity equal to 30 MED: 2 tablets per day

Are there any exceptions to this rule?

The time limits for an acute prescription (seven days for adults and five days for minors) can be extended in a few cases.

  • Traumatic crushing of tissue
  • Amputation
  • Major orthopedic surgery
  • Severe burns
  • Pain that is expected to last longer than seven to five days

When a prescription opioid is used for longer than seven or five days or exceeds the 30 MED rule, the healthcare professional must document it fully in the patient’s record. The reason for using an opioid and the reason behind the dosage must be explained in the record. A prescription that is more than 30 MED for the daily dose or lasts longer than seven days for an adult or five days for a minor, can be subject to review from the State Medical Board.

The rule doesn’t apply to the below situations:

  • Patients in palliative care
  • Patients diagnosed with a terminal condition or in advanced treatment (advanced cancer treatment, for example)
  • Patients in Hospice for end-of-life care
  • Patients being treated for opioid addiction with a substance approved by the FDA for opioid detoxification or management
  • Inpatient prescriptions

Who can and can’t prescribe opioids?

Advanced practice registered nurses (APRNs) and physician assistants (PAs) working in walk-in settings like Express, Walk-in, or Urgent Care Clinics cannot prescribe opioids. Healthcare providers with a DEA number (Drug Enforcement Administration) can prescribe opioids.

Last reviewed by a Cleveland Clinic medical professional on 05/02/2019.

References

  • The Ohio State Medical Board. Prescribing of opiate analgesics for acute pain. (https://med.ohio.gov/Portals/0/DNN/PDF-FOLDERS/Laws-Rules/4731-11-13%2C%20eff%208-31-17.pdf) Accessed 6/26/2019.
  • The Center for Disease Control and Prevention. Opioid Overdose. (https://www.cdc.gov/drugoverdose/index.html) Accessed 6/26/2019.

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