Strayerism – Morphine IR

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Tiffany A. -

What about for morphine non-responders? I had an opioid naive first time kidney stone patient who was getting zero relief despite maximizing repetitive doses of morphine, gave one dose of fentanyl and resolved all his pain. I'd love to send patients home on something like MSIR so that they can utilize tylenol/NSAIDs at therapeutic doses without risking toxicity, but if morphine didn't work in the department IV, will it work at home PO?

Reuben Strayer (@emupdates) -

Everyone responds to individual opioids (and every other drug) a little differently, and certainly some folks seem more susceptible to certain side effects of certain agents than others. I always recommend that, for outpatient analgesia, if you're concerned, do a test dose in the ED to demonstrate that it works at that dose for that patient, prior to discharging.

Saul N. -

This segment does not mention Tramadol. Wouldn't Tramadol make more sense instead of Morphine IR if we are concerned about addiction and an opioid is indicated? Is the concern that Tramadol is not strong enough?

Reuben Strayer (@emupdates) -

Tramadol and codeine, the so-called weak opioids, have greatly fallen out of favor with drug safety experts. Tramadol in particular is on the whole not particularly effective compared to non-opioids, not less abuse-prone than conventional opioids, and burdened by a number of unique and important adverse effects.

http://empharmd.blogspot.com/2015/05/three-reasons-not-to-prescribe- tramadol.html

Reuben Strayer (@emupdates) -

http://empharmd.blogspot.com/2015/05/three-reasons-not-to-prescribe-tramadol.html

Mark M., MD -

Wondering where the evidence comes from with many of these statements?

Lidocaine patch doesn't work (Palmer AmFam Phys 2017: 96(10) & Hashimi Mol Pain 2012:April 24:8:29)

Topical NSAIDS unpredictably similar to oral NSAIDS with the gel costing $1,050! (Derry Cochrane Database June 15, 2015 CD007402)

ACP 2017 Guideline on nonpharmacologic treatment of low back pain shows no significant benefit from the majority of these modalities.

Oral NSAIDS kill more patients in the US than any other medication (Wolf NEJM 1999;340:1888) and harmful with DM, HTN, CHF, CAD, PVD.

The "no opioid prescription > 3-7 days" by the CDC explicitly excludes patients with trauma or surgical procedures--and this is based upon the weakest level of science.

All of these recommendations are based upon the fear of addicting patients on opioids without making a distinction between low risk patients vs high risk patients. We have a lot of data in the post surgical opioid naive patient (some of which are still high risk) and the amount of long term use from short acting opioids is 0.4%.

Reuben Strayer (@emupdates) -

Hi Mark. The notion that injudicious prescribing leads to long term opioid use is not controversial anymore. It took us 20 years to figure it out, but now we know, some opioid naive patients who get a percocet script are set down the path to addiction by that script. Here are about 25 papers on the matter.

https://www.dropbox.com/sh/56tqogboid0r9ml/AAA_-05rIYrhVsxDZZpidr5va?dl=0

There are certainly ways to reduce the likelihood that you will cause long term harms with your prescriptions, including risk stratification. Unfortunately, we don't have evidence-based tools to guide us in risk stratification; which isn't to say that you shouldn't risk stratify based on what is currently felt to be best practice by consensus, but much better is to take measures to prescribe opioids more judiciously across the board, because most people who are currently discharged from ED with an opioid script would do very well without that script.

reuben

Mark M., MD -

While we do not yet have a tool, almost all of the literature on these topics are very consistent: Here are high-risk characteristics for long-term use & misuse (unfortunately these are not weighted).

1. Chronic pain patients
2. Addiction (including nicotine, alcohol, opioids, benzodiazepines, etc)
3. Psychiatric Illness (anxiety, depression, etc)
4. Electronically flagged individuals from pharmacies or medical facilities

The key word then is "judicious"- use judgment. If you have a high-risk patient with subjective complaints, use a non-opioid approach. If you have a low-risk individual with objective complaints, use whatever it takes including opioids. Why would we recommend a "one-size-fits-all-non-opioid-first" approach? That is not "judicious".

While one can claim an anecdotal report of some "normal" guy who went to the ED and got his first script of Percocet, and now he shoots heroin because it is cheaper--this kind of message is not supported by our best data concerning the opioid naive patient.

James W. -

Sorry I'm late to the party on this, but my understanding is that we are beyond anecdata and that the actual data do support the notion that opiate-naive patients, regardless of the classic warning signs, are at some risk of becoming long-term users just from that initial prescription.

A couple papers supporting this argument:
1. Miech R, Johnston L, O’Malley PM, Keyes KM, Heard K. Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics. 2015;136(5):e1169-e1177.
2. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term Analgesic Use After Low-Risk Surgery. Arch Intern Med. 2012;172(5):425.
3. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018 Jan 17;360:j5790.

The Miech article is particularly interesting because it actually identifies adolescents with the strongest anti-drug sentiments as those at highest risk of developing opiate misuse following a prescription.

Reuben Strayer (@emupdates) -

Absolutely agree with your consensus-based list; would add social dysfunction (isolated/unstable housing) and young age. #4 on your list I think is more evidence of misuse than risk factor for misuse, see these yellow and red flags: https://goo.gl/GtaCjC

Absolutely agree with the notion of using judgment to risk-stratify patients with regard to their likelihood to be benefitted and harmed by opioids, and in fact that is exactly I recommend: for every patient you're considering discharging with an opioid script, calculate the likelihood that patient will be helped or harmed by opioids, and if you think the balance favors helped, write a prescription in such a way as to minimize harms (small number of less abuse-prone opioid pills).

Furthermore, as I am always saying, the goal is not to reduce opioid use, the goal is to reduce opioid harms. The harms, in opioid-naive patients, come from the prescription (and more specifically, the duration of the prescription). Opioid naive patients who present to the ED in severe pain should absolutely be treated with "whatever it takes" at the outset of care, i.e. a multi-modal analgesic approach, including opioids.

Thanks for your comments.

reuben

Christopher K. -

Any thoughts on any liquid meds for our younger pediatric ortho patients? On a quick call most pharmacies near me only stock the Norco elixir when asking about meds at them (no morphine elixir at 2 of the local pharmacies I called).

Reuben Strayer (@emupdates) -

hi chris. appropriately dosed, round the clock acetaminophen+ibuprofen will go a long way in kids being discharged with fractures. if, after simple analgesia, fracture pain is sufficient to cause suffering, a couple days of an opioid Rx is appropriate. Codeine should be avoided in kids (not great in adults either, but should not be used in kids). Liquid morphine, hydrocodone, and oxycodone are all available and reasonable as a 1-3 day prescription for kids. I would be very, very cautious with outpatient opioids in teenagers - the are probably the population most likely to engage in misuse of prescribed opioids.

reuben

Garrett E. -

Hey Dr. Strayer. I'm an EM2 at an institution in Central Texas. I've recently received push-back from our clinical pharmacists/one of my attendings with regards to Rx'ing Morphine tabs for outpatient mgmt of pain (most recently, sent a bicep tendon rupture home w/ outpatient f/u with Ortho in 3d). They stated that this medication is typically reserved for "chronic pain" patients and those with advanced malignancies and are typically reserved for Rx by pain specialists/Oncologists and not for the ED setting. I had no data or literature to back up my use of Morphine IR other than this EMRAP episode, and would appreciate data/literature to read up on so that I can rebut my colleagues and be able to better adopt this practice.

Thank you for your work and input!

Reuben Strayer (@emupdates) -

hi garrett. note that optimizing your prescription opioid choice is the least important of the 3 ways to make the development of long term opioid use from your prescription less likely. Far more important:

1. reduce the number of patients you send home with an opioid prescription
2. in those that you do send home with a prescription, prescribe a small # of pills.

If you focus on those two strategies, you will make a huge impact, without changing the opioid preparation you choose. So I would not die on this hill, certainly not as a resident. But here is some literature. Note the poster, this will be published soon in an EM journal.

https://www.dropbox.com/sh/zx9o24k6t2mksgt/AACofZxAXYihe-zagaDBXOXza?dl=0

Gregory T., M.D. -

Reuben,
I have prescribed oral morphine twice over the last few months and had no problems. My concern is that when prescribed every 4 hours, it is 90 mg per day which is likely to raise red flags. Have you seen problems with this? Do you also prescribe naloxone with it?

Reuben Strayer (@emupdates) -

Thanks for the question, Gregory.

The 90 MMEs per day is a red flag in *chronic* opioid therapy, not for a 3 day supply.
Also, I now generally prescribe one half tab every 4 hours instead of the full 15 mg. Note that in other countries the smallest tab is 5 mg; for some reason in the US the smallest tab is 15 mg.

Prescribing or dispensing nasal naloxone with any opioid script is excellent practice.

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