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Terrence Brown is a 71-year-old male with neuropathic pain due to diabetic peripheral neuropathy, managed with oxycodone 10mg/acetaminophen 325mg (Percocet) prescribed 4 times daily. A thorough examination of his medication requires calculation of his morphine milligram equivalents (MME) followed by a thorough evaluation of CDC guidelines regarding opioid prescribing. By estimating his average daily MME and comparing it to established CDC standards, we can determine whether Mr. Brown’s current medication regime is justified or requires enhanced monitoring/interventions.

Calculated Terrence’s MME (milligram morphine equivalent) – Determining Terrence’s MME started with identifying that oxycodone had an MME of 1.5. Terrence’s daily oxycodone dose was 40mg (10mg per dose, 4 times daily). Terrence’s calculated MME was as follows: 40mg oxycodone x 1.5 (=) 60 MME. The CDC indicated an MME of 50 or greater should be associated with further evaluation because of the increased risk of overdose and other serious adverse events. Terrence’s calculated MME was associated with a higher risk, and hence, further evaluation of Terrence and his treatment was warranted. This step established the importance of the MME, especially in older adults. Older persons experience further physiological decreases in their opioid receptors’ responsive ability. Thisfurthera patient’s risk associated withMMEs- a consideration that remains important within clinical evaluation.

Consideration for additional medical monitoring is advisable given Terrence’s MME level exceeds the 50 threshold and his age. The risks for increased opioid toxicity, falls, mental clouding, and overdose are “increased in older adults”.Given the limited information available on Terrence’s renal and hepatic function, history of drug use,polypharmacy, and co-morbidities, it would be appropriate to consult a pain management specialist or pain pharmacist about the appropriateness of dose escalation and potential drug-drug interactions.Gabapentinoids,SNRIs, or physical therapy have been shown to be beneficial if clinically appropriate and can minimize the use of opioids. Patient counseling and education of patient and family members about overdose risks and proper medication use, and adverse effects, also remain a priority. I am interested in hearing more from my peers regarding any experiences with interprofessional collaboration or other alternative therapies they may use for older adult patients.

Naloxone is recommended adjunct to Terrence’s opioid pain management strategy to significantly reduce the risk for opioid overdose. Terrence’s age and increased opioid daily MME durg (80mg) a prime predictor for development of adverse events related to opioids like overdose. According to Centers for Disease Controled and Prevention’s (CDC) Clinical practice guidelines for prescribing opioids, it is advised to concomitantly approach naloxone to any highest risk groups for opioid overdose predicted patients. Specifically patients on high daily dose i.e >50MME/day, polypharmacy and concurrent diagnosis(Dowell, 2022). With respect to our patient profile, naloxone adjunct can provide a significant therapeutic option in case of patient develops respiratory depression or overdose, which is more likely to develop in elderly people like Terrence due to variable pathophysiological effects. Appropriate education and counseling should be provided regarding drug to patient and caregiver for their useful management at these instances. Moreover, being non-controlled substance, it is a useful for comprehensive plan for opioid management in Terrence along with regular monitoring and follow up for continuation or discontinuation of therapy as addiction prevention strategy.

When considering the CDC’s Clinical Practice Guidelines (CPG) opioid therapy should only be considered when the benefit significantly outweighs the risks and the non-opioid therapy and non-pharmacologic therapy options are not tolerated, ineffective or are contraindicated in the patient. Guidelines for the treatment of neuropathic pain often suggest medications, such as duloxetine or pregabalin, before the cautious prescribing of opioids. Considering Terrence’s age is 67andhe suffers from diabetic neuropathy, his current medication therapy management plan may not be the ideal first line choice without other therapies failing or beingintolerated. The CPG does suggest that if there isnot other alternative appropriate options, then careful rationale and reassessment of patient opioid therapy is important. I would love to hear my classmates’ opinions on changing Terrence’s medication therapy management plan or whether they would keep it the same, considering the clinical picture.

Reference

Dowell, D. (2022). CDC clinical practice guideline for prescribing opioids for pain—United States, 2022.MMWR. Recommendations and Reports,71.https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?os=www.nbcchicago.com&ref=app

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