HealthAugust 29, 2016

CDS screening: A proactive approach to morphine equivalent dosing

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Morphine equivalent dosing (MED) determines a patient’s cumulative intake of any drugs in the opioid class in an effort to help reduce the likelihood of overdose. The primary side effect of opioid overdose is respiratory depression, which frequently leads to serious complications or death. No one wants that.

While there are morphine milligram equivalent tables available and ways to calculate MED, the fact of the matter is that many healthcare organizations take a reactive approach. Basically, nurses monitor patients for telltale signs of too high an intake of opioids — such as constipation and early markers for respiratory depression. The team can then respond after inappropriate dosing has occurred to counteract the already discernible effects of potential overdose.

Technology now presents a solution to help hospitals and healthcare businesses be more proactive and avoid opioid overdose in the first place, rather than monitor, wait, and take action after the fact. EMR-integrated MED screening takes into account patient profile, prescription, and medication administration data within the electronic record to generate a warning of potential opioid overdose before it occurs.

How does MED screening work?

In its 2014 Call Letter, the Centers for Medicare & Medicaid Services (CMS) encouraged institutions’ P&T committees to develop specifications for cumulative MED as part of their own formularies and guidelines based on the institution’s philosophy and needs. If the functionality is available, an institution can customize its EMR MED screening to recognize a hospital-wide threshold that matches its specific opioid guidelines.

Each opioid is given a potency score compared to morphine as a base level. MED is the sum of the potency score of all opioids a patient is likely to take, and that total is used to determine if the patient is nearing a potentially dangerous threshold.

MED comes into play at the prescriber level — when an order is written — and again at the nurse administrator level. It becomes especially helpful when dealing with patients taking PRN medications, to help administrators calculate the maximum daily dose of all a patient’s possible combined PRNs. A warning could be generated during either of these activities.

MED screening can also be employed as a safety check on the commercial side of healthcare, potentially alerting retail pharmacists to a patient exceeding the threshold, so that they can return to the prescriber for verification or to recommend an alternative therapy.

Determining a threshold

CMS publishes morphine milligram equivalent tables. In its 2017 Call Letter draft, CMS recommends to its sponsors a point-of-sale (POS) soft edit threshold of 90-120 mg daily cumulative MED when ordered by two or more prescribers of the overlapping opioid prescriptions, and a hard edit threshold of 200 mg. In 2013, CMS determined that approximately 775,000 beneficiaries (or 2% of Medicare Part D enrollees) met or exceeded 200 mg MED for at least one day. That number does not take into account cancer or hospice patients, which CMS advises not be considered when determining the appropriate threshold for acute pain management patients.

In addition to chronic pain management and oncology, MED also does not apply to pediatric pain management. It is specifically intended to be a measurement of acute adult prescriptions.

MED is only truly useful in clinical screening scenarios, as it evaluates safe administration. It is intended to help prevent opioid overdose, not to flag potential narcotic diversion or addiction.

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