I’ll share an interesting story about the data used for the prescription drug database in Wisconsin and other states. I’ve been holding back on writing about this issue in hopes that the reason for the story would be corrected, and I would have no story to tell. But that hasn’t happened. Brandeis and CDC made wrong calculations on buprenorphine PDMP Data.
A new law in Wisconsin requires all prescribers to check the prescription drug database when prescribing any controlled substance. I’m surprised that no privacy advocates have complained about the database, which tells prescribers about the controlled substances used by their patients over the past 5 years, the pharmacies their patients used, and any suspicions of law enforcement about their patient in regard to controlled substances. The database, or PDMP, is a significant tool for preventing doctor-shopping and diversion. But the PDMP provides a great deal of information about activities by patients that they rightfully believed to be private just a few years ago.
But this story isn’t about privacy. I’ll leave that for another day. This story is about the information provided by experts at the CDC, the top health agency in the world, about buprenorphine. A mountain of nonsense about buprenorphine permeates healthcare, law enforcement agencies, and addiction treatment programs. But one could optimistically expect the CDC to get it right. Right?
When a prescriber follows the new law and looks up a patient on the PDMP, the web page includes a graph that displays the patient’s use of opioids over the past three months, displayed as the oral morphine equivalence. The graph has a blue line on the graph that represents 50 mg of oral morphine per day, and a red line that represents 90 mg of morphine per day. Another line represents the patient’s daily opioid dose, and the entire graph is shaded red during the time that the patient also used benzodiazepines. Neat!
For most patients, the red and blue lines are clearly visible, and the patient’s opioid use is displayed in relation to those lines. But for patients on buprenorphine, the red and blue lines are pushed against the bottom of the graph by the line that shows the patient’s opioid usage. Why? Because according to the PDMP, a patient on 16 mg of a buprenorphine medication is taking the equivalent of 900 mg of morphine per day!
Anyone with a basic understanding of buprenorphine knows about the ceiling effect of the drug. Unlike with opioid agonists, the opioid potency of addiction-sized dosages of buprenorphine cannot be directly extrapolated from the potency at lower dosages. With oxycodone, 10 mg of the drug is ten times stronger than 1 mg of the drug. With buprenorphine, 2 mg of the drug is about as potent as 8 mg, which is about as potent as 24 mg. The PDMP, though, shows 16 mg of buprenorphine to be 16 times stronger than 1 mg of buprenorphine.
When I noticed the error in the data I emailed the people who developed the Wisconsin PDMP. They responded and wrote that they appreciated the information, but Brandeis University provided the data about opioid dose equivalency, so Brandeis was responsible for the accuracy (or lack of accuracy) of the data.
So I wrote to the folks at Brandeis who provided the information for Wisconsin and other states’ PDMPs. They responded that THEIR information comes from the CDC, and so the CDC was ultimately responsible for the dosage conversion data. They also said that doctors shouldn’t use the information for opioid dose conversions, and there was no danger to that effect because of the fine print at the bottom telling doctors to avoid using the information in that way.
I wrote to the CDC, cc’ing everyone and their cousins to make certain that the right person received my email. I wrote, respectfully, what I’ve written here—that the information about buprenorphine failed to take the ceiling effect into account, and that the misinformation could potentially lead to patient harm, if a doctor did what doctors tend to do, i.e. use the most readily available information about dose equivalency and trust that information, especially if it comes from an official site like their state’s Prescription Drug Database.
The CDC replied with a form-email. Given that a genuine response takes about one minute, I can’t believe that the person who received my email saved a significant amount of time by searching out that reply, but I suppose we citizens would become spoiled if the government responded personally! The form email thanked me for my interest in the CDC, and provided a link where I could read more about the great work they do.
I admit that I get worked up about things sometimes. And yes, I was annoyed to get a form email providing a link to more information from the CDC, after writing to correct their wrong information. So I sent an email expressing that annoyance to everyone in the story up to this point. I’m sure that at least a few of the people in the ‘to’ box had a good laugh, and I suspect that I annoyed a few more. Whatever.
A couple weeks later I noticed a new paragraph under the dose-equivalence graph, telling doctors to avoid using the opioid dose-conversion information to actually convert opioid dosages. The small print at the bottom of the page was made larger, and placed higher in the page, directly below the display of morphine equivalents. I don’t know if the change had anything to do with my emails or was only a coincidence.
But then yesterday I received an email from one of my patients, after he consulted with his surgeon about an upcoming operation. The patient wrote about that doctor, paraphrasing a bit: “she showed me a graph that said my tolerance is equal to 900 mg of morphine. I don’t know what that means exactly but she will need to give me a high dose of pain medicine without killing me.” I eventually spoke with that doctor. Guess where the graph came from?!
This the punchline by the way, in case you’re skimming the story. The patient wrote that his doctor used the PDMP to convert the amount of morphine he would need after surgery, in spite of the ‘warning’ on the web site. What a shock!
I shared my patient’s email with the people at the WI PDMP, Brandeis University, and the CDC, letting them know that even though they added a paragraph to their data telling doctors that their data was nonsense, doctors STILL used that data in a way that could kill somebody.
Should they be proud of that misplaced trust? I have no idea. But why don’t they just USE THE CORRECT DATA??!!
John Nienow MD · April 27, 2017 at 6:02 pm
What can possibly be the point of such data? Buprenorphine is not a drug that one “converts” to from an “equianalgesic” dose, in the same manner as switching from oxycodone to fentanyl. It’s hard for me to understand what the utility is. Do authorities not even understand the unique pharmacology?
Jeffrey Junig MD PhD · April 27, 2017 at 7:34 pm
The paragraph on the PDMP web site says that the information shouldn’t be used to convert between opioids, but at the same time, the data is presented as opioid-equivalency compared to morphine. I see your point, that it isn’t really even appropriate to include the data in that way.
Interestingly, the PDMP in Wisconsin does NOT include methadone dispensed for addiction treatment, even though drug interactions are potentially more dangerous in those cases. In a logical world, the methadone data would be more important than the buprenorphine data.
As for the unique pharmacology, I don’t know if anyone receiving my emails understood my point. Nobody acknowledged the simple point I was trying to make– that you can’t just take the potency at 200 micrograms and extrapolate in a straight line.
JEFF · April 28, 2017 at 3:00 am
Very interesting post. This is kind of scary — it is unbelievable how little most doctors know about this drug which is why a lot of them will go to sites like this for information. 900mg of morphine equivalence is just ludicrous. Makes ya wonder just how this could be published on such a “revered” site. I have observed too many idiots holding jobs of high positions – it’s not what you know but who you know on how you rise to the top and this was likely written by someone who shouldn’t be in that position. Anyone ever heard of Double Checking or Verifying data – Especially on a CDC website in which MD’s go for info???
LISA M. NOYES-DUGUAY, M.D. · April 28, 2017 at 6:21 am
I applaud you on this article. I sent an email to the folks at the RI PMP about the morphine equivalents reported for Suboxone as well and received no reply. I don’t think they know how to address this issue so they ignore it and we, as providers, look like we are irresponsible with our prescribing which clearly is not true!
Courtney Brown · April 30, 2017 at 1:16 pm
First, I just wanted to say thank you for your continued efforts, Dr.Junig. I agree, this is very scary. I wondered, as Dr. Nienow did, what could be the point of this data? Also, is this the same in the state in which I currently reside (DE)? Turns out it is. So now my question is, what can we (your readers) do about it? As always, I will be sharing your blog with the groups I’m currently involved with and would just like to know if you have any suggestions?
Jeffrey Junig MD PhD · April 30, 2017 at 1:58 pm
I’m not sure how it is displayed for other states, but when patients are looked up in Wisconsin a graph is displayed that shows the dose of opioids over the past few months. That information is charted alone with reference lines for 50 or 90 mg morphine per day, and the entire chart is shaded red if benzodiazepines were prescribed at the same time. If the patient fills the prescription 2 days early, the line indicating use spikes higher, as if the medications from those two days were suddenly added on to the amount of opioid taken by the patient.
I’m admittedly cynical on this issue, but I don’t want to assume the motives for the graph. The PDMP is very useful in other ways. The good thing about the graph, I suppose, is that it gives a quick, superficial look at the amount of opioid taken by the paitent (or more accurately, taken out of the pharmacy by the patient!). The cynical view is that the graph is intended to shame doctors for prescribing opioids, or to encourage them to reduce prescribing opioids. And of course that is a goal right now for public health agencies as well as law enforcement. I suspect some physicians feel a cold chill about having their prescribing practices displayed in that way. And maybe they SHOULD feel a chill.
I don’t think anyone is deliberately trying to make buprenorphine treatment look bad. But so many physicians lack even basic understanding about buprenorphine, a medication that has been prescribed in the US for almost 15 years– and it won’t help anyone to throw out more misinformation.
I don’t know what else to do. One idea is to leave buprenorphine off the chart completely, just as methadone is left off for privacy concerns. But my argument has also been that addiction should be treated just as we treat every other chronic illness, and it may be harmful in the long run to keep pretending that there is a dividing line between the disease of addiction and other diseases that have a behavioral component (which would be most diseases).
The best thing would be to just get the data correct. That would not be difficult; the challenge would be arriving at consensus on the maximum opioid effect possible from buprenorphine. My calculations, based on numbers we all agree upon, place that morphine equivalence at about 110 mg oral morphine.
Finally I’ll note that there are a number of opioid conversion calculators on the internet. Some are better than others, but they all make a similar mistake. But the data is much more dangerous when placed on a site associated with the US Government, as doctors are more likley to assume the information to be accurate.
Kevin · December 8, 2017 at 3:44 pm
I have switched from methadone to suboxone before and my pain management doctor-fearutred on many shows talking about how buprenorphine is a great medication. He is well aware of your work also. Any way when I wanted to switch to suboxone he had me to get down to 30 mg of methadone and then not take any for 48 hours – he gave me a few morphine tablets to help deal with withdrawals. I was inducted after 48 hours with no problems. My question is I eventually switched to hydro morph contin 24 mg twice daily. I want to get back on the suboxone. I no longer have access to my last pain management specialist and my new one is nice but I don’t think he understand as well how to switch back to buprenorphine. Could you give some guidance that I can discuss with him please it would really be appreciated. Thanks so much. Also thank you for your blog and videos I am sure they have helped thousands and thousands of people and tons of doctors. Kevin
Jeffrey Junig MD PhD · February 1, 2018 at 8:13 pm
Thank you very much for your nice comments. I appreciate your comments about induction after methadone; I do those from time to time and I wish I had more data on the length of time necessary before induction. Methadone is SO variable between people, in so many ways– different metabolisms, different degrees of protein binding, different sensitivities to side effects like sedation, etc– so maybe the problem feeling comfortable comes from the fact that some people need more time than others.
I’m not that familiar with hydromorph contin. You must be Canadian? That’s a hard-core opioid…but anyway, your first doctor was incredibly kind to give you morphine while waiting for the methadone to leave your system. That is not exactly legal in the US since about 1913 (maybe it was legal, since you were treated for pain). But with the hydromorph the induction delay depends on whether you swallow the pills, or cruch them and use them nasally or IV. The drug itself is metabolized quickly, on the same order as heroin. But since it is extended release, it sits in your gut for 12-24 hours. I don’t have direct experience but I would want a person to wait 36 hours after swallowing hydromorph contin. If the person was crusing it and using it, I woudl think 24 hours would be plenty of time.
Jeffrey Junig MD PhD · February 1, 2018 at 9:12 pm
I’m sorry– I was away from this blog for several months. Let me know if you still have questions– I answerd this post on another page as well.