Alternative Facts on Opioid Risk

Alternative Facts on Opioid Risk | Dr. Jeffrey Fudin

While media muckrakers and anti-opioid zealots continue to fuel a fire of opiophobia and political strategists march like zombies in a parade of vote-seeking rhetoric, a simple fact remains ignored.  

Morphine Equivalent Daily Dose (MEDD) equal to or above 100mg per day scores third on the risk scale for opioid-induced respiratory depression (OIRD).

Government agencies and third party payers continue to employ MEDD limits while ignoring other equally or more important factors that influence risk of opioid-related deaths, including that opioid abuse does not equal chronic opioid use in legitimate patients.  

Opioid dose alone is not at the top of the list for items that increase risk of opioid-induced respiratory depression.  

And even if it were, as I’ve written about many times before (See The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development), an opioid dose in one person is not necessarily equivalent to that same dose in another.

Furthermore, there is no universally accepted morphine equivalent daily dose to make that calculation even if it were.

And, to make matters worse, the recently posted CDC online opioid calculator is grossly flawed for morphine to methadone conversions to the point of being dangerous.

I write this post today though to highlight that while all drugs, including opioids, have elevated toxicity as the doses increase, opioids are unique in that tolerance develops to various toxicities if the dose is escalated slowly, but there are well-known co-prescriptions that elevate the risks for all patients, opioid tolerant or not.

Somewhere lost in the crossfire of anti-opioidism are these very real dangers that I believe are masked to patients and clinicians by a political veil.

In Zedler and colleagues’ recent article, it is clear that taking antidepressants and/or benzodiazepines carry a higher risk than 100mg MEDD

In other words, rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher.

Many, many pain patients are prescribed both opioids and antidepressants – like me. While I hear that antidepressants are supposedly only useful for their placebo effect, I have tried several and found that several are useless for me but others have helped me greatly, perhaps even saved my life.

Does this mean we should not be offered relief from our potentially suicidal depression caused by our intractable pain?

With 90% confidence, the RIOSORD establishes that for patients taking opioids, concomitant antidepressants or benzodiazepines elevated the risk score higher than a MEDD exceeding 100mg per day.

This can be seen in Table 3 of her publication and is pasted below for a quick look.

An ethical and moral question remains unanswered;

Why do feeble journalists, politicians, and even some clinicians continue to hang their hats on MEDD alone while ignoring very real evidence that other factors are equally or more important?

listing of Table 3 

In the past 6 months, has the patient had a health care visit (outpatient, inpatient, or ED) involving any of the following health conditions?
(each question has a point value for ‘yes’ answers I’ve listed after the question)

  • Substance use disorder (abuse or dependence)?  25
    (This includes alcohol, amphetamines, antidepressants, cannabis, cocaine, hallucinogens, opioids, and sedatives/anxiolytics)
  • Bipolar disorder or schizophrenia?  10
  • Stroke or other cerebrovascular disease?  9
  • Kidney disease with clinically significant renal impairment?  8
  • Heart failure?   7
  • Nonmalignant pancreatic disease (e.g., acute or chronic pancreatitis)?  7
  • Chronic pulmonary disease (e.g., emphysema, chronic bronchitis, asthma, pneumoconiosis, asbestosis)?  7
  • Recurrent headache (e.g., migraine)?  5

Does the patient consume:

  • Fentanyl?  13
  • Morphine?  11
  • Methadone?  10
  • Hydromorphone?  7
  • An extended-release or long-acting formulation of any prescription opioid?  5
  • A prescription benzodiazepine?  9
  • A prescription antidepressant?  8

Is the patient’s current maximum prescribed opioid dose ≥100 mg morphine equivalents per day?   7
(Include all prescription opioids consumed on a regular basis)  

Total point score (maximum = 146)



2 thoughts on “Alternative Facts on Opioid Risk

  1. Laura P. Schulman, MD, MA

    Dr. Fudin is actually a PharmD, a pharmacist, and not a medical doctor. While I appreciate input from pharmacy, I find it aggravating that someone who does not see patients would present himself as “Doctor,” not because I feel that non-physicians don’t deserve to use the title, but because I think the lay public already has trouble figuring out who to listen to. The article you quote here is a good example why pharmacists need to distance themselves from patient management: If patients in pain are scored on risk factors prior to initiating treatment, then those of us who have asthma, or are in treatment for depression and anxiety with certain medicines, might well be sent away in pain, because our pharmacist thinks we are too high risk. Yes, even if our physician has written a prescription, the pharmacist (who may very well start calling him/herself “Doctor,” just to further confuse things) might look at our records and decide we meet threshold for refusing to dispense.

    Liked by 1 person

    1. Zyp Czyk Post author

      Dr. Fudin has been a very active and high profile advocate for all chronic pain patients. He interacts with many patients and thus has unusual understanding and sympathy for our condition, so I trust his views and am very grateful to have his help in our battle against the abomination of the CDC guidelines.

      However, I do agree it’s confusing when everyone starts calling themselves a doctor. Most pharmacists don’t have anywhere near Dr. Fudin’s competence and experience, so I would protest if they tried to use the title. In this case though, it gives his advocacy a stronger voice in the debate.



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