Effect of a Multidisciplinary Review Panel on Daily Morphine Milligram Equivalents for Patients With Chronic Pain

Abstract

Introduction/Objective:

Physicians and other health care professionals are challenged regularly to balance managing pain for patients with chronic pain receiving chronic opioid therapy (COT) with following the national guidelines and standards regarding daily morphine milligram equivalents (MME). This quality improvement project aimed to determine the effect of referral to a multidisciplinary review panel on daily MME for patients receiving COT for chronic pain.

Methods:

This quality improvement project included patients who had an established relationship with a primary care or community internal medicine clinician at a large health care organization and were referred to a newly created multidisciplinary review panel for their recommendations regarding treatment of pain. Criteria for patient referral were diagnosis of a chronic, painful condition, and use of chronic opioid medications. These patients were selected and referred at the discretion of their primary care clinician from January 2, 2019, through December 31, 2020. Data for this project were collected at the time of initial referral to the panel and 6 months after recommendations. The daily MME were assessed at the 2 time points.

Results:

Thirteen patients were referred to the review panel during the project period. The median daily MME at the time of referral was 180. Daily MME decreased by a median of 14 MME after 6 months. The MME did not increase during the project period for any participants.

Conclusions:

Referral of patients receiving COT to a multidisciplinary review panel may reduce their daily opioid dose.

Introduction

Managing patient use of chronic opioid therapy (COT) remains a challenge for clinicians in all specialties, but this responsibility most often rests with primary care clinicians. ¹ The use of COT has been brought into the national spotlight with the increasing numbers of deaths attributed to overdose from COT.^2,3 Suicide deaths are strongly associated with opioid prescribing, and reductions in opioid prescribing in communities are associated with decreased suicide rates. ⁴ Various stakeholders (national and state governmental agencies, medical organizations, health care organizations, and consumer groups) have been involved in overseeing and regulating the various aspects of opioid prescribing and management of COT. The misuse and abuse of prescription opioids also carries a substantial economic burden. ⁵

A special communication published by the Centers for Disease Control and Prevention in 2016 ⁶ and further refined in 2022 ⁷ proposed 12 recommendations regarding opioid prescribing for primary care clinicians. Recommendation 4 is that clinicians should avoid prescribing more than 50 morphine milligram equivalents (MME) per day or else carefully justify the decision to increase it beyond that level because higher doses generally do not afford additional benefit in pain reduction or improved function. ⁸

The treatment of chronic pain during the opioid crisis has also presented opportunities for organizations to develop and optimize institutional approaches to care. The current trend within organizations is continued decreasing of MME levels, in accordance with the recommendations from federal and state agencies. Thus, various strategies have been considered to assist clinicians in reaching these new goals, such as providing educational tools for patients and clinicians regarding the use of nonopioid treatments for chronic pain. Many such nonopioid and nonpharmacologic treatments have shown efficacy in numerous studies. These treatments range from well-established therapies such as osteopathic manipulative treatments to more novel treatments such as mindful meditation (Box 1).^{9 -13}

Box.

Nonopioid and Nonpharmacologic Treatments for Chronic Pain.

Nonopioid

Antidepressants

Anticonvulsants

Nonpharmacologic

Meditation and yoga

Dialectic behavioral therapy

Osteopathic manipulation

Exercise

Smoking cessation

Other interventions, including facet injections or spinal stimulators

Resources available to clinicians to assist in the management of COT vary widely by region. Clinicians and organizations continue to search for innovative pain management strategies for these patients and strategies to abide by the national standards to reduce the daily MME to the recommended levels of less than 50 MME per day. This quality improvement project aimed to determine the effect on daily MME in patients receiving COT for chronic pain who were referred to a multidisciplinary review panel.

Methods

Our institutional review board acknowledged that, in accordance with the Code of Federal Regulations, 45 CFR 46.102, this project constituted quality improvement and did not require review. A multidisciplinary review panel was created at our facility consisting of a primary care physician (also serving as moderator) and physiatrist (both Doctors of Osteopathic Medicine), a pharmacist (Doctor of Pharmacy), and a psychiatrist (Doctor of Medicine). All were certified in their respective specialties. A similar, but expanded, program at another region in the health system is described in detail by [withheld for anonymous review]. ¹⁴

The purpose of the review panel was to be a resource for clinicians seeking additional recommendations on the treatment of pain for specific patients. Each group member made recommendations based on their individual area of expertise. It was not the specifically stated intention of the panel to decrease the daily MME for the referred patients. Rather, this project was undertaken retrospectively to assess the effect of the panel on daily MME. Information regarding the availability and use of the review panel was disseminated to all family medicine and community internal medicine clinicians in the organization. These primary care clinicians referred patients to this review panel from January 2, 2019, through December 31, 2020. All patients who met the inclusion criteria—older than 18 years, presence of a chronic painful condition and diagnosis, and using COT—were reviewed by the panel and included in the project. There were no exclusion criteria.

After a patient referral was made, the panel members would independently review the patient’s health record. Review included relevant office notes, imaging reports, laboratory results, physical therapy notes, and specialist consult notes. The patients were not physically examined or interviewed by the panel members. The panel then would meet as a whole to discuss recommendations to be made, which were communicated to the referring clinician. For the purposes of this project, the specific recommendations made are not included. The specific recommendations were individualized to each referred patient and could not be standardized for the purposes of replication.

At the time of initial referral and at 6 months after recommendations were made, the daily MME was calculated for each patient by using the Washington State Agency Medical Directors Group MME Calculator (https://agencymeddirectors.wa.gov/Calculator/DoseCalculator).

Results

Among 13 patients included in this review (7 men and 6 women), the median age was 54 years (Table 1). All of the patients were receiving COT for a chronic pain condition. The primary diagnosis listed in the referral was “chronic pain syndrome.” The median MME at the start of the project period was 180 (range, 30-435). The MME decreased by a median of 14 for all patients, with women having a larger median decrease than men (26.25 vs 10 MME) (Table 1). MME did not increase during the project period for any participants. No deaths were reported, and no participants were lost to follow-up during the project period.

Table 1.

Participant Characteristics and MME. ^a

Characteristic	All patients (N = 13)	Men (n = 7)	Women (n = 6)
Median age, years	54	53	58.5
Race, White	13	7	6
Median MME
Initial	180 (30-435)	90 (30-435)	273.5 (30-400)
6 months	130	70	177.5
Median change	−14	−10	−26.25

Abbreviation: MME, morphine milligram equivalents.

^aValues are median (range) or No. of participants.

Feedback received from the referring physicians was positive. Although a formal metric was not used to assess satisfaction, referring physicians stated that the recommendations enhanced patient care while simultaneously reducing the daily MME.

Discussion

Treatment of chronic pain is complex, and coordinating resources and adjunctive therapies can sometimes be a daunting and time-consuming task for clinicians. This is further complicated by the varying guidelines providers must follow. States have varying guidelines for MME. For example, Maine has a 100-MME daily limit except for cases of terminal pain, ¹⁵ and California has specific guidelines about using doses higher than 80 MME. ¹⁶ Wisconsin strongly discourages physicians from prescribing more than 90 MME per day and requires 2 h of continuing medical education every year regarding responsible opioid prescribing.^9,17 In addition to following the national and state guidelines for MME, other organizational strategies and recommendations may be in place for clinicians to follow in chronic pain treatment.

Because of the complexity and constant change in the treatment of chronic pain and the use of opioid medications, providing a resource that will provide meaningful clinical advice may improve a patient’s pain while at the same time reducing their daily MME. As clinicians continue to look for ways to treat patients with chronic pain while adhering to the national standards of reducing daily MME, a multidisciplinary review panel, such as that described here, may be helpful in many settings. In this quality improvement project, patients referred to the review panel had lower daily MME 6 months after the review. The reduction in MME would indicate that this review was helpful. Feedback from referring providers also indicated benefits of the review. This project had several limitations, however. The sample size was small, and a control group was not used to compare whether daily MME was generally decreasing in the patient population at large compared with the cohort. Also, the specific panel recommendations were not studied to assess their effect on daily MME.

Although research is ongoing to evaluate effects of and best strategies to assist with tapering of COT, a survey of patients with chronic noncancer pain and their family members showed a high rate of respondent interest in clinical trials to assess strategies to reduce MME, and many respondents believed that further exploring alternative pain management options would also be important. ¹⁸ How best to do this, however, while balancing pain management and also being aware of recommendations and guidelines, can be challenging. Use of a multidisciplinary review panel for patients using COT did show a reduction in MME after 6 months and may be an effective way to support providers who manage COT for these clinically complicated patients.