OpioidCalc App, a calculator of the total daily morphine milligram equivalents (MME)

There are many methods of managing pain. One of the methods is using opioid analgesics, usually if other methods to relieve pain are not effective. But, opioids are often overused, meaning they've been prescribed even if there's no proven benefit.

Data shows that the use of prescription opioid analgesics has increased 10-fold over the past 20 years in the US. These opioids are mostly prescribed as an effective way to manage certain types of acute pain and cancer pain, but they are also used in manners other than prescribed and without prescriptions, which presents a serious problem for public health.

Opioid analgesic misuse constitutes a national epidemic, often leading to addiction and overdose, and eventually death. In 2011, nearly 17,000 individuals died from opioid analgesic–related overdose deaths in the US. 

There is a correlation of overdose and overdose-related deaths with opioid prescribing patterns, meaning that higher opioid dosages are associated with increased risk of overdose. Opioid dosages greater than or equal to 100 morphine milligram equivalents (MME) per day increase overdose risk by nine times compared with lower dosages (up to 20 MME).

The important fact is that all these deaths are preventable. This effort requires better awareness about the problem and smarter opioid prescribing patterns.

Health care providers should play a critical role in reversing the epidemic of opioid analgesic misuse and overdose. There are lot of actions and campaigns across the US trying to raise awareness and provide resources that would be useful for both providers and patients to help decrease opioid analgesic misuse and its health consequences.

New York City is one of the jurisdictions that have been significantly impacted by the opioid analgesics misuse and overdose. It has been estimated that during a 13-year period (2000-2013), the rate of opioid analgesic overdose deaths increased by 256%. In 2013, a total of 215 New Yorkers, or more than one person every other day, died from opioid analgesic overdose. 

That's why the New York City Department of Health and Mental Hygiene (DOHMH) started using a complex, 'multi-pronged' approach to address the problem of opioid misuse and overdose, which includes developing an innovative public health drug surveillance system, promoting overdose prevention with Naloxone, improving access to addiction treatment, conducting public education media campaigns, etc.

DOHMH also has published opioid prescribing guidelines that summarize key principles of safe and sensible prescribing practices, one of which is to avoid high-dose opioid prescriptions or ≥100 MME/day. As a part of that effort, presuming that healthcare providers who prescribe opioids might not be familiar with calculating morphine milligram equivalents per day, NYC DOHMH with support from CDC and expertise from medical and tech specialists developed OpioidCalc, a free mobile app for iOS and Android phones that performs this calculation for them.

OpioidCalc app allows users (healthcare providers) to quickly and easily calculate the total daily MME a patient is taking, based on type of opioid analgesic, its strength, and quantity.

It is designed as a simple calculator that includes several opioid analgesic options, such as codeine, fentanyl transdermal patches, hydrocodone, methadone, etc.

Tapping on the field below each opioid analgesic, opens the wheel that allows users to input dosage and frequency. The dosages and frequencies are predetermined based on the type of opioid analgesic.

This calculator allows users to include multiple types of opioid analgesics in the total daily MME calculation. 

For example, if the patient has just started using fentanyl patches (25mcg), but the acute injury-induced back pain still persists, so you want to prescribe short term Vicodin (10mg/2 per day) until the patch starts working. The total daily MME in this case would be 80, which doesn't indicate overdose, but it's still too close to the critical levels.

The best course of action here would be not prescribing fentanyl patches (or other long-acting opioids) at all, but prescribing smaller doses of Vicodin or other short-acting opioids in order to treat acute pain and keep daily MME levels below 20.

It should be noted that the purpose of this calculator is to help assess overdose risk in patients already taking opioid analgesics, not to convert from one opioid to another.

If the total daily MME is greater than or equal to 100, the OpioidCalc app will display the alert, indicating an increased risk for overdose. This alert will also suggest you to reassess the patient's pain status and treatment plan, and provide you with a link to the NYC DOHMH opioid-prescribing guidelines for additional information.

These guidelines open as a PDF within the app, but sadly, this document isn't mobile friendly. It's too small, and doesn't open completely. When you double tap on it to open it and make it bigger, it just opens to a blank screen. This happens on Android I've used for this test, but I don't know if it's displayed correctly on iPhone. This is basically the only flaw if this app that would hopefully be fixed in one of the future updates.

Although having really simple design, without much additional features, the OpioidCalc app does the great job. It provides safe and sensible, evidence-based prescribing practices, with the aim of reducing misuse of opioid analgesics, including related overdose deaths. 

Benefit: The app is for use by prescribing clinicians only. It may be of use to nurses and pharmacists who can use this app collaboratively with prescribers.