To calculate a daily MME for a patient: 1. Determine the total daily amount of each opioid the patient takes. 2. Convert each amount to MME by multiplying the total daily amount by the appropriate conversion factor (see Table 3). 3. Total all MMEs to obtain the MME/day for the patient. Example MME calculation A patient evaluated in the clinic reports taking the following ● Flexeril: 10 mg three times a day. ● Xanax: 0.5 mg three times a day. The total amount of oxycodone per day: 50 mg (20 mg × 2) + (10 mg × 3) MME/day = 75 (50 mg/day oxycodone × 1.5 [MME conversion factor]) medication for their back pain. ● OxyContin: 20 mg twice daily. ● Oxycodone: 10 mg three times a day (usually). associated with actual or potential tissue damage or described in terms of such damage (Cohen et al., 2021). It is critical to understand that pain is not only a neuronal response but also involves cognitive processes that make it a subjective experience that does not require identifiable tissue damage to be significant (Halpape et al., 2022). Pain perception may be related to the site of the pain, such as the face or eye. Pain in children and pregnant individuals has unique considerations that a specialist should evaluate. In addition, pain accompanied by other physical and psychological conditions needs to be evaluated. Masking a comorbid condition by simply treating the pain could result in exacerbating the condition. Chronic pain that extends beyond the average healing time for a given injury is operationalized as pain lasting over three months (Cohen et al., 2021). Chronic pain is often clinically distinguished as being related to cancer (or other terminal illness) or noncancer/terminal illnesses. The physiologic purpose of acute pain is to bring attention to potential or actual tissue damage so that appropriate action can be taken to alleviate the pain (e.g., remove your handp from the hot stove). The firing rate of peripheral neurons that detect painful stimuli, known as nociceptors, leads to the interpretation of pain intensity. However, the perception of nociceptor firing may influence the painful stimulus and the sensitization of the peripheral and central nervous systems. In most patients, acute pain resolves when the affected tissue heals; however, some patients progress from acute to chronic pain in a process called pain chronification. The underlying cause(s) is/are not established but may be related to central nervous system changes in pain facilitation and inhibition (Pak et al., 2018). Pain chronification is based on acute pain (e.g., low back, postsurgical, diabetic neuropathy) and social and psychological factors, including maladaptive pain, coping behaviors, concurrent psychiatric illness, and pain catastrophizing. Other factors associated with chronic pain include female gender, increased age, and lower household income (Pak et al., 2018). Chronic pain is characterized by persistent pain, disability, emotional disturbances, and social withdrawal symptoms that coexist and influence each other. The source of the pain may be known or unknown and may be considered a chronic disease syndrome (Halpape et al., 2022). Opioid analgesics for acute pain in adults The decision to use opioid analgesics for acute pain is difficult. Not all acute pain requires management with an opioid analgesic. Predicting the intensity and duration of pain after an injury can be challenging. Overprescribing opioids results in excess medication available for misuse and diversion. Studies
Table 4. Examples of 50 and 90 MME/day for Commonly Prescribed Opioids (CDC, 2022c) Opioid Strength 50 MME/ Day 90 MME/Day
Exceeds acetaminophen maximum daily dose
5 mg/325 mg
50 mg (10 tablets)
Hydrocodone – acetaminophen
10 mg/325 mg
50 mg (5 tablets) 33 mg (~2 tablets) 33 mg (~1 tablet) 12 mg (<3 tablets)
90 mg (9 tablets) 60 mg (4 tablets) 60 mg (2 tablets) ~20 mg (4 tablets)
15 mg
Oxycodone sustained release
30 mg
Methadone
5 mg
Prescribing opioids for acute and chronic noncancer pain in adults Pain is an unpleasant sensory and emotional experience
The role of opioid analgesics in managing acute and chronic pain is well established, and opioid prescriptions for pain- related issues increased dramatically in the 1990s. As a result, the number of emergency department visits, substance abuse treatment admissions, hospital stays, and deaths due to unintentional drug overdoses increased substantially, leading to a significant public health issue in the subsequent decades. Opioid prescriptions decreased by 44.4% between 2011 and 2020, including a 6.9% decrease from 2019 to 2020 (American Medical Association [AMA], 2021). Along with the sharp decline in opioid prescriptions, prescribing practitioners and other healthcare professionals used the state PDMP more than 910 million times in 2020 (AMA, 2021). The 2021 Overdose Epidemic report issued by the AMA (2021) also highlighted that more than 104,000 physicians and other healthcare professionals had an X-waiver to allow them to prescribe buprenorphine for the treatment of opioid use disorder. This was an increase of 70,000 providers since 2017, yet 80% to 90% of people with a substance use disorder received no treatment (AMA, 2021). The nation continues to see increases in overdoses due to illicit fentanyl, fentanyl analogs, methamphetamine, and cocaine, according to the CDC (2022d). In addition, state public health, media, and other reports show that drug-related overdose and death have worsened nationwide (CDC, 2022d). Evidence-based practice! There is evidence that prescribing opioids for acute musculoskeletal injuries may result in long- term use and consequent harm. Riva et al. (2020) conducted a systematic review and meta-analysis of adults with opioid prescriptions for outpatient care of acute musculoskeletal injuries in an adjusted model that explored risk factors for prolonged use. The meta-analysis included 13,263,393 participants receiving prescriptions lasting more than seven days and higher doses of morphine milligram equivalents daily. The study found that avoiding the prescription of opioids for acute musculoskeletal injuries for patients with past or current substance use disorder, restricting opioid prescriptions to seven days or less, and using lower doses when specified are potentially essential targets to reduce rates of opioid use.
have shown routine prescribing of excessive opioids for many types of surgical procedures and painful conditions treated in emergency departments (Kene et al., 2022). Riva et al. (2020) found that high-risk populations, that is, workers’ compensation patients receiving disability benefits, Veterans Affairs claimants,
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