3. When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids. 4. When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. 5. For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages. 6. When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. 7. Clinicians should evaluate benefits and risks with patients within one to four weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients. 8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone. 9. When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
10. When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances. 11. Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. 12. Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death. Morphine Milligram Equivalent (MME) Morphine milligram equivalent (MME) thresholds guide the risk of overdose when prescribing opioids for pain. Morphine milligram conversion factor analyzes and normalizes opioid prescription data to determine a daily MME value (see Table 7). MME defines limits for the total amount of opioid analgesics prescribed to the patient as part of state legislation, Medicare/Medicaid, and other payers. The CDC recommends calculating the total daily dose of opioids (as MMEs) to identify patients who may benefit from closer monitoring, reduction, or tapering of opioids, prescribing naloxone (Narcan), or other measures to reduce the risk of overdose. MME calculations omit buprenorphine and other opioids used to treat opioid use disorder. Compared to dosages of 1 to <20 MME/day, dosages of 50 to <100 MME/day increase the risks of opioid overdose by factors of 1.9 to 4.6. 80 CDC guidance states that clinicians should carefully assess patients when considering increasing dosage to >50 MME/day and should avoid or
carefully assess and justify a decision to increase the total opioid dose >90 MME/day. 81 While the CDC has not explicitly stated that opioids should not be used in quantities >90 MME/day, many states and payers limit opioid prescriptions to <90 MME/day regardless of the underlying condition. 82 (see Table 5). Patients who already take and have tolerated doses that exceed the 90 MME/day threshold should be monitored closely and slow tapers can be attempted under close supervision to avoid the potential harmful effects of withdrawal. IMPORTANT: Do not use the MME conversion factor or the MME amount determined for conversion from one opioid to another or to guide dosing medication or assisted treatment for opioid use disorder. The MME conversion factor and amount may overestimate the amount for conversion, resulting in serious adverse effects such as respiratory depression or death. 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. 3. Total all MMEs to obtain the MME/day for the patient. Example MME Calculation Patients evaluated in the clinic report taking the following medication for their back pain. • OxyContin 20 mg twice daily • Oxycodone 10 mg three times a day (usually) • Flexeril 10 mg three times a day • Xanax 0.5 mg three times a day The total amount of oxycodone per day: 70 mg (20 mg × 2) + (10 mg × 3) MME/day = 105 (70 mg/day oxycodone × 1.5 [MME conversion factor])
Table 7. Selected Opioid Oral MME Conversion Factors
Oral Opioids (doses in mg/day except where noted)
Conversion Factor
Codeine
0.15
Fentanyl transdermal (mcg/hour)
2.4
Hydrocodone
1 4
Hydromorphone Methadone: 1 - 20 mg/day 21 - 40 mg/day 41 - 60 mg/day 61 - 80 mg/day
4 8
10 12
Morphine Oxycodone
1
1.5
Oxymorphone
3
Tramadol
0.1
14
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