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. 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
Table 7: Selected Opioid Oral MME Conversion Factors Codeine 0.15
Fentanyl transdermal (mcg/hour)
2.4
Hydrocodone
1
Hydromorphone
4
Methadone: 1-20 mg/day
4
21-40 mg/day
8
41-60 mg/day
10
61-80 mg/day
12
Morphine
1
Oxycodone
1.5
Oxymorphone
3
Tramadol
0.1
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.
Book Code: TN24CME
Page 43
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