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. 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).
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.
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])
● Flexeril 10 mg three times a day. ● Xanax 0.5 mg three times a day.
Book Code: MDCO1025
Page 63
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