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 Patients evaluated in the clinic report taking the following medica- tion for their back pain: ● OxyContin: 20 mg twice daily. ● Oxycodone: 10 mg three times a day (usually). Since we are dealing with immediate-release oxycodone, the MME conversion factor remains the same as for OxyContin (1.5). Thus, the MME for oxycodone 10 mg three times a day would be: 10 mg x 3 (daily) x 1.5 = 45 MME/day So, the total MME for the provided medication regimen is: 60 MME/day (OxyContin) + 45 MME/day (oxycodone) = 105 MME/day ● Flexeril: 10 mg three times a day. ● Xanax: 0.5 mg three times a day. Total amount of oxycodone per day: Pain is an unpleasant sensory and emotional experience associ- ated 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 cogni- tive 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. Pain in children and pregnant wom- en 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 condi- tion by simply treating the pain could result in exacerbating the condition. Chronic pain lasts beyond the average healing time for a given injury, operationalized as pain lasting greater than three months (Cohen et al., 2021). Chronic pain is often clinically distin- guished as related to cancer (or other terminal illness) or noncan- cer/terminal illnesses. The physiologic purpose of acute pain is to bring attention to potential or actual tissue damage so that appropriate action can alleviate the pain (e.g., remove your finger 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 cen- tral 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, post - surgical, diabetic neuropathy) and social and psychological fac- tors, including maladaptive pain coping behaviors, concurrent psychiatric illness, and pain catastrophizing. Other factors associ- ated with chronic pain include female gender, increased age, and lower household income (Pak et al., 2018). Chronic pain is char- acterized 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).
Please note that MME calculations are approximate conversions used to compare the strength of different opioids to morphine. Table 4: Examples of 50 and 90 MME/day for Commonly Prescribed Opioids 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 Sus- tained Release
30 mg
Methadone
5 mg
Note . CDC, 2022c. PRESCRIBING OF OPIOIDS IN THE MANAGEMENT OF ACUTE AND CHRONIC NONCANCER PAIN IN ADULTS
The role of opioid analgesics in managing acute and chronic pain is well established, and opioid prescriptions for pain- related is- sues increased dramatically in the 1990s. As a result, the num- ber of ED visits, substance-abuse treatment admissions, hospital stays, and deaths due to unintentional drug overdoses increased substantially, and this led 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 (AMA, 2021). Along with the sharp decline in opi- oid 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 highlights that more than 104,000 physi- cians and other healthcare professionals have an X-waiver to allow them to prescribe buprenorphine for the treatment of opioid use disorder. This is an increase of 70,000 providers since 2017, yet 80% to 90% of people with a substance use disorder receive no treatment (AMA, 2021). The nation continues to see increases in overdose due to illicit fentanyl, fentanyl analogs, methamphetamine, and cocaine, ac- cording to the U.S. Centers for Disease Control and Prevention (2022d). In addition, state public health, media, and other reports show that drug-related overdose and death have worsened na- tionwide (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 pre- scriptions for outpatient acute musculoskeletal injuries in an ad- justed model that explored risk factors for prolonged use. The meta-analysis included 13,263,393 participants receiving pre- scriptions lasting more than seven days and higher morphine milligram equivalents per day. The study found that avoiding prescribing opioids for acute musculoskeletal injuries to pa- tients with past or current substance use disorder restricted to seven days or less, and using lower doses when specified, are potentially important targets to reduce rates of opioid use.
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