Morphine milligram equivalent (MME) Morphine milligram equivalent (MME) thresholds guide the risk of overdose when prescribing opioids for pain. The morphine milligram conversion factor analyzes and normalizes opioid prescription data to determine a daily MME value (see Table 3). 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 (Dowell et al., 2016). 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 (AAFP, 2021). 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 (CDC, 2021) (see Table 4). Table 3: 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 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. 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
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. Total amount of oxycodone per day:
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 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 Sustained Release
30 mg
Methadone
5 mg
Note . CDC, 2022c. PRESCRIBING OF OPIOIDS IN THE MANAGEMENT OF ACUTE AND CHRONIC NONCANCER PAIN IN ADULTS
Pain is an unpleasant sensory and emotional experience 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. Pain in children and pregnant women 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 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 distinguished as related to cancer (or other terminal illness) or noncancer/terminal illnesses.
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