Safety in Numbers: Morphine Milligram Equivalents (MME)

 

opioids quadrupled

The Centers for Disease Control and Prevention (CDC) state in its opioid prescribing guidelines fact sheet, that, “when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”

It is important to note that the CDC guidelines do not say that physicians cannot prescribe doses above 90 MME. However, justification in the patient’s chart should be provided in detail.

Several states, have adopted rules regarding daily MME amounts. California, has written guidelines that require justification for a daily opioid dosage above 80 MME, other states require consultation, some merely suggest it.

Maine has implemented a 100 MME per day limit on opioid prescriptions (except for terminal cancer and palliative care).

Let’s do the math. Exactly how much is 90 MME:

• 90 mg of hydrocodone (9 tablets of hydrocodone/ acetaminophen 10/325)

• 60 mg of oxycodone (~2 tablets of oxycodone sustained-release 30 mg)

• ~20 mg of methadone (4 tablets of methadone 5 mg)

The CDC has provided guidance for how to calculate MME for commonly prescribed opioids (see table). Calculate the patient’s total daily dose of their current opioid (including “as needed” doses), and multiply by the conversion factor shown in the table. This would be the patient’s MME dose per day.

MME Table

 

View Table in HTML

The CDC also has a mobile app available for download featuring a Morphine Milligram Equivalent (MME) calculator, summaries of key recommendations and a link to the full Guidelines. It is available in the Apple Store or via Google Play for Android devices.

Backlash to the 90 MME Policy

The backlash regarding the policy implementation from the medical community has focused on several issues. The calculation utilized to assess the 90 MME marker as an independent calculation not considering unique patient conditions such as age, potential drug-drug interactions, comorbidities, weight, metabolization, and renal/hepatic function. Polypharmacy may increase potential overdose scenarios as well.

Controversy aside...What is the end goal of these policies? Simply, an effort to limit the number of opioid overdose deaths. A number that continues to increase across America, impacting all demographic groups.

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Additional Resources:

CDC Guidelines for Prescribing Opioids for Chronic Pain Fact Sheet

CDC Calculating Daily Dose Fact Sheet

CDC Calculating MME Total Daily Dose Fact Sheet

CVS Opioid Quantity Limits Reference GuideASAM Public Policy Statement on Morphine Equivalent Units

Opioid Dose Calculator

 

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