How should Morphine Milligram Equivalents (MME) be managed monthly in patients taking chronic opioids?

From the Guidelines

When managing Morphine Milligram Equivalents (MME) for patients on chronic opioid therapy, clinicians should assess MME monthly to ensure appropriate dosing and minimize risks, aiming to keep the total daily MME below 50 MME when possible, and exercise extreme caution above 90 MME due to significantly increased overdose risk, as recommended by the CDC guideline for prescribing opioids for chronic pain 1. Start by calculating the total daily MME using conversion factors for each opioid medication the patient is taking.

• For chronic opioid therapy, aim to keep the total daily MME below 50 MME when possible, and exercise extreme caution above 90 MME due to significantly increased overdose risk.
• Monthly monitoring should include documentation of the current MME, assessment of pain control, functional status, side effects, and signs of misuse.
• If the MME is high, consider implementing a gradual tapering plan with dose reductions of 5-10% every 2-4 weeks as tolerated.
• During monthly visits, also evaluate for opioid use disorder, review the prescription drug monitoring program (PDMP), perform urine drug testing as appropriate, and assess for potential drug interactions.
• Patients should be prescribed naloxone if their daily MME exceeds 50, as recommended by the CDC guideline 1. This careful monthly monitoring approach helps balance pain management with safety concerns, as higher MME levels correlate with increased risks of respiratory depression, overdose, and death, and is supported by the evidence from the CDC guideline for prescribing opioids for chronic pain 1.

From the Research

Dealing with MME from Month to Month for Chronic Opioid Users

• When managing chronic opioid therapy, it is essential to weigh the risks against any possible benefits throughout the therapy, including assessing for the risks of opioid misuse, opioid use disorder, and overdose 2.
• Chronic pain is a significant comorbid condition among individuals with opioid use disorder (OUD), and it is crucial to prioritize interdisciplinary collaboration and evidence-based policies for quality pain management in addiction care 3.
• Clinical surveillance during the course of long-term opioid therapy is vital, and a pragmatic approach to clinical care should include medical and mental health assessment before initiating opioid therapy, clinical surveillance, and clinical considerations for opioid tapering 4.
• Many patients taking common long-acting opioids for chronic nonmalignant pain require dosing more frequently than recommended by product labeling, and may take additional rescue doses per day 5.
• When considering chronic opioid therapy, physicians should consider buprenorphine for patients at risk of opioid misuse, opioid use disorder, and overdose, and interventions should be performed to change the patient's behavior if aberrant behavior continues 2.
• If patients are discontinuing opioid therapy, the dosage should be decreased slowly, especially in those who have intolerable withdrawal, and it is not unreasonable for discontinuation of chronic opioid therapy to take many months 2.