Is a dosage of 90 Morphine Milligram Equivalents (MME) too high?

From the Guidelines

A dosage of 90 Morphine Milligram Equivalents (MME) per day is considered high and represents a threshold where risks increase significantly. This level is generally viewed as the upper limit for chronic pain management according to current clinical guidance, as stated in the 2022 CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1. At 90 MME or above, patients face substantially increased risks of overdose and adverse effects, including respiratory depression, sedation, constipation, and potential for dependence or addiction. For context, 90 MME equals 90 mg of morphine, 60 mg of oxycodone, or 900 mg of codeine daily. Whether this dose is appropriate depends on individual factors such as pain severity, medical history, opioid tolerance, and other treatments being used.

Key Considerations

• Patients on this dosage should be closely monitored by healthcare providers with regular reassessment of pain control, function, and side effects.
• Risk mitigation strategies should be implemented, including naloxone prescriptions, regular urine drug testing, and checking prescription drug monitoring programs.
• For many patients, especially those with chronic non-cancer pain, efforts to gradually reduce dosage below this threshold while incorporating non-opioid and non-pharmacological pain management approaches may be beneficial for long-term safety, as suggested by the CDC guideline 1 and other studies 1.
• Clinicians should carefully evaluate a decision to increase dosage on the basis of individualized assessment of benefits and risks and weighing factors such as diagnosis, incremental benefits for pain and function relative to risks with previous dosage increases, as recommended in the 2022 CDC guideline 1 and the 2016 CDC guideline for prescribing opioids for chronic pain 1.

Recommendations

• Clinicians should start opioids at the lowest effective dosage and use caution when increasing opioid dosages, as stated in the 2022 CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.
• Before increasing total opioid dosage to ≥50 MME/day, clinicians should pause and carefully reassess evidence of individual benefits and risks, as recommended in the 2022 CDC guideline 1.
• Additional dosage increases beyond 50 MME/day are progressively more likely to yield diminishing returns in benefits for pain and function relative to risks to patients as dosage increases further, as noted in the 2022 CDC guideline 1.

From the FDA Drug Label

If a patient has been receiving opioid-containing medications prior to taking oxycodone hydrochloride tablets, the potency of the prior opioid relative to oxycodone should be factored into the selection of the total daily dose (TDD) of oxycodone Individually titrate oxycodone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions

The FDA drug label does not provide a specific dosage in Morphine Milligram Equivalents (MME) that is considered too high. However, it emphasizes the importance of individual titration to achieve adequate analgesia while minimizing adverse reactions. The label also warns about the risks of respiratory depression and other adverse effects associated with opioid use, highlighting the need for careful dose selection and monitoring 2.

Key considerations for determining a safe dosage include:

• The patient's prior opioid use and potency
• The need for individual titration to achieve adequate analgesia
• The risk of adverse reactions, including respiratory depression
• The importance of careful monitoring and dose adjustment as needed 2.

Given the lack of specific guidance on a maximum safe dosage in MME, it is essential to exercise caution and carefully evaluate each patient's needs and response to opioid therapy.

From the Research

Dosage Considerations

• The question of whether 90 Morphine Milligram Equivalents (MME) is too high depends on various factors, including the patient's medical history, current health status, and the specific condition being treated 3, 4.
• Studies suggest that opioids can be beneficial for chronic non-cancer pain in carefully selected patients, but the potential for serious adverse effects and local regulations promote caution in both prescribers and users 3.
• The use of opioids for chronic pain requires careful consideration of the potential risks and benefits, as well as regular monitoring and multimodal therapy 4, 5.

Comparison to Existing Research

• A study from 1986 found that two-thirds of patients required less than 20 morphine equivalent mg/day, and only 4 took more than 40 mg/day, suggesting that lower doses may be effective for some patients 5.
• More recent studies have highlighted the importance of safe prescribing practices and the introduction of abuse-deterrent opioid formulations to limit the risks of opioid abuse and overdose 6, 7.
• Guidelines recommend opioids as an option for patients with severe back pain who do not find adequate pain relief from acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), but emphasize the need for careful consideration of individual patient factors 7.

Key Findings

• Opioid therapy can be a safe and effective option for chronic non-cancer pain in carefully selected patients, but requires regular monitoring and careful consideration of potential risks and benefits 3, 5.
• Lower doses of opioids may be effective for some patients, and the use of abuse-deterrent formulations and safe prescribing practices can help minimize the risks of opioid abuse and overdose 5, 6, 7.