What dose of Morphine Milligram Equivalents (MME) per day do the 2016 Centers for Disease Control and Prevention (CDC) guidelines recommend Primary Care Providers (PCPs) avoid exceeding when prescribing opioids for chronic pain?

CDC Guidelines Recommend Avoiding Opioid Dosages of 90 MME or More Per Day

The 2016 CDC guidelines recommend that primary care providers avoid increasing opioid dosages to 90 morphine milligram equivalents (MME) or more per day for chronic pain management. 1

Tiered Approach to Opioid Dosing

The CDC guidelines establish a clear tiered approach to opioid prescribing based on MME thresholds:

1. Starting Dose: Begin with the lowest effective dosage

   • Use immediate-release formulations rather than extended-release/long-acting opioids
   • Increase by smallest practical amounts when necessary

2. First Caution Threshold - 50 MME/day:

   • When approaching or exceeding 50 MME/day, providers should:
     • Reassess whether opioids are meeting treatment goals
     • Implement additional precautions
     • Increase frequency of follow-up
     • Consider offering naloxone and overdose prevention education 1

3. Second Caution Threshold - 90 MME/day:

   • Providers should avoid increasing dosages to ≥90 MME/day
   • If considering dosages ≥90 MME/day, providers must:
     • Carefully justify the decision based on individualized assessment
     • Weigh diagnosis-specific benefits against risks
     • Consider consultation with pain specialists
     • Document the clinical reasoning 1

Evidence Supporting These Thresholds

The CDC based these recommendations on evidence showing dose-dependent risks:

• At ≥50 MME/day: Increased risk of overdose compared to <20 MME/day 1
• At ≥90 MME/day: Significantly higher risk of overdose and death 1
• One study showed adjusted odds ratio for opioid-related death increased from 1.32 at 20-49 MME/day to 2.88 at ≥200 MME/day 1

Special Considerations for Existing Patients

For patients already on high-dose opioids (≥90 MME/day):

• Offer opportunity to reevaluate continued use at high dosages
• Discuss risks of high-dose therapy in a nonjudgmental manner
• Consider gradual, collaborative tapering when appropriate 1

Implementation Challenges

Since the guidelines' release, there have been some unintended consequences:

• Some providers have implemented arbitrary cutoffs or rapid tapers 2
• The 90 MME threshold has sometimes been treated as an absolute limit rather than a guideline 2
• Some patients with chronic pain have reported inadequate pain management 2

Key Takeaways for Primary Care Providers

1. Use caution when prescribing opioids at any dosage
2. Reassess benefits and risks when considering doses ≥50 MME/day
3. Avoid increasing dosages to ≥90 MME/day whenever possible
4. If exceeding 90 MME/day, document clear clinical justification
5. Consider non-opioid and non-pharmacological pain management strategies

The guidelines emphasize that these recommendations apply to chronic pain management outside of active cancer treatment, palliative care, and end-of-life care 1, 3.