What are the recommendations for managing patients on high Morphine Milligram Equivalent (MME) medication?

Managing Patients on High Morphine Milligram Equivalent (MME) Medication

Clinicians should avoid increasing opioid dosages to ≥90 MME/day and should work with patients already on high dosages to taper to safer levels due to the established evidence showing increased overdose risk at higher opioid dosages. 1, 2

Risk Stratification by MME Thresholds

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

• <20 MME/day: Baseline risk level
• 20-49 MME/day: 1.32× increased risk of overdose compared to <20 MME/day 2, 3
• ≥50 MME/day: Significantly increased risk requiring additional precautions 1, 2
• ≥90 MME/day: Substantially higher risk requiring careful justification or tapering 1, 2
• ≥200 MME/day: 2.88× increased risk of opioid-related death 2

Management Algorithm for Patients Based on MME Level

For Patients Approaching or at ≥50 MME/day:

1. Reassess whether opioid treatment is meeting the patient's treatment goals 1
2. Implement additional precautions:
   • Increase frequency of follow-up visits 1
   • Offer naloxone and provide overdose prevention education to patients and household members 1, 2
   • Consider urine drug testing and review of prescription drug monitoring program data more frequently

For Patients at ≥90 MME/day:

1. For patients not yet at this level: Avoid increasing to ≥90 MME/day unless carefully justified based on:

   • Specific diagnosis
   • Documented incremental benefits for pain and function relative to harms
   • Other treatments tried and their effectiveness
   • Consultation with pain specialists 1, 2

2. For patients already at ≥90 MME/day:

   • Explain in a nonjudgmental manner the evidence showing increased overdose risk at higher opioid dosages 1
   • Empathically review benefits and risks of continued high-dosage therapy 1
   • Offer to work with the patient to taper opioids to safer dosages 1
   • For patients who agree to taper, collaborate on a personalized tapering plan 1
   • For those remaining on high doses, establish clear treatment goals, maximize non-opioid and non-pharmacologic treatments, and consider pain specialist consultation 1

For Patients Not Responding to High-Dose Therapy:

If patients do not experience improvement in pain and function at ≥90 MME/day, or show escalating dosage requirements:

1. Discuss alternative approaches to pain management 1
2. Consider tapering to lower dosage or discontinuation 1
3. Consult with a pain specialist 1

Special Considerations

Patients with Renal Impairment:

• Consider rotating to methadone (if not contraindicated) as it is excreted fecally 1
• Avoid morphine, meperidine, codeine, and tramadol unless no alternatives exist 1
• For opioids primarily eliminated in urine (fentanyl, oxycodone, hydromorphone), carefully titrate and frequently monitor for accumulation 1

Managing Tapering in Long-Term Users:

• Patients tapering after years on high dosages may require very slow tapers 1
• Include pauses in the taper to allow gradual accommodation to lower dosages 1
• Monitor for signs of anxiety, depression, and opioid use disorder that might emerge during tapering 1
• Research suggests mandatory dose reductions may not necessarily worsen self-reported pain scores 4

Common Pitfalls and How to Avoid Them

1. Failure to recognize state-specific requirements: Some states require specific clinical protocols at certain MME thresholds. For example, Washington state requires pain specialist consultation before increasing to >120 MME/day 1

2. Overlooking co-prescribed medications: Benzodiazepines and gabapentinoids significantly increase overdose risk when combined with high-dose opioids 1

3. Inadequate monitoring: Higher MME levels require more frequent monitoring for adverse effects, particularly sedation (which typically precedes respiratory depression) 1

4. Abrupt discontinuation: Avoid sudden discontinuation of high-dose opioids, which can lead to withdrawal, increased pain, and psychological distress 1, 5

5. Neglecting to offer naloxone: Patients on ≥50 MME/day should be offered naloxone with education on its use for both patients and household members 1, 2

By following these evidence-based recommendations, clinicians can better manage patients on high MME medications while prioritizing patient safety and quality of life.