From the Guidelines
As a primary care nurse practitioner, it is generally recommended to maintain chronic pain patients on less than 50 MME per day when possible, with careful consideration before exceeding 90 MME daily, as higher doses significantly increase overdose risk, as noted in the 2022 CDC clinical practice guideline for prescribing opioids for pain 1.
Key Considerations
- When prescribing opioids, start with the lowest effective dose and implement a clear tapering plan, considering the patient's individual needs and risk factors for opioid-related harms.
- Common medications include hydrocodone (1 MME per mg), oxycodone (1.5 MME per mg), and morphine (1 MME per mg), and their doses in MME equivalents should be carefully calculated to minimize the risk of overdose.
- Always use prescription drug monitoring programs before prescribing, obtain informed consent, establish treatment goals, assess risk factors for opioid-related harms, and schedule regular follow-ups to evaluate benefits and risks, as emphasized in the 2022 CDC guideline 1.
Risks and Benefits
- Higher MME doses significantly increase overdose risk, with research showing that doses above 50 MME daily double the risk compared to doses below 20 MME daily, as reported in the 2022 CDC guideline 1.
- The benefits of high-dose opioids for pain are not well established, and few trials have evaluated opioid dosages of ≥90 MME/day, as noted in the 2022 CDC guideline 1.
State Regulations and Clinical Protocols
- State regulations may impose additional restrictions on opioid prescribing, so it is essential to familiarize yourself with local prescribing laws and clinical protocols, such as those in Washington state, which require consultation with a pain specialist before increasing long-term opioid therapy dosage to >120 MME/day, as mentioned in the 2022 CDC guideline 1.
Clinical Decision-Making
- Clinicians should carefully evaluate a decision to increase opioid dosage after an individualized assessment of benefits and risks, weighing factors such as diagnosis, incremental benefits for pain and function relative to risks, other treatments and effectiveness, and patient values and preferences, as emphasized in the 2022 CDC guideline 1.
From the Research
Maximum Morphine Milligram Equivalent (MME) Allowance
- The provided studies do not directly address the maximum MME allowance as a primary care Nurse Practitioner (NP) 2, 3, 4, 5, 6.
- However, study 5 discusses the impact of a multimodal analgesia protocol on inpatient and outpatient opioid use, including MME, but does not specify a maximum allowance for NPs.
- Study 6 compares the analgesic efficacy of morphine sulfate immediate release vs. oxycodone/acetaminophen for acute pain, but also does not provide information on maximum MME allowance for NPs.
Relevant Information
- Study 4 highlights the role of NPs as primary care providers, but does not address MME allowance.
- Studies 2 and 3 discuss opioid metabolism, drug-drug interactions, and analgesic combinations, but do not provide information on maximum MME allowance for NPs.