What is the CDC recommended daily morphine equivalents (MME) for patients with chronic pain?

CDC Recommended Daily Morphine Milligram Equivalents

The CDC recommends clinicians carefully reassess benefits and risks when considering increasing opioid dosage to ≥50 MME per day, and should avoid increasing dosage to ≥90 MME per day or carefully justify such decisions based on individualized assessment of benefits and risks. 1

Key Dosage Thresholds

The CDC establishes a tiered approach to opioid dosing with specific action points:

50 MME/Day Threshold

• Before reaching 50 MME/day, clinicians must pause and carefully reassess whether opioids are meeting the patient's treatment goals. 1
• At or above 50 MME/day, implement additional precautions including increased frequency of follow-up and considering offering naloxone. 1
• Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/day but are exposed to progressive increases in risk as dosage increases. 1

90 MME/Day Upper Limit

• Clinicians should avoid increasing dosages to ≥90 MME/day or must carefully justify such decisions based on diagnosis, incremental benefits for pain and function relative to harms, other treatments and effectiveness, and recommendations from pain specialists. 1
• If patients do not experience improvement in pain and function at ≥90 MME/day, or if there are escalating dosage requirements, clinicians should discuss other approaches to pain management and consider tapering. 1
• Established patients already prescribed high dosages (≥90 MME/day) should be offered the opportunity to reevaluate their continued use in light of evidence regarding the association of opioid dosage and overdose risk. 1

Starting Principles

Clinicians should start opioids at the lowest effective dosage, typically equivalent to 20-30 MME/day for opioid-naïve patients. 2

• Use immediate-release opioids instead of extended-release/long-acting formulations when initiating therapy. 1
• Increase dosage by the smallest practical amount when necessary. 1
• Use caution when prescribing opioids at any dosage. 1

MME Conversion Factors

To calculate total daily MME, multiply the daily dose of each opioid by its conversion factor 1:

• Morphine: 1.0
• Oxycodone: 1.5
• Hydrocodone: 1.0
• Hydromorphone: 4.0 (2016) or 5.0 (2022)
• Fentanyl transdermal (mcg/hr): 2.4
• Codeine: 0.15
• Methadone: 4.0-12.0 (dose-dependent) or 4.7 (2022)
• Tramadol: 0.2
• Tapentadol: 0.4

Critical Conversion Cautions

Do not use calculated MME doses to determine doses when converting between opioids—the new opioid should be dosed substantially lower than the calculated MME to avoid overdose due to incomplete cross-tolerance. 1, 3

• Methadone requires particular caution due to its long and variable half-life, with peak respiratory depressant effect occurring later and lasting longer than peak analgesic effect. 1
• Transdermal fentanyl is dosed in mcg/hr (not mg/day) and its absorption is affected by heat and other factors. 1
• IV opioids are 2-3 times more potent than oral equivalents due to avoidance of first-pass metabolism. 3

Common Pitfalls

• Abrupt dose reductions from ≥90 MME to low doses are associated with significantly increased overdose risk (7.87 times higher than stable low-dose patients). 4
• Large dose increases (≥2 dosing categories) are associated with increased fatal overdose risk, particularly when previous or current dose is ≥60 MME/day. 4
• The 90 MME/day threshold is not intended as an inflexible standard but as a guidepost to inform clinician-patient decision-making. 1
• Concurrent benzodiazepine use significantly increases overdose risk at any opioid dose. 1, 4