Opioid Prescribing Quantity

Aka: Opioid Prescribing Quantity, Morphine Milligram Equivalent, Morphine Equivalent, Transitioning Between Opioids, Maximal Effective Opioid Doses in Chronic Pain

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II. Precautions

  1. See Opioid Prescription in Acute Pain
  2. Prescribe the lowest effective dose for the shortest appropriate course
  3. Consider home Naloxone prescription for Overdose by patient or other household member (e.g. child)
  4. Adjust for Chronic Opioid Analgesic Therapy (COAT)
    1. Work with COAT provider on acute and subacute dosing

III. Preparations: Morphine Equivalent Opioid Doses (MME)

  1. IMPORTANT: Doses are for comparison only - do not use these doses
  2. Most potent agents (compared with Morphine)
    1. Buprenorphine Film: 40 MME (2 mg film is equivalent to 80 mg Morphine)
    2. Fentanyl (Sublimaze) 20 mcg per hour IV or 2.4 MME
    3. Fentanyl transdermal (25 mcg patch) or 7.2 MME (2.4 MME x 3 days)
    4. Hydromorphone (Dilaudid) 1.5 mg IV (7.5 mg orally) or 4 MME
    5. Methadone 2.5 mg IV (5 mg orally)
      1. See Methadone for conversion ratios
      2. Conversion ratio to Morphine is variable per dose
        1. Low Dose (<=20 mg/day): 7.5 mg or 4 MME
        2. Moderate Dose (20-60 mg/day): 3.75 to 3 mg or 8-10 MME
        3. Very High Dose (>60 mg/day): 2.5 mg or 12 MME
    6. Oxymorphone 10 mg orally or 3 MME
    7. Nalbuphine (Nubain) 10 mg IV or 1 MME
  3. Morphine (comparison)
    1. Morphine 10 mg IV (30 mg orally) or 1 MME (by definition of Morphine Milligram Equivalent)
  4. Less potent agents (compared with Morphine)
    1. Oxycodone 20 mg orally or 1.5 MME
    2. Hydrocodone 30 mg orally or 1 MME
    3. Meperidine (Demerol) 75 mg IV (300 mg orally) or 0.1 MME
  5. Least potent agents
    1. Codeine 120 mg IV (200 mg orally) or 0.15 MME
    2. Tramadol (300 mg orally) or 0.1 MME

IV. Protocol: Transitioning Between Opioids

  1. Option 1: Rapid conversion
    1. Step 1: Discontinue Drug 1
      1. Calculate equi-Analgesic doses (see MME above)
    2. Step 2: Begin the new Drug 2
      1. Start dose at 20-50% of equi-Analgesic dose
      2. Accounts for drug tolerance to discontinued drug
  2. Option 2: Cross titration
    1. Step 1: Initiate new Opioid while still taking old Opioid
      1. Start new Opioid at lowest available dose
      2. Decrease old Opioid by 10-30%
    2. Step 2: Titrate up the new Opioid while tapering off the old Opioid over 3-4 weeks
      1. Increase new Opioid by 10-20% each week
      2. Decrease old Opioid by 10-25% each week
  3. Precautions
    1. Do not use equi-Analgesic dose or conversion charts for dosing Methadone or non-IV Fentanyl
  4. References
    1. (2012) Presc Lett 19(8): 43

V. Dosing: Maximal Effective Opioid Doses in Chronic Pain

  1. Immediate release agents
    1. One to two tablets up to 4 times daily
  2. Sustained release agents
    1. Morphine: 200 mg/day
    2. Oxycodone: 120 mg/day
    3. Fentanyl: 100 mcg/hour
    4. Methadone: 60 mg/day
  3. References
    1. Chou (2009) Journal of Pain [PubMed]

VI. Preparations: Acute prescriptions (typical)

  1. See Acute Pain Management
  2. Limit to 4 days of Opioid and 100 Morphine Milligram Equivalence (MME) for total course
  3. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin): Up to 20 tabs per total course
  4. Oxycodone IR (5 mg tabs): Up to 13 tabs per total course
  5. Hydromorphone (2 mg tab): Up to 12 tabs per total course

VII. Preparations: Acute prescriptions (major surgery or Trauma)

  1. Limit to 7 days of Opioid and 200 MME for total course
  2. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin): Up to 40 tabs per total course
  3. Oxycodone IR (5 mg tabs): Up to 26 tabs per total course
  4. Hydromorphone (2 mg tab): Up to 25 tabs per total course

VIII. Preparations: Post-Acute Pain (5 to 45 days after acute event)

  1. Prescribe in 7 day increments of no more than 200 MME per 7 days
  2. Avoid >700 cummulative MME
  3. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin): Up to 40 tabs/week
  4. Oxycodone IR (5 mg tabs): Up to 26 tabs per week

IX. Preparations: Chronic Pain (>45 days)

  1. See Chronic Pain Management
  2. Limit to low dose (up to 50 MME/day) in most patients
    1. Hydrocodone/Acetaminophen (5 mg/300 mg, Vicodin) 10 tabs/day (up to 50 mg/day)
    2. Oxycodone IR (5 mg tabs) 6 tabs/day (up to 33 mg/day)
    3. Oxycodone SR (15 mg, Oxycontin) 2 tabs/day (up to 33 mg/day)
    4. Methadone (5 mg) 2 tabs/day (up to 12 mg/day)
  3. Avoid high dose (up to 90 MME/day) in most cases
    1. Informed Consent regarding risk of Opioid Dependence and other adverse effects
    2. Attempt to taper to 50 MME/day
    3. Hydrocodone/Acetaminophen (10 mg/300 mg, Vicodin): 9 tabs/day (up to 90 mg/day)
    4. Oxycodone IR (10 mg tabs) 6 tabs/day (up to 60 mg/day)
    5. Oxycodone SR (30 mg, Oxycontin) 2 tabs/day (up to 60 mg/day)
    6. Methadone (5 mg) 4 tabs/day (up to 20 mg/day)

X. Resources: Dosing Calculators (including MME)

  1. PPM Opioid Calculator
    1. http://opioidcalculator.practicalpainmanagement.com/

XI. References

  1. (2018) Minnesota Opioid Prescribing Guidelines
    1. https://mn.gov/dhs/assets/mn-opioid-prescribing-guidelines_tcm1053-337012.pdf

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