Hello, and welcome to the sixth module of the CDC series Applying CDC's Guideline for Prescribing Opioids. In this module, we'll review the CDC recommended options for dosing and titrating opioids. You will have the opportunity to review recent evidence regarding the benefits and harms of opioid therapy; explore methods for safely prescribing, titrating, tapering, or discontinuing opioid therapy; and review best practices for evaluating continued use of opioids in collaboration with patients. These strategies help address resistance, facilitate goal setting, and promote behavior change. Throughout this module, you will be presented multiple choice knowledge checks to test your mastery of the content.
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CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016
You may find it useful to refer to the CDC Guideline during this module. You can access, download, and print a copy of this and other helpful documents by selecting the Resources tab at any time. Some screens include a link icon which, when selected, opens additional online resources. Let's take a closer look at the navigation features of this web-based training. As you've experienced already, the Next and Back buttons enable you to move to a new screen or back to a previous screen. If either the Next or Back button is dimmed, it is disabled, and you will need to complete an action onscreen to continue. Refer to the navigation prompt located at the bottom of the screen to help you determine how to proceed. Selecting the Menu button in the upper right corner opens a list of all the topics available in the module. A selection made from the list advances the training to that topic. Pressing the open Menu tab a second time will collapse it. There is also a set of audio controls located at the bottom of the training window. Here you can pause or play the narration, control the volume, and open the text transcript for the narration if needed. Most slides, however, will not be narrated, and this set of controls will be dimmed and disabled.
Morphine milligram equivalents (MME) is an opioid dosage's equivalency to morphine.
The MME/day metric is often used as a gauge of the overdose potential of the amount of opioid that is being given at a particular time.
Calculating the total daily dosage of opioids helps identify patients who may benefit from closer monitoring, reduction or tapering of opioids, prescribing of naloxone, or other measures to reduce risk of overdose.
The Calculating Total Daily Dose of Opioids For Safer Dosage fact sheet can be found in the Resources section.
| Opioid (doses in mg/day except where noted) | Conversion Factor |
|---|---|
| Codeine | 0.15 |
| Fentanyl transdermal (in mcg/hr) | 2.4 |
| Hydrocodone | 1 |
| Hydromorphone | 4 |
| Methadone: | |
| 1-20 mg/day | 4 |
| 21-40 mg/day | 8 |
| 41-60 mg/day | 10 |
| >=61-80 mg/day | 12 |
| Morphine | 1 |
| Oxycodone | 1.5 |
| Oxymorphone | 3 |
A new patient is suffering from chronic lower back pain. For his pain, he takes extended-release oxycodone 30 mg BID. What is the daily MME that your patient has been prescribed?
| Opioid (doses in mg/day except where noted) | Conversion Factor |
|---|---|
| Codeine | 0.15 |
| Fentanyl transdermal (in mcg/hr) | 2.4 |
| Hydrocodone | 1 |
| Hydromorphone | 4 |
| Methadone: | |
| 1-20 mg/day | 4 |
| 21-40 mg/day | 8 |
| 41-60 mg/day | 10 |
| >=61-80 mg/day | 12 |
| Morphine | 1 |
| Oxycodone | 1.5 |
| Oxymorphone | 3 |
A new patient is suffering from chronic lower back pain. For his pain, he takes ER oxycodone 30 mg BID. What is the daily MME that your patient has been prescribed?
The first step is to determine the total daily amount of each prescription.
30 mg X 2 = 60 mg oxycodone/day
Oxycodone has a conversion factor of 1.5.
60 mg X 1.5 = 90 MME per day total
Dosages >=50 MME per day increase risk for opioid-related harms.
| Opioid (doses in mg/day except where noted) | Conversion Factor |
|---|---|
| Codeine | 0.15 |
| Fentanyl transdermal (in mcg/hr) | 2.4 |
| Hydrocodone | 1 |
| Hydromorphone | 4 |
| Methadone: | |
| 1-20 mg/day | 4 |
| 21-40 mg/day | 8 |
| 41-60 mg/day | 10 |
| >=61-80 mg/day | 12 |
| Morphine | 1 |
| Oxycodone | 1.5 |
| Oxymorphone | 3 |
The CDC Opioid Prescribing Guideline Mobile App contains an MME calculator. Select the link below for information about how to get the app for your modile device.
https://www.cdc.gov/drugoverdose/prescribing/app.htmlDo not use the calculated dose in MMEs to determine dosage for converting one opioid to another.
When changing opioid prescriptions, the dosage of the opioid to which the patient is being converted should be lower than the calculated MME of the current opioid regimen to avoid unintentional overdose caused by incomplete cross-tolerance and individual differences in opioid pharmacokinetics. Consult the medication label.
USE EXTRA CAUTION with methadone, transdermal fentanyl, and buprenorphine:
Providers should use caution when prescribing opioids at any dosage. In general, avoid combining IR with ER/LA opioids.
Assess for medical conditions that may pose serious and life-threatening risks with opioid use, such as the following:
DOB: 3/14/1964
Chief complaint/reason for visit: Ongoing lower back pain
Medical History:
Social History:
[Patient] My back pain just isn't getting any better. It is really hard for me to get moving in the morning.
[Provider] I know you have been dealing with this issue for a while. Let's review what you have tried.
[Patient] I have tried physical therapy, plus some exercise to stay active and to move around as much as I can. Yoga didn't do anything for me. None of the three medications you prescribed me has helped much either. First I took the acetaminophen three times a day for a few weeks. Then I tried taking naproxen twice daily for a month. Finally, switching to the duloxetine didn't help much either.
[Provider] I understand your frustration. We are going to work on this together. Tell me more about what you feel you should be able to do but can't right now.
The correct answer is a, b, c, and d. Considering her persistent pain and limitations in function, which she reports have not improved with nonopioid and nonpharmacological therapies, initiating a discussion of opioid therapy is reasonable. It is also important to document a PEG assessment as part of the evaluation and for future comparison. Establishing goals for improvement and setting realistic expectations of therapy, including a plan for discontinuation, would be prudent. Acupuncture could also be tried for this type of pain.
It would be premature to recommend an opioid prescription without first reviewing her complete medical history, including risk factors, and discussing possible side effects.
[Provider] An average of 8 on your PEG assessment is significant. Tell me more about what you feel you should be able to do but can't right now.
[Patient] I don't think it is too much to expect to be able to tend to my garden a few times a week. Also just walking… I used to walk three times a week but my back pain makes this less enjoyable.
[Provider] You have tried quite a few things. I think it is time to try something new, but we need to discuss a few things to make sure they are appropriate.
The correct answer is a, b, c, d, e, f, and g. Each risk factor is likely to increase susceptibility to opioid-associated harms. Providers should assess these risk factors periodically. Close monitoring and cautious dose titration should be used if opioids are prescribed for patients with a serious risk factor.
[Provider] You have tried quite a few things. We could consider starting a low-dose opioid to take in the morning to see how that works.
[Patient] I am really nervous about taking opioids. You hear such bad things in the news lately.
[Provider] We have already assessed for risk factors, but I want to remind you about the risks associated with taking acetaminophen, which is in this opioid formulation. You shouldn't take any additional acetaminophen while taking this opioid. You should also be aware of some potential side effects associated with opioid use. These include sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression. You shouldn't drive until you know how the dose will affect you.
[Patient] It would be best then for me to start on the weekend to see how it goes.
[Provider] Yes, that is a good idea. We will start with a 4-day trial to see how it works for you and if there are any prohibitive side effects.
The correct answer is b. 2.5/325 QID PRN would be the lowest effective IR opioid dosage of the options listed here. Extended-release opioids should be avoided when initiating opioid therapy. 10/325 mg oxycodone/acetaminophen QID is above the recommended threshold of 50 MME/day and would be too high of a starting dose especially in a patient who has never taken opioids.
Reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of starting dose escalation.
Avoid increasing dosage to >=90 MME/day or carefully justify a decision to titrate dosage to >=90 MME/day.
If patients do not experience improvement in pain and function at >=90 MME/day, or if there are escalating dosage requirements, providers should discuss other approaches to pain management with the patient.
Consider working with patients to taper opioids to a lower dosage or to taper and discontinue opioids, and consider consulting a pain specialist for assistance with identifying other methods of pain treatment.
Offer established patients already taking >=90 MME/day the opportunity to reevaluate their continued use of high opioid dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. Providers should collaborate with patients who agree to taper opioids to lower dosages in creating an opioid tapering plan and should not dismiss patients from their practice who need additional support to adjust to the plan.
Some states also have limits on duration and dosage of opioids. Select the Resources tab to access the Menu of Prescription Drug Time and Dosage Limit Laws.
Providers should reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or a dose escalation. Patients who do not have pain relief with opioids at 1 month are unlikely to experience pain relief with opioids at 6 months.
Evidence suggests that the probability of long-term opioid use increases within the first few days after starting a new opioid prescription, with the sharpest increase between 5 and 31 days of treatment.
Reassessment of pain and function within 4 weeks of initiating opioids provides an opportunity to minimize risks of long-term opioid use by discontinuing opioids among patients not receiving a clear benefit from these medications.
Source: Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006-2015. MMWR Morb Mortal Wkly Rep 2017;66:265-269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.
Providers should reevaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Continuing opioid therapy for 3 months substantially increases risk for opioid use disorder (OUD) as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as a problematic pattern of opioid use leading to clinically significant impairment or distress. Follow-up earlier than 3 months might be necessary to provide the greatest opportunity to prevent the development of OUD.
Experts note that risks for opioid overdose are greatest during the first 3-7 days after opioid initiation or an increase in dosage, particularly when ER/LA opioids are initiated. This also includes methadone and transdermal fentanyl.
Follow-up within 3 days is appropriate when initiating or increasing the dosage of methadone due to its unique risk profile, including cardiac arrhythmias along with QT prolongation and a long and variable half-life.
Follow-up within 1 week is appropriate when initiating or increasing the dosage of other ER/LA opioids.
DOB: 3/14/1964
Chief complaint/reason for visit: Two-week follow-up after initiating opioid therapy.
Medical History:
Social History:
[Provider] It's been about two weeks. How are you feeling after starting the new opioid pills?
[Patient] I can tell it is helping, but I am still in too much pain to be as active as I would like. I have been taking all four doses each day. I know you said having no pain was unrealistic, but I haven't seen a dramatic improvement either.
[Provider] Ok. Let's compare your pain now with what we measured before. Describe your pain on average since our last visit, 0 for no pain and 10 for pain as bad as you can imagine.
[Patient] It is around a 6.
[Provider] What number best describes how, this past week, pain has interfered with your enjoyment of life, 0 for doesn't interfere at all to 10, completely interferes?
[Patient] That is a 7.
[Provider] What number would you use to describe, during the past week, pain has interfered with your general activity?
[Patient] Although I do feel a bit better, I still can't really do what I want, so I would have to say 7 again.
[Provider] Ok. That isn't really a big change from your assessment last week. Are you having any side effects?
[Patient] I am having some constipation and drowsiness but they haven't really given me too much trouble.
The correct answer is b, c, and d. Any increase should be the smallest practical amount and should be done in coordination with other pain therapies. Benefits and risks associated with the increase should be continually monitored. Patients should also be aware of the indications that suggest or require tapering.
[Provider] Based on our discussion, you are gaining benefit with few, if any negative side effects. Let's make a small increase and see if pain relief and increased function are the result.
[Patient] Should I continue to take it in the same way?
[Provider] Now that each pill is stronger, you should start by only taking one when the pain is severe. You might find the higher dose might be all you need for an extended period of time. Don't assume you will continue to take all four every day.
You should also closely monitor your side effects and be cautious with driving again until you know how it will affect you.
[Patient] Do I need to come back in two weeks again?
[Provider] Yes, I want to see you back in two weeks. If you have any concerns or notice side effects, I would like to see you right away.
|
Opioid (doses in mg/day except where noted) |
Conversion Factor |
|---|---|
|
Codeine |
0.15 |
|
Fentanyl transdermal (in mcg/hr) |
2.4 |
|
Hydrocodone |
1 |
|
Hydromorphone |
4 |
|
Methadone: |
|
|
1-20 mg/day |
4 |
|
21-40 mg/day |
8 |
|
41-60 mg/day |
10 |
|
>=61-80 mg/day |
12 |
|
Morphine |
1 |
|
Oxycodone |
1.5 |
|
Oxymorphone |
3 |
The correct answer is c. 5 mg oxycodone QID is 20 mg/day. When you multiply 20 by the conversion factor of 1.5, the result is 30 MME/day.
The correct answer is a, c, and d. Providers should reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or a dose escalation. Patients who do not have pain relief with opioids at 1 month are unlikely to experience pain relief with opioids at 6 months.
Reassessment of pain and function within 1 month provides an opportunity to discontinue opioids for patients not receiving a clear benefit or at risk for harm from these medications.
Although ER/LA opioids were not recommended for this patient, a one-week follow-up would be appropriate when initiating or increasing the dosage of ER/LA opioids.
There is no evidence that ER/LA opioids are more effective or safer than IR opioids, and there is a higher overdose risk when initiating treatment with ER/LA opioids as compared to IR opioids. Methadone is associated with a disproportionate number of overdose deaths.
Higher dosages of opioids add risk without clear benefit. Furthermore, benefits of high-dose opioids for chronic pain have not been established. A randomized controlled trial found no difference in pain or function between liberal dose escalation and maintenance of current opioid dosage. 1
1. Naliboff BD, Wu SM, Schieffer B, et al. A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain. J Pain. 2011;12(2):288-296.
Higher dosages increase risk of serious harm, including fatal and nonfatal overdose. Dosages >=50 MME/day increase the risk of overdose by at least two-fold compared with dosages ≤20 MME/day. Dosages greater than 100 MME/day increase overdose risk up to nine times.
Nine well-designed observational studies 2 published since 2010 demonstrated an association between opioid dosage and opioid-related overdose.
2. Four of the nine studies are located in the Resources tab.
ER/LA opioids should be reserved for severe, continuous pain and should be considered only for patients who have received IR opioids daily for at least 1 week without improvement. ER/LA opioids are also often used when treating end-of-life pain.
In general, the use of ER/LA opioids in combination with IR opioids should be avoided.
Methadone should not be the first choice for an ER/LA opioid. Only providers familiar with methadone's unique risks and who are prepared to educate and closely monitor their patients should consider prescribing.
Methadone is associated with cardiac arrhythmias and QTc prolongation, and it has complicated pharmacokinetics and pharmacodynamics, including a long and variable half-life, as well as a peak respiratory depressant effect occurring later and lasting longer than its peak analgesic effect. Methadone can be hard to taper and can interact with other drugs unpredictably.
Even the lowest dose of transdermal fentanyl is too high for starting opioid therapy. Intermittent or as-needed doses are not possible. Only consider prescribing transdermal fentanyl if you are familiar with its dosing and absorption properties and are prepared to educate patients about its use.
Absorption can be unreliable or variable. For example, heat (e.g., hot showers/baths, fevers) can release medication suddenly, leading to overdose.
Introduce the idea of an opioid taper prior to starting the taper to allow the patient to fully consider the idea, share concerns, and agree to the tapering plan.
Validate and normalize concerns while explaining how the known risks of long-term opioid treatment outweigh the limited benefits. Be sure to answer all the patient's questions when explaining why opioid therapy is not working. Emphasize how maintaining the current opioid dose, or increasing it, puts the patient at serious risk.
Also explain that dose increases will not necessarily reduce pain. A dose decrease, although counterintuitive, may decrease pain and lead to improvements overall by reducing negative effects of opioid therapy and alleviating opioid-induced hyperalgesia, or heightened pain sensitivity.
Patients often are afraid of overwhelming pain or withdrawal symptoms and need to be reassured that a careful dose-lowering plan can minimize these effects. Reinforce that you will not abandon the patient and that you will work to address the patient's pain control in other ways.
If clinically meaningful improvements in pain and function are not sustained or if risks outweigh benefits, clinicians should work with patients to reduce opioid dosage or to discontinue opioids when possible.
Explain to your patient why tapering is necessary. Experts agree that tapering plans may be individualized based on patient goals and concerns. Discuss the plan for tapering and clearly explain how pain will be managed, including strategies for reducing withdrawal symptoms.
Taper slowly enough to minimize symptoms and signs of opioid withdrawal. Be prepared to pause the taper if the patient experiences a severe flare of pain or withdrawal symptoms. Tapers might also have to be slowed once low dosages have been reached.
Once the taper has begun, continue to make steady progress over time. A slower, more prolonged taper can be used if needed for low-risk patients.
Once the smallest available dose is reached, the interval between doses can be extended. Opioids may be stopped once the patient is taking them less frequently than once a day.
If surgery or trauma occurs during the taper, it may be necessary to go back to the pre-event dose and/or slow the pace of the taper to account for new acute pain.
More rapid tapers might be needed for patient safety under certain circumstances (e.g., for patients who have experienced overdose on their current dosage).
Providers should discuss with patients the increased risk of overdose on an abrupt return to previously prescribed higher dosages.
If attempts to taper are unsuccessful, assess your patient for OUD.
Diagnosing OUD requires a thorough evaluation over multiple visits with a patient. Additional information, including the results of urine drug testing and PDMP reports, should be considered when OUD is suspected.
To learn more about OUD, the process for diagnosis, and medication-assisted treatment options, review the 5th module of this series: Assessing and Addressing Opioid Use Disorder.
DOB: 10/09/1965
Chief complaint/reason for visit: Ongoing hip pain, with poor daily function.
Past Medical History:
Social History:
[Provider] Good afternoon. It is good to see you again. At our last visit, we discussed the possibility of tapering your oxycodone. What are your thoughts about this?
[Patient] My wife and I discussed it. She desperately wants me off of the oxycodone.
[Provider] I am glad you discussed it together. How are you feeling about this idea?
[Patient] She doesn't think the oxycodone pills are helping, but I am worried about out-of-control pain. I just don't understand why more isn't better. I have increased my oxycodone over the years, and each time it helped tremendously. I started out taking 10 mg pills twice a day, and now I take 30 mg pills twice a day.
[Provider] It is not unusual that oxycodone helps in the beginning, with the effectiveness fading over time. What other ways did you manage your pain in the past? I would like to try other ways to manage your pain that are less risky.
[Patient] It happened so suddenly, there wasn't much else to try. I did go to PT for a bit, but honestly it was painful and I didn't stick with it. Just changing the pills to a higher dose seems pretty simple to me.
The correct answer is b, and c. This patient is currently taking 90 MME/day of oxycodone. Given the increased risk of overdose and lack of significant improvement in pain and function, increasing the dosage above 90 MME/day is not justifiable. The provider should optimize other therapies and work with the patient to taper opioids to lower dosages or to taper and discontinue opioids.
[Provider] Well, let's think about this. There is little evidence showing that high dose opioids are effective in managing pain and you are taking a dose that puts you at high risk for overdose.
[Patient] It sounds like you think I have an addiction.
[Provider] All opioids have addictive properties. Your body has built up a tolerance to opioids, which now means you must take more to have the same effect. You are likely physically dependent on it too, which will make stopping even harder. It's normal for anyone to develop tolerance to opioids over time. This is an expected natural response to opioid medications.
[Patient] OK. That is the first time anyone has explained it to me like that. So, when I am in pain, I take oxycodone, and then need to take more oxycodone for the same pain over and over…
[Provider] It is likely that reducing your dosage will ultimately make you feel better.
The correct answer is yes. This patient is taking 90 MME per day, without optimization of nonopioid methods of managing pain. It is reasonable to maximize nonopioid therapy while offering this patient an opioid taper, carefully explaining the risks and benefits of opioid therapy.
[Provider] There are many other ways to manage pain, and I am here to work on this with you. First, we need to gradually lower your dose of oxycodone over time to a safer level.
[Patient] That is the taper we were talking about last time. Am I going to go into withdrawal like someone who has an addiction?
[Provider] That is an excellent question. If we taper too quickly, you will feel withdrawal symptoms, which can include muscle aches, gastrointestinal issues, restlessness, sweating, and changes in mood, such as anxiety. Insomnia, tremors, and a fast heart rate are also common. We will take it as slow as you need for your body to adjust, which can help avoid, or at the very least, ease these symptoms.
[Patient] So, what are the next steps?
[Provider] We need to develop a plan that works for you.
[Patient] What if it doesn't work or the pain increases?
[Provider] We will meet often to discuss your progress. If we need to pause, we can until you are ready to continue the taper. We will work together to continue lowering your dose at a pace that feels right for you.
The correct answer is a, c, and e. Providers should discuss the increased risk for overdose on abrupt return to a previously prescribed higher dose. Tapers can be flexible, depending on a patient's comfort level but should move towards an overall dosage reduction. A reasonable starting regimen would be a reduction of 10% of the original dose/week or month, which should be adjusted for each patient's unique situation. Providers should optimize pain management to support the taper and/or discontinuation. Maximize use of nonpharmacological treatments for pain, as well as appropriate nonopioid pharmacologic options.
When starting opioid therapy, providers should prescribe IR opioids instead of ER/LA opioids. When opioids are started, providers should prescribe the lowest effective dosage.
Providers should use caution when prescribing opioids at any dosage; should carefully reassess evidence of individual benefits and risks when increasing dosage to >=50 morphine milligram equivalents (MME)/day; and should avoid increasing dosage to >=90 MME/day or carefully justify a decision to titrate dosage to >=90 MME/day.
Providers should evaluate benefits and harms with patients within 1 to 4 weeks of opioid therapy initiation for chronic pain or dose escalation. Providers should also evaluate benefits and harms of continued therapy with patients at least every 3 months or more frequently.
If benefits do not outweigh harms of continued opioid therapy, providers should ensure other therapies are optimized and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
You may now continue to the Training and Continuing Education Online System (TCEOnline) to receive continuing education credit for this training module.
Please register on TCEOnline, search for the course (WB2861), select the appropriate credit type, and complete the course evaluation and posttest in the Participant Services section.
Select Information for Providers at the URL below for clinical tools and other resources designed to help you apply these recommendations in your practice.
