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reported by norman j clement rph., dds
THE MYTH OF MORPHINE MILLIGRAM EQUIVALENT DAILY DOSE
In 2016, the CDC issued its Guidelines for Prescribing Opioids for Chronic Pain Patients. In publishing the guidelines, the CDC explicitly stated that they were meant to be voluntary and “not prescriptive,” stating that healthcare practitioners knew their patients’ unique clinical situation and should weigh the potential risks and benefits when prescribing opioids. Many of its recommendations were based on what the CDC characterized as “Type 3” or “Type 4” evidence, which are categories of less probative evidence with a significant risk of inaccuracy. The guidelines thus came under significant criticism from many pain and addiction specialists for lacking a strong basis in the evidence.
Others criticized the use of morphine milligram equivalents (MMEs) in determining the appropriate dosing of different opioids. As Fudin and others have argued, MME dosing was designed in an attempt to examine opioids with similar analgesic effects. It should not be used to determine an exact mathematical dosing conversion.
“MME IS NOT A STANDARDIZE CLINICAL METRIC”
The pharmacology and unique properties of each opioid and patient individuality must be considered when a therapeutic opioid conversion is contemplated. Conversion should not simply rely on a mathematical formula embedded within the CDC calculator software.
Furthermore, the current calculation for methadone employed by the calculator could allow for potentially dangerous conversions. This is especially problematic, considering this calculator is intended to target nonspecialist general practitioners. We expect a higher scientific accuracy and integrity level from an agency entrusted to protect citizens’ health and welfare.
Recognizing the controversy surrounding MMEs, in August 2021, the FDA held a “public workshop” entitled “Morphine Milligram Equivalents: Current Applications and Knowledge Gaps, Research Opportunities, and Future Directions.” The workshop’s stated purpose was to “provide an understanding of the science and data underlying existing MME calculations for opioid analgesics, discussing the gaps in these data, and discussing future directions to refine and improve the scientific basis of MME applications.”
NABARUN DASGUPTA et al.
DOES THE MATH
During the workshop, Nabarun Dasgupta of the University of North Carolina Injury Prevention Research Center presented research stating: “Contrary to conventional wisdom, conversion values are not based on pharmacologic properties. Instead, they arose 60 years ago from small single-dose clinical studies in post-operative or cancer populations with pain score outcomes; toxicologic effects (e.g., respiratory depression) were not evaluated.”
The research concluded: “The overlooked inconsistency among daily MME definitions revealed by our study calls into question the clinical validity of a single numerical risk threshold. . . . Our findings call into question state laws and third-party payer MME threshold mandates. Without harmonization, the scientific basis for these mandates may need to be revisited.”86 Some critics consider the use of MMEs to be “junk science.”
Nevertheless, many states implemented statutory or regulatory limits on the dose (in MMEs) and number of opioids that may be prescribed to patients in acute, chronic, and postoperative situations, respectively, and they encouraged policies promoting the rapid or abrupt tapering of chronic pain patients off the opioid therapies on which they had been maintained long-term.
In 2018, Oregon proposed a mandatory reduction to zero opioids calculation for methadone employed by the calculator could allow for potentially dangerous conversions. This is especially problematic, considering this calculator is intended to target nonspecialist general practitioners. We expect a higher level of scientific accuracy and integrity from an agency entrusted to protect citizens’ health and welfare in Medicaid patients over 12 months. The state reversed itself after receiving fierce criticism from pain management and addiction specialists.
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