8.7.0 Recommendation #5 - Lowest Effective Dose

Recommendation #5:

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 considering 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 (recommendation category: A, evidence type: 3).

8.7.1 Functional Description

Patient has been prescribed opioids for chronic pain.

Patient has been prescribed opioids with ambulatory abuse potential that cover 80 days or more in the previous 90 days.

To be generalizable to areas where dispense information is not available, base the calculation on prescriptions, and assume all prescribed medications were taken, including for PRN (as needed) medications. Assume PRN medications are taken at the maximum frequency.

Patient does not appear to be at end of life.

Calculate the morphine milligram equivalence (MME) for the opioid being prescribed plus any other active opioid prescriptions.

if MME >= 50 and < 90, provide a recommendation to taper:

High risk for opioid overdose - consider tapering.

Total morphine milligram equivalent (MME) is 60 mg/day. Consider tapering to < 50.

if MME >= 90, provide a recommendation to taper now:

High risk for opioid overdose - taper now.

Total morphine milligram equivalent (MME) is 100 mg/day. Taper now to < 50.

For both recommendations, provide the information used to calculate the MME as a table of results to provide the clinician with sufficient information to understand how the equivalence was calculated, as well as the source of the data used in the calculation.

In addition, provide links to the CDC Guidance, as well as the MME conversion table.

For both recommendations, one of the following responses should be required:

  • Will reduce dosage
  • Risk of overdose carefully considered and outweighed by benefit; snooze 3 months.
  • Acute pain; snooze 1 month.
  • N/A-see comment (will be reviewed by medical director); snooze 3 months.

8.7.2 Content

The following artifacts formalize the description of the logic and behavior defined by this recommendation.

ResourceTypeDescription
Opioid Terminology Management Knowledgdebase Logic (OMTK) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledgebase Logic (OMTK)CQL SourceFor reference, the complete CQL source for the OMTK Logic Library.
Opioid Terminology Management Knowledgdebase Data (OMTK) LibraryLibraryCQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledgebase Data (OMTK)CQL SourceFor reference, the complete CQL source for the OMTK Logic Library.
Common Opioid Decision Support LogicLibraryCQL Library that provides common logic for the recommendations
Common Opioid Decision Support LogicSTU3 CQL SourceFor reference, the complete CQL source for the common logic.
CDC Opioid Prescribing Guideline Recommendation #5PlanDefinitionEvent-Condition-Action rule that implements behavior for CDC Opioid Prescribing Guideline Recommendation #5
Recommendation #5 - lowest effective dosageLibraryCQL Library that provides logic for evaluating whether a prescription exceeds the MME of 50 mg/day
Recommendation #5 - lowest effective dosageSTU3 CQL SourceFor reference, the complete CQL content for recommendation #5.