Morphine Milligram Equivalents (MME) Calculator
Calculates total daily morphine milligram equivalents.
When to use
Pearls/Pitfalls
Why use
When to use
- Use in opioid-naïve and opioid tolerant adult patients.
- Do not use in pediatric patients, due to unpredictable rates of absorption and risk of overdose.
- Do not use in patients with malignant pain or those requiring end-of-life care.
Pearls/Pitfalls
- Uses morphine as the reference point for conversion of other oral opioids to MME.
- Should be used only for oral opioid conversion to MME, not for conversion of one opioid to another.
- Equianalgesic dose ratios are approximations and do not account for genetic factors, incomplete cross-tolerance, and pharmacokinetics.
- Does not give information on efficacy, but is used to assess comparative potency of other analgesics.
- Pharmacokinetics and conversion for methadone and tapentadol are particularly complex, and clinicians should err on the side of being especially conservative with those conversions in particular.
Why use
- MME is a numerical standard against which most opioids can be compared, yielding a comparison of each medication’s potency.
- Helps determine whether a cumulative daily dose of opioids is associated with increased risk of overdose.
- Helps identify patients who may benefit from closer monitoring, reduction or tapering of opioids, naloxone prescription, and other measures to reduce risk of potential opioid abuse and/or overdose.
Next
Evidence
Next
MANAGEMENT
- CDC guidelines recommend prescribing the lowest effective opioid dose and to use caution when prescribing opioids at any dosage, particularly when increasing dosage to ≥50 MME/day. Doses ≥99 MME/day should be avoided or carefully justified (and titrated accordingly).
- American College of Emergency Physicians (ACEP) guidelines recommend avoiding routinely prescribing outpatient opioids in patients with acute exacerbation of chronic noncancer pain in emergency settings.
CRITICAL ACTIONS
Avoid concurrent opioid and benzodiazepine prescribing, as it increases the potential for overdose (CDC guidelines).
Evidence
FORMULA
Addition of the assigned points, as above.
| Opioid | Common dosages | MME conversion factor2 |
|---|---|---|
| Codeine | 15mg, 30mg, 60mg, 2.4 mg/mL, 6 mg/mL | 0.15 |
| FentaNYL buccal or sublingual tablets | 100 mcg, 200 mcg, 300 mcg, 400 mcg, 600 mcg, 800 mcg | 0.13 |
| FentaNYL patch (Duragesic) | 12.5 mcg, 25 mcg, 37.5 mcg, 50 mcg, 62.5 mcg, 75 mcg, 87.5 mcg, 100 mcg | 2.4 |
| HYDROcodone (Vicodin, Norco, Lortab) | 2.5 mg, 5 mg, 7.5 mg, 10 mg, 1 mg/mL, 0.5 mg/mL, 0.667 mg/mL | 1 |
| HYDROmorphone (Dilaudid) | 2 mg, 4 mg, 8 mg, 12 mg, 16 mg, 32 mg, 1 mg/mL | 5 |
| Methadone3 | 5 mg, 10 mg, 40 mg | 4.7 |
| Morphine | 10 mg, 15 mg, 20 mg, 40 mg, 45 mg, 50 mg, 60 mg, 70 mg, 75 mg, 80 mg, 90 mg, 100 mg, 120 mg, 130 mg, 150 mg, 200 mg, 2 mg/mL, 20 mg/mL | 1 |
| OxyCODONE (OxyCONTIN, Roxicodone) | 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg, 1 mg/mL, 20 mg/mL | 1.5 |
| OxyMORphone | 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 1 mg/mL | 3 |
| Tapentadol3, mg | 0.4 | |
| TraMADol (Ultram), mg | 0.2 | |
| Buprenorphine4 | 10 |
- Dosage in mcg/hr for fentaNYL patch, in mcg for fentaNYL buccal or sublingual tablets, and in mg for all other opioids.
- These dose conversions are estimated and cannot account for individual differences in genetics and pharmacokinetics.
- Conversion of methadone and tapentadol is particularly complex.
- Buprenorphine is listed but, as a partial opioid agonist, is not expected to be associated with overdose risk in the same dose-dependent manner as doses for full agonist opioids and is therefore omitted from the calculator.
FACTS & FIGURES
| MME range | Comparative risk* | Recommendation | Annual overdose rate |
|---|---|---|---|
| 1 to <20 MME/day | Reference | Acceptable therapeutic range for acute pain and opioid-naïve patients | 0.2% |
| 20 to <50 MME/day | 2x higher risk of overdose | There is no completely safe opioid dose; use caution when prescribing opioids at any dose and always prescribe the lowest effective dose | Data not available |
| 50 to <100 MME/day | 3.7x higher risk of overdose | Strongly consider non-opioid analgesics and decreasing daily opioid dose | 0.7% |
| ≥100 MME/day | 8.9x higher risk of overdose | Consult pain specialist to reassess pain regimen and decrease dosage and/or wean off opioids | 1.8% |
| 1 to <20 MME/day | Reference | Acceptable therapeutic range for acute pain and opioid-naïve patients | 0.2% |
EVIDENCE APPRAISAL
- 80% of patients on prescription opioids were prescribed low doses (<100 mg MEDD) by a single provider—these patients account for 20% of all prescription opioid overdoses.
- 10% were prescribed high doses (≥100 mg MEDD) by a single prescriber—these patients account for 40% of all prescription opioid overdoses.
- 10% sought care from multiple doctors and were prescribed high daily doses—these patients account for an additional 40% of all prescription opioid overdoses.
Additionally,
- Patients receiving >100mg daily MMEs are nine times more likely to overdose, and 12% of those overdoses result in death.
- Patients receiving ≥50 mg daily MME are twice as likely to overdose in comparison to patients taking <20 mg daily MME.
- Research experts, federal agencies (CDC, Bureau of Justice Assistance, Substance Abuse and Mental Health Services Administration), and states prescription drug monitoring programs (PDMPs) use the amount of daily MME prescribed to better gauge abuse potential, overdose potential of opioids, and tapering and/or weaning off opioids.
