ACTION                  CALCULATE morphine milligram equivalence (MME) for opioid being prescribed AND all other active opioid prescriptions

INTERVENTION     DISPLAY notification to provider:

                              1) If morphine milligram equivalent (MME) >=50 and <90 (Recommendation category: A; evidence type: 3):
                              RECOMMENDATION: High risk for opioid overdose - consider tapering to <50 MME per day
                              RATIONALE: Providers should start opioids at the lowest effective dosage, use caution when increasing opioid dosages, and increase dosage by
                              the smallest practical amount. Before increasing total opioid dosage to >=50 MME per day, providers should reassess whether opioids are
                              meeting the patient’s treatment goals. If a patient’s opioid dosage for all sources of opioids combined is >=50 MME per day, providers should
                              implement additional precautions, including increased frequency of follow-up and consider offering naloxone.

                              2) If morphine milligram equivalent (MME) >=90 (Recommendation category: A; evidence type: 3):
                              RECOMMENDATION: High risk for opioid overdose - taper now to <50 MME per day
                              RATIONALE: Providers should avoid increasing opioid dosages >=90 MME per day or should carefully justify a decision to increase dosage to 
                              >=90 MME per day based on individualized assessment of benefits and risks and weighing factors such as diagnosis, incremental benefits for pain
                              and function relative to harms as dosages approach 90MME per day, other treatments and effectiveness, and recommendations based on
                              consultation with pain specialists. If patients do not experience improvement in pain and function at >=90 MME per 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. Established patients already prescribed high
                              dosages of opioids (>=90MME/day), including patients transferring from other providers, should be offered the opportunity to reevaluate their
                              continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. For patients who
                              agree to taper opioids to lower dosages, providers should collaborate with the patient on a tapering plan.

                              3) If Does Not Meet Inclusion Criteria:
                              RECOMMENDATION: No recommendation provided, as patient does not meet inclusion criteria
                              RATIONALE: The recommendation applies to adults aged >=18 years with chronic pain prescribed >=50 MME per day of opioid medications for
                              >=80 days in the previous 90 days

                              4) If Excluded:
                              RECOMMENDATION: No recommendation provided, as patient meets exclusion criteria
                              RATIONALE: The recommendation does not apply to children aged <18 years and patients receiving active cancer treatment, palliative care and 
                              end-of-life care 

INTERVENTION    DISPLAY notification to provider:
                               TABLE: Morphine milligram equivalence (MME) calculation and results
                               RATIONALE: Provide sufficient information to understand how the equivalence was calculated and source of the data used in the calculation

INTERVENTION    DISPLAY link to morphine milligram equivalence (MME) table: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

INTERVENTION    DISPLAY link to relevant recommendation statement available at CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
                                             

INTERVENTION    DISPLAY link to reference information: https://jamanetwork.com/journals/jama/fullarticle/2503508
 

ACTION                 DOCUMENT provider response

                               1) Will reduce dosage

                               2) Risk of opioid overdose carefully considered and outweighed by benefit; re-evaluate in 3 months

                               3) Acute pain; re-evaluate in 1 month

                               4) N/A - see comment (will be reviewed by medical director); re-evaluate in 3 months

INTERVENTION    DISPLAY link to patient opioid education materials relevant to care plan:
                               Prescription Opioids: What You Need to Know: https://www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf
                               Promoting Safer and More Effective Pain Management: https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-Patients-a.pdf
                               Preventing an Opioid Overdose: https://www.cdc.gov/drugoverdose/pdf/patients/Preventing-an-Opioid-Overdose-Tip-Card-a.pdf