Setting Opioid Dosage Limits in Clinical Practice

Keeping opioid prescribing to 200 mg/d morphine equivalent or less may provide a measure of safety.

With the ever-increasing concern regarding overdose in patients prescribed opioid medication, there is a growing interest in possibly establishing clinic-determined daily dose limitations when opioid medications are prescribed. Although this safeguard alone may not prevent overdose deaths, it might provide an additional measure of safety in which higher doses of opioid medication can inadvertently lead to more unwanted opioid-induced events. 

In one pain clinic where such limitations have been placed, the amount of opioid prescribed per patient is maintained at levels substantially lower than 200 mg/d morphine equivalent. A total of 18% of the patient panel are now on a treatment regimen involving two opioids (a short-acting agent along with a longer-acting opioid) and 83% are using a single opioid agent. Most patients are successfully managed using a morphine equivalent dosage range between 60 mg/d and 90 mg/d.

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Patients are informed at their initial visit that limitations have been established; no more than 90 mg/d of any morphine equivalent will be issued using immediate-release opioid medication and no more than 200 mg/d of a morphine equivalent dosage will be prescribed per any given day using a combination of a short-acting and longer-acting opioid. 

The limitation and expectation are discussed in detail with patients when they are first seen, and if a current dosage is no longer effective, they are informed that opioid rotations will take place vs escalations in dosages that exceed the limitations of the clinic. Even when patients have initially presented with higher doses than those allowed in this particular clinic, after discussing the prescribing limitations of the clinic, most have agreed to opioid tapers and have been adequately treated with lower doses of opioid medication within the prescribing limitations of the clinic.  

Although there may always be exceptions to prescribed opioid limitations, it has been beneficial for this particular pain clinic to have established such parameters. The patients are informed of the prescribing limitations early on in their treatment and this has been reported to be appreciated and not considered a hindrance by the patients being prescribed such potentially dangerous agents. 

Have you experienced a similar occurrence with your patients? Share your  experience in the Comments section below. Mr Pacheco will be available to provide insight and feedback to your comments in this moderated forum.