PHARMACIST STEVE

All the answers in this blog post was provided by perplexity.ai – all I did was to ask some questions!

While I am not an attorney, it is my understanding that many states have limits on malpractice settlements that are often below what amounts of  the legal fees to fund a case for malpractice.

It is my understanding, law firms look for people that have been harmed by some entity – especially a large corporations with “deep pockets”

It is well established/documented that the MME system has no real valid large double blind clinical studies with a control group to support its conclusions, especially when those conclusions are applied to treating chronic pain pts.

Since the vast majority of practitioners are employees of large hospital system, when all the practitioners are “persuaded” to follow some hard/cold opioid dosing guidelines that are well below the dosing ranges that are published in the FDA prescribing guidelines.

So a entity establishing dosing guidelines limits that are nothing but a FRACTION of the FDA’s prescribing guidelines for a specific medication, that would strongly suggest that SUBSTANDARD CARE IS BEING MANDATED.

Causing unnecessary pain & suffering, premature deaths and often suicides.

---

could find the original parameters for the establishing the original MME equivalents and I believe that was done during the 1970 and has there been any updates or revisions and if so what was those parameters?

The original Morphine Milligram Equivalent (MME) parameters were developed to standardize opioid prescribing by expressing potency relative to morphine, primarily for comparing different opioids and aiding in safe dosage adjustments. While the concept traces back to clinical pharmacology work from the 1970s, there is little evidence of a single formalized or universally adopted framework from that era; standardized MME conversion tables became prominent much later, especially with opioid prescribing guidelines in the 2000s and 2010s.[1][2][3]

Original MME Calculation Parameters

The standard formula for calculating daily MME is:

$$\text{MME}=(\text{Dose Strength per Unit})\times (\text{Units per Day})\times (\text{Opioid-specific Conversion Factor})$$

These conversion factors reflect the relative potency of each opioid compared to morphine.

### Updates and Revisions to MME Parameters

There have been significant updates and periodic revisions to the MME standards, particularly as reflected in CDC guidelines:
– The CDC and other regulatory bodies periodically revise MME conversion tables based on new evidence, observed clinical outcomes, and concerns about overdose risks.
– Notably, the CDC made updates in their 2022 guideline, reflecting adjusted conversion factors for certain opioids (e.g., methadone and tramadol had significant changes in their factors).[6][7][8]
– The parameters for calculating MME now emphasize more precise conversion factors, updated every few years, and stress caution in cross-opioid dose conversions due to incomplete cross-tolerance and patient variability.[5][6]

References and Further Information

Modern resources, including the 2022 CDC Clinical Practice Guideline, provide the authoritative conversion factors and detailed explanation of calculation methods. For full lists of current conversion factors and descriptions of methodologies, consult the CDC official guidelines or clinical documentation from NIH and state PDMPs.[2][7][8][5][6]

In summary, while the MME concept originated in the 1970s, robust and widely adopted parameters and tables are much more recent and have undergone several important updates, especially by the CDC in response to new evidence and evolving clinical needs.

[1](https://www.youtube.com/watch?v=KVoKRLWwduI)
[2](https://heal.nih.gov/files/2025-03/MME%20Calculator%20FAQ_508.pdf)
[3](https://www.eviq.org.au/clinical-resources/eviq-calculators/3201-opioid-conversion-calculator)
[4](https://pmc.ncbi.nlm.nih.gov/articles/PMC9477978/)
[5](https://health.maryland.gov/pdmp/Documents/Clinical%20Docs/MME%20Fact%20Sheet.pdf)
[6](https://www.albme.gov/press-release/changes-to-mme-conversion-calculations-reflected-in-pdmp-database)
[7](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[8](https://archive.cdc.gov/www_cdc_gov/opioids/data-resources/index.html)
[9](https://meps.ahrq.gov/data_files/publications/rf45/rf45.shtml)
[10](https://apps.health.ny.gov/pub/ctrldocs/bne/nyosammeformulation.pdf)
[11](https://medicaid.alabama.gov/alert_detail.aspx?ID=16245)
[12](https://www.nj.gov/humanservices/dmahs/boards/durb/newsletters/34-01_DURB_Newsletter_MME.pdf)
[13](https://scholarlycommons.henryford.com/hfjhrs2025/2/)
[14](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[15](https://www.cms.gov/files/document/methodology-comparison.pdf)
[16](https://www.sciencedirect.com/science/article/pii/S174868152400336X)
[17](https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/docs/2022-CDC-Opioid-Prescribing-Guideline-Updates.pdf)

So there has never been any double blind clinical trials with a control group to validate or update the MME standards since the 1970’s and these MME standards are mostly or totally observational and/or consensus of how many experts ?

There have never been any large-scale, double-blind clinical trials with a control group specifically established to validate or revise the core MME (Morphine Milligram Equivalent) standards since their introduction. The MME conversion factors used today are based almost entirely on a combination of observational pharmacologic data, literature review, single-dose studies, and expert consensus rather than rigorous randomized controlled trials.[1][2]

### Scientific Basis and Validation

– The conversion factors for MME are derived largely from early pharmacology work, single-dose potency studies, clinical experience, and expert panel discussions—not from systematic, blinded trials comparing equivalent clinical outcomes across opioids.[2]
– Validation efforts and updates, such as those led by the CDC, involve comparative effectiveness research, retrospective analyses of prescription data, and integration of available pharmacologic data, but not large prospective, double-blind, randomized studies.[3][4][2]
– The most recent changes and adjustments are made by consensus panels with periodic literature review, relying on the accumulated judgment of pain management and pharmacology experts rather than new interventional clinical evidence.[2]

 

 

 

 

 

 

Modern publications and patient-advocacy organizations confirm that MME limits and conversions are not based on formal, rigorous science or double-blind clinical trials, but remain consensus tools created for guidance and policy, with recognized limitations and substantial variability for individual patients.[2]

In conclusion, MME values remain an observational, consensus-based tool, not formally validated or updated with double-blind clinical trial data since the original rough potency estimates were established.No, there have never been any large-scale double-blind clinical trials with a control group specifically designed to validate or update the MME (Morphine Milligram Equivalent) standards since their development. The MME conversion factors and standards used today are almost entirely based on observational data, single-dose potency studies, and the consensus of clinical experts in fields such as pharmacology and pain management—not randomized controlled trial evidence.[1][2]

Nearly all updates and adjustments to MME values in guidelines (including CDC guidelines) come from panel reviews of the existing clinical literature, animal studies, case reports, and collective clinical experience of expert teams. These panels typically include pain management specialists, pharmacologists, and regulatory experts, but the precise number and selection process vary by group or guideline update.[2]

As a result, MME remains an expedient and widely used clinical tool, but its actual scientific validation is limited, and its reliability at the population level has sometimes been challenged. Blinding, randomization, and placebo-controlled methods—the gold standard for validating clinical interventions—have not been applied to the establishment or revision of MME standards.[2]

[1](https://pubmed.ncbi.nlm.nih.gov/39907478/)
[2](https://www.thedoctorpatientforum.com/debunking-lies/508-milligrams-of-morphine-equivalent-mme-and-mme-limits-are-a-scientific-concept)
[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC9477978/)
[4](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[5](https://clinicaltrials.gov/show/NCT00325377)
[6](https://www.clinicaltrials.gov/study/NCT00134524)
[7](https://heal.nih.gov/files/CDEs/2024-04/opioid-mme-crf.docx)
[8](https://www.frontiersin.org/journals/pain-research/articles/10.3389/fpain.2025.1612572/full)
[9](https://www.cms.gov/files/document/methodology-comparison.pdf)
[10](https://medinform.jmir.org/2024/1/e53625/)
[11](https://blueprintgenetics.com/tests/single-gene-tests/mme-single-gene-test/)
[12](https://apps.health.ny.gov/pub/ctrldocs/bne/nyosammeformulation.pdf)
[13](https://pmc.ncbi.nlm.nih.gov/articles/PMC8851821/)
[14](https://www.invitae.com/us/providers/test-catalog/gene-252961)
[15](https://www.communitycarenc.org/sites/default/files/2017-12/Opioid-Morphine-EQ%20Conversion%20Factors.pdf)
[16](https://clinicaltrials.gov/study/NCT04491175)
[17](https://www.albme.gov/press-release/changes-to-mme-conversion-calculations-reflected-in-pdmp-database)
[18](https://reporter.nih.gov/search/12E8CC0C488BC4D77598B8961CAA4A01A2FFCEB861BF/project-details/11240717)
[19](https://wa-provider.kaiserpermanente.org/static/pdf/public/guidelines/opioid.pdf)
[20](https://www.clinicaltrials.gov/study/NCT03847311)

So these conclusion were based on a SINGLE DOSE to pts dealing with surgically induced acute pain, thermal induced acute pain or some other induction of acute pain?

Yes, the foundational MME (Morphine Milligram Equivalent) ratios were mostly derived from single-dose studies given to patients with experimentally induced acute pain, such as surgical procedures, thermal injury models, or other controlled acute pain scenarios.[1][2][3]

### Methodology of MME Conversion Factors

– Early opioid equivalency tables depended on studies where a single dose of an opioid was administered, and pain relief was evaluated—often in patients with surgically-induced pain, experimental thermal injury, or dental pain procedures.[2][3][1]
– These studies were typically short-term and involved volunteers or patients without chronic pain histories or opioid tolerance, making the results less generalizable to populations with chronic pain or complex opioid needs.[1][2]
– The conversion ratios measured analgesic potency using standardized pain scales and sometimes crossover designs but did not account for individual variation, chronic dosing, tolerance development, or metabolic differences over time.[2][1]

### Limitations and Generalizability

– The relative potency data from these acute pain models serve as the basis for the equianalgesic tables that underpin MME conversion, but these do not translate perfectly to chronic pain, nor do they account for risks such as opioid tolerance, incomplete cross-tolerance, or individual pharmacodynamics—limitations which are widely acknowledged in recent guidelines and literature.[4][2]
– There is widespread recognition that these tables can lead to imprecision and even risk when applied to chronic pain management practices, especially for opioid rotation; most expert consensus recommends significant caution and clinical judgment.[4][1]

In summary, MME conversion standards are based on single-dose research in acute pain models and were not validated for chronic pain, repeated dosing, or complex clinical scenarios. They remain a tool with substantial limitations and should be used with clinical caution.[3][1][2][4]

[1](https://www.sciencedirect.com/science/article/pii/S0885392409006307)
[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC3555047/)
[3](https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2009.03456.x)
[4](https://pmpawarxe.zendesk.com/hc/en-us/articles/41323540381587-Morphine-Milligram-Equivalency-MME-Insights-into-a-Complex-Metric)
[5](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[6](https://www.ncbi.nlm.nih.gov/books/NBK537482/)
[7](https://www.eviq.org.au/clinical-resources/eviq-calculators/3201-opioid-conversion-calculator)
[8](https://www.mdanderson.org/documents/for-physicians/algorithms/clinical-management/clin-management-post-op-pain-web-algorithm.pdf)
[9](https://heal.nih.gov/files/CDEs/2024-04/opioid-mme-crf.docx)
[10](https://academic.oup.com/painmedicine/article/13/suppl_1/S12/1909004)
[11](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[12](https://www.sciencedirect.com/science/article/pii/S174868152400336X)
[13](https://www.ncbi.nlm.nih.gov/books/NBK526115/)
[14](https://emedicine.medscape.com/article/2138678-overview)
[15](https://attcnetwork.org/wp-content/uploads/2024/07/Acute-Pain-Post-op-Pain-MPATTC_23July2024.pdf)
[16](https://clincalc.com/opioids/)
[17](https://pmc.ncbi.nlm.nih.gov/articles/PMC7736143/)
[18](https://ascopubs.org/doi/10.1200/JCO.22.02198)
[19](https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/opioid-prescribing.html)
[20](https://mn.gov/dhs/opip/opioid-guidelines/pain-phase/acute-pain.jsp)

Since pain is a subjective issue with a pt, how could any consistent results be expected. How many pts were involved in these observational studies?

The early studies underpinning MME conversion factors often involved small patient groups, and most were single-dose studies using subjects with experimentally induced acute pain rather than chronic pain patients. Pain, as a subjective experience, naturally introduced wide variability in responses—making consistent results challenging and the data less reproducible across patient populations.[1][2][3]

### Typical Sample Sizes

– Many foundational opioid equivalency studies involved fewer than 100 participants, sometimes as few as 10–40, with some larger efforts occasionally reaching 100–200 subjects, but these were exceptions rather than the norm.[2][4]
– More recent prospective cohort studies for acute pain may include hundreds or up to 1,550 participants, but these do not specifically validate the classic MME conversion tables used for equianalgesic calculations.[5]
– Pilot and comparator studies in the last decade on specific opioids still often report “relatively small sample size,” making robust statistical conclusions difficult.[6]

### Impact of Subjectivity

– Because pain reporting relies on individual patients’ subjective assessment using numeric or visual analog scales, the resulting potency ratios are averages that mask considerable patient-to-patient variability.[3][2]
– Equianalgesic dose tables are therefore widely recognized as starting points and must be adapted for each individual, particularly in cases of underlying opioid tolerance, comorbidities, and other unique clinical factors.[7][2]

In conclusion, the evidence base for MME ratios comes from observational and single-dose studies with limited sample sizes and high interpatient variability, meaning consistent results are not guaranteed and individualized adjustments are required in real-world practice.Consistent results from MME conversion studies were always limited because pain is inherently subjective and highly variable between patients. The original research often involved relatively small sample sizes—many studies included dozens to, at most, a few hundred subjects—and almost all relied on acute pain models with single-dose exposures.[1][2][7][3]

Most classic equianalgesic studies used fewer than 100 participants per group, and even some more recent prospective observational studies or cohort studies with hundreds of participants have not specifically focused on validating or updating the basic MME conversion tables themselves. This means the results cannot be viewed as universally consistent—the experts themselves acknowledge that variability and individual response differences are significant.[4][2][5][1]

So, the underlying data for opioid potency and equivalency, and thus MME tables, come from small single-dose studies where pain was usually induced experimentally, with results averaged across patients who may respond very differently. This creates a tool that is useful for starting clinical decisions but is not a precise or universally reliable metric.[2][3][1]

[1](https://www.sciencedirect.com/science/article/pii/S0885392409006307)
[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC4590088/)
[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC3555047/)
[4](https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21823)
[5](https://bmjopen.bmj.com/content/12/7/e058782)
[6](https://scholars.uky.edu/en/publications/relative-potency-of-intravenous-oxymorphone-compared-to-other-%C2%B5-o)
[7](https://apm.amegroups.org/article/view/38250/29318)
[8](https://www.sciencedirect.com/science/article/pii/S0885392401002949)
[9](https://www.ncbi.nlm.nih.gov/books/NBK458655/)
[10](https://academic.oup.com/painmedicine/article/17/1/85/1752837)
[11](https://pmc.ncbi.nlm.nih.gov/articles/PMC8514134/)
[12](https://www.ohsu.edu/sites/default/files/2019-01/Opioids_final_report_update-6_Jul_11.pdf)
[13](https://www.nature.com/articles/s41372-024-02121-z)
[14](https://www.ncbi.nlm.nih.gov/books/NBK607985/)
[15](https://www.ncbi.nlm.nih.gov/books/NBK535402/)
[16](https://www.sciencedirect.com/science/article/pii/S0039606021000349)
[17](https://academic.oup.com/painmedicine/article-pdf/17/5/892/6845415/pme.12920.pdf)
[18](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786200)
[19](https://www.dovepress.com/practical-management-of-opioid-rotation-and-equianalgesia-peer-reviewed-fulltext-article-JPR)
[20](https://emedicine.medscape.com/article/2138678-overview)
[21](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)

Consensus among experts and guidelines acknowledges significant limitations in the use of MME tables for managing chronic pain, particularly in patients with high-intensity or complex chronic pain. While MME tables may offer a rough framework for opioid rotation or initial dosage considerations, their accuracy and safety for chronic pain management—especially high-dose, long-term cases—are widely debated, and their generalizability remains questionable.

### Evidence and Expert Consensus

– Recent consensus statements and systematic reviews confirm that MME tables are subject to high variability among individuals and across different opioids, making them vulnerable to misapplication in chronic pain populations.[3]
– The CDC and other organizations have acknowledged that recommendations for MME-based dosing thresholds (e.g., limits at 90 MME/day) are not based on high-quality evidence, and that rigid adherence can be harmful to certain chronic pain patients who have benefited from higher doses.[4][1]
– Professional guidelines urge clinicians to use MME tables with caution for chronic pain, reduce reliance on arbitrary limits, and instead adopt individualized, patient-centered approaches when considering opioid therapy and tapering.[2][5]

### Clinical Reality

– Many chronic pain specialists and panels advise that MME conversions do not address incomplete cross-tolerance, pharmacokinetics, metabolic differences, nor the long-term adaptation seen in high-intensity chronic pain.[2]
– For chronic pain, especially severe cases, judicious, individualized opioid management is key—using MME tables only as approximate guides, not absolute rules.[3][2]

 

 

 

 

 

 

 

In summary, current expert consensus and available research strongly suggest that MME tables, while useful for standardization, are not reliably viable as stand-alone tools for chronic or severe pain management—especially in high-intensity, long-term opioid therapy contexts. Clinicians are urged to employ individualized methods and clinical judgment rather than strict MME-based controls.Most studies and expert consensus now agree that MME tables—originally designed for standardization and acute pain—have significant limitations and only limited viability for chronic pain management, especially for patients with high-intensity, complex pain.[7][1][2][3]

Recent guidelines and reviews highlight these key issues:
– There is high variability and limited accuracy in using MME for chronic pain patients, due to differences in tolerance, metabolism, cross-tolerance, individual drug effects, and the adaptive changes seen with long-term opioid exposure.[2][3]
– Rigid MME-based dosing limits can be harmful—for example, the CDC acknowledges that the 90 MME/day threshold is not rigorously supported by science and that forced tapering or strict adherence to MME protocols can negatively impact patients who have benefited from higher doses.[1][4]
– Specialist societies and consensus panels recommend using individualized clinical judgment, careful patient monitoring, and shared decision-making when managing chronic pain with opioids, rather than relying exclusively on MME tables.[5][7]

In summary, while MME tables may provide a baseline for comparison or initial prescribing, the evidence and expert opinion clearly indicate they should not be used as rigid standards for chronic pain management in high-intensity patients. Instead, tailored, nuanced approaches are strongly recommended.[7][1][3][2]

[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5135486/)
[2](https://mn.gov/dhs/opip/opioid-guidelines/pain-phase/chronic-pain.jsp)
[3](https://www.nature.com/articles/s41598-025-17979-y)
[4](https://www.aafp.org/pubs/afp/issues/2020/0415/p458.html)
[5](https://www.aafp.org/pubs/afp/issues/2020/0915/p335.html)
[6](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[7](https://pubmed.ncbi.nlm.nih.gov/38117465/)
[8](https://www.painphysicianjournal.com/current/pdf?article=Nzc3Nw%3D%3D&journal=157)
[9](https://pmc.ncbi.nlm.nih.gov/articles/PMC10949542/)
[10](https://www.sciencedirect.com/science/article/pii/S174868152400336X)
[11](https://www.medicaid.gov/sites/default/files/Medicaid/Prescription-Drugs/Downloads/Drug-Utilization-Review/DUR-FFS-Reports/AR-DUR-FFY17.pdf)
[12](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[13](https://jamanetwork.com/journals/jama/fullarticle/2503508)
[14](https://wa-provider.kaiserpermanente.org/static/pdf/public/guidelines/opioid.pdf)
[15](https://www.ncbi.nlm.nih.gov/books/NBK535402/)
[16](https://www.fda.gov/media/147152/download)
[17](https://www.mirecc.va.gov/VISN16/docs/pain-management-pocket-guide.pdf)
[18](https://www.ncbi.nlm.nih.gov/books/NBK458655/)
[19](https://www.aafp.org/pubs/afp/issues/2016/0615/p982.html)
[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC7139205/)

 

Could it be considered malpractice if a practice or large hospital system established hard/cold dosing limits based on the MME system for all pts

It could be considered malpractice—or at least a form of substandard care—if a practice or hospital system imposes strict, non-individualized MME-based dose limits for all patients, especially when these policies disregard patient-specific needs and established evidence regarding chronic pain management.[1][2]

### Legal and Ethical Risks

– Current clinical guidelines from the CDC and other authorities clearly emphasize that MME limits should not be rigidly enforced, and care should be individualized.[3][1]
– The CDC specifically warns against forced or abrupt tapering based only on MME thresholds, acknowledging potential harm and risk of legal liability for providers who follow overly strict protocols without clinical justification.[2][1]
– Professional consensus and several recent publications have stated that blanket application of dosing ceilings not supported by patient-specific evaluation can pose real risks, sometimes leading providers to face malpractice claims if patient harm occurs as a result.[4][2]

### Regulatory and Case Precedent

– There is growing documentation of adverse events, such as unmanaged pain, withdrawal, and even suicide, when strict MME-based limits are imposed without individual assessment.[1][2]
– Malpractice is defined in part as failure to meet the standard of care, and most authorities now recognize that rigid, unmodified MME limits fall short for chronic and complex pain patients, possibly amounting to negligence if harm follows.[2][4]

|

 

 

 

 

In summary, health systems and practices implementing hard MME limits without regard for individual patient assessment and clinical judgment may risk accusations of malpractice—especially if patients are harmed and current best-practice guidelines have been ignored.[3][4][1][2]

[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5135486/)
[2](https://www.aafp.org/pubs/afp/issues/2020/0415/p458.html)
[3](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[4](https://www.aafp.org/pubs/afp/issues/2020/0915/p335.html)

Filed under: General Problems