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As anyone practicing medicine in the United States is aware, we are experiencing an opioid crisis. This situation is very different from that of illegal drugs because these medications are necessary for many of our patients, and many podiatrists use opioids for pain management. Starting January 1, 2019 the Centers for Medicare and Medicaid instituted new prescribing guidelines. Here’s your Practice Perfect public service announcement to help with your opioid prescribing practices.
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Medicare Opioid Use Guidelines1
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Opioid naïve patients – 7 day limit (42 pills for a medication taken every 4 hours)
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These rules also apply to patients taking benzodiazepine medications.
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90 MME Threshold – 90 morphine milligram equivalents (MME) per day allowed. This is not a mandated limitation but rather a threshold where the prescribing physician will be automatically informed.
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Figure 1. Opioid Conversion Table
| Opioid |
Conversion Factor |
| Codeine |
0.15 |
| Fentanyl transdermal |
2.4 |
| Hydrocodone |
1 |
| Hydromorphone |
4 |
| Morphine |
1 |
| Oxycodone |
1.5 |
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Conversion Example: Prescribe oxycodone/acetaminophen 10mg/300mg every 4 hours = 6 times/day = 60mg/day = 60 x 1.5 = 90 MMEs
This would be the absolute maximum dose before triggering a prescribing physician notification. It is also recommended to concurrently prescribe naloxone (see below).
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Electronic prescribing of opioids will be mandated starting in 2021.
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Certain medications will require an electronic prior authorization when prescribed.
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“Patient lock-in” programs will take effect – Medicare patients will be required to obtain their opioid prescriptions from certain pharmacies and physicians.
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Centers for Disease Control and Prevention (CDC) Provides Additional Recommendations2
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Prescribe naloxone with the opioid for all doses greater than or equal to 50 MME or for those at increased risk of overdose.
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Naloxone (opioid receptor antagonist) comes in an intra-nasal (1 mg/mL, and 2 mg/mL) or subcutaneous auto-injector (0.4 mg/mL) and is prescribed one subQ PRN overdose. Remember that naloxone has an elimination half-life of 60-90 minutes, so the respiratory depression and somnolence of an opioid overdose may return after a single naloxone dose (depending on the half life of the opioid), requiring another administration. Repeat every 2-3 minutes as necessary. If no changes are noted after 10 minutes then consider alternative causes of the symptoms.3 No dosing adjustments are necessary for renal or hepatic disease.
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Don’t prescribe extended-release or long-acting opioids for acute pain.
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Don’t prescribe opioids in patients already taking benzodiazepines.
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Use prescription drug monitoring programs (mandated by many states) to check for other outstanding prescriptions.
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A Prescriber's Guide to the New Medicare Part D Opioid Overutilization Policies for 2019. Centers for Medicare & Medicaid. Release date November 1, 2018. Last accessed February 2, 2019.
Follow this link
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Guideline for Prescribing Opioids for Chronic Pain. Centers for Disease Control and Prevention. cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf. Last accessed February 2, 2019.
Follow this link
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Rhyee SH, Traub SJ, Grayzel J. General Approach to Drug Poisoning in Adults. UpToDate. Accessed February 2, 2019.
Follow this link
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