ABILENEPAIN

Daily MME calculator

Oral morphine milligram equivalents, up to six concurrent opioids. Each line shows the factor that produced it.

Total daily MME
0
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5090

Methadone conversion method

Bands are the 2016 CDC values, still used by CMS in its Overutilization Monitoring System. The 2022 guideline replaced them with a single 4.7, which is what most PDMPs report. The band keys off total daily methadone dose. Neither is a titration tool.

Not a rotation tool. Reduce the calculated equivalent 25–50% for incomplete cross-tolerance — more for methadone.

Oral equivalents only. Not for IV, epidural, or intrathecal dosing.

Combination products: enter the opioid component only.

Enter what is taken. PDMPs derive MME from quantity dispensed ÷ days supply; expect a different number.

Anticoagulant hold intervals

Two guidelines, shown side by side. They are different documents with different scopes — where they diverge, you are choosing, not looking up.

Guideline

These are two parallel documents, not an old one and a new one. Both are current ASRA publications from different author groups. Neither replaced the other. The 2025 paper replaced the 2018 regional guideline (4th ed) — it did not replace the pain guideline, and its own introduction points to a separate document for interventional pain procedures.

Planned procedure

Agents the patient is taking

Shared decision making is not optional. For any patient on antithrombotic therapy for secondary prevention, the decision to hold belongs jointly to you, the patient, and the prescribing cardiologist or neurologist. Document it.

Where the two diverge, the pain document is usually the conservative one — particularly on aspirin and NSAIDs, which the 2025 regional guideline says need no hold at all for neuraxial blocks while the 2018 pain guideline calls for six days before a high-risk pain procedure. That difference is not an error in either document: the case reports driving the pain guideline came from epidural steroid injections and SCS lead placement, and the 2025 text names invasive pain procedures as the exception to its own permissive stance.

ASIPP also publishes competing guidance (Pain Physician 2024;27[S6]:S1–S94), materially less conservative than either of these. Three documents now exist. Pick one as house standard, write it down, and make sure every provider in the practice is on the same one.

Both panels state their recommendations do not define standard of care and rest on limited data. Neither replaces judgment on the individual patient.

Steroid equivalence & load

Anti-inflammatory equivalence between injectable corticosteroids, particulate status by agent, and a running cumulative total for one patient.

Convert

Route safety

Cumulative load — this patient

Add each injection over the period you care about. Nothing is saved; this clears when you close the tool.

There is no evidence-based annual ceiling. Commonly cited limits — three or four injections per year, or per level — are convention and survey practice, not trial data. Survey work shows roughly 40% of physicians allow four per level per year, and a small minority allow more. Treat any number as a prompt to reconsider, not a rule.

Equivalence is systemic anti-inflammatory potency. It does not predict epidural efficacy or duration. Particulate agents form a depot and act longer locally; dexamethasone and betamethasone produce shorter immune suppression than methylprednisolone. Do not use these ratios to argue two epidural injections were "the same."

Epidural corticosteroid injection is off-label. The FDA has not approved any corticosteroid for epidural administration, and its 2014 safety communication about rare serious neurological events stands unmodified.

Watch for what cumulative steroid actually does: HPA axis suppression lasting weeks, glycemic escalation in diabetics, bone density loss, and infection risk — none of which appear on the day of injection.

Procedure room

Local anesthetic ceilings, LAST rescue, sedation titration, and reversal. Enter weight once; every panel updates.

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Quick answer

All agents at this weight

Values are the conventional manufacturer-labeling ceilings, capped at the absolute maximum where one applies. They are not evidence-based thresholds: LAST has occurred well below these numbers, and site vascularity (intercostal > caudal > epidural > peripheral) drives peak plasma level more than total milligrams. Reduce in the elderly, cardiac, hepatic, or pregnant patient.

LAST — lipid emulsion 20%

Simultaneously: call for help · stop injecting · 100% oxygen, secure airway, avoid hypoxia and acidosis · benzodiazepine for seizure · ACLS if arrest.
Modified ACLS: epinephrine in small boluses, ≤1 mcg/kg. Avoid vasopressin, calcium channel blockers, beta blockers, and further local anesthetic. Propofol is not a substitute for lipid.
Monitor after stabilization: 2 h following a resolved seizure; 4–6 h following a resolved cardiovascular event. Alert the nearest cardiopulmonary bypass capability early if refractory.

Order of bolus versus infusion, and method of infusion, are not critical — give it early. Maximum total lipid 12 mL/kg.

Moderate sedation — titration

The combination is the danger, not either drug. Benzodiazepine plus opioid produces respiratory depression out of proportion to either alone. Give one agent, wait its full peak, then reassess before giving the other. Most procedural sedation catastrophes are stacked doses given before peak effect.

Reduce initial dose and total by roughly half in the elderly, debilitated, hepatic or renal impairment, or anyone with sleep apnea. Continuous capnography and pulse oximetry, and someone whose only job is monitoring the patient.

Reversal

Have the kit in the room. A LAST kit (lipid, syringe, tubing, printed checklist) belongs wherever local anesthetic is injected, not down the hall.

Sources: ASRA Local Anesthetic Systemic Toxicity checklist, 2020 version (Neal JM, Neal EJ, Weinberg GL. Reg Anesth Pain Med 2021;46:81–82) · naloxone and flumazenil intervals from FDA product labeling.

Opioid taper planner

Percentages are of the original dose, which is how CDC and HHS express them. Schedules can be generated from an MME figure, from the actual tablets, or from patch strengths.

Mode

Enter a total daily MME. Produces a percentage schedule — useful for planning, but the targets will not land on dispensable doses.

Reduction rate

Schedule

A pause is not a failure. HHS is explicit that a taper still counts as successful if it moves very slowly or stops for a while so the patient can adapt. Build pauses in rather than treating the schedule as a contract.

Do not taper abruptly in a physically dependent patient. The FDA's 2019 safety communication was issued because rapid or forced discontinuation produced serious withdrawal, uncontrolled pain, and psychological crisis. Rate is a clinical decision made with the patient, not a policy applied to them.

Screen for opioid use disorder before tapering. If OUD is present, the answer is buprenorphine or methadone treatment, not a dose reduction schedule.

Reassess at every step — function, pain, withdrawal, mood. Offer naloxone throughout; tolerance falls as the dose comes down.

Product strengths are a snapshot dated 22 Aug 2026, drawn from FDA labeling. Availability changes, and what is manufactured is not the same as what your pharmacy stocks or a payer will cover. Confirm before writing.

Sources: CDC Clinical Practice Guideline, MMWR Recomm Rep 2022;71(RR-3), Recommendation 5 · HHS Guide for Clinicians on Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics, 2019 · VA/DoD 2022 · FDA product labeling via DailyMed.