What is a reasonable increased maximum dose of oxycodone (OxyContin) for a patient with chronic right hip pain due to severe arthritis and hip fracture, currently taking 5-10 milligrams (mg) every 4 hours (q4h) as needed (prn), with a previous limit of 8 tablets per day?

From the Guidelines

A reasonable increased maximum dose order for this patient would be oxycodone 5-10 mg every 4 hours as needed with a maximum of 12 tablets (60-120 mg) per day. This adjustment would allow the patient to have more flexibility in managing her nighttime pain while still maintaining appropriate limits. The current restriction of 8 tablets daily (maximum 80 mg) may be insufficient for her chronic pain from severe arthritis and hip fracture, particularly during nighttime hours. When implementing this change, it would be important to monitor the patient closely for side effects such as respiratory depression, constipation, and sedation, even though she has tolerated the medication well so far. According to the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1, the conversion factor for oxycodone is 1.5, which can be used to determine the morphine milligram equivalent (MME) dose. However, it's crucial to note that equianalgesic dose conversions are only estimates and cannot account for individual variability in genetics and pharmacokinetics 1. Additionally, consider adding a scheduled long-acting opioid at bedtime to provide more consistent overnight pain relief rather than relying solely on as-needed short-acting medication. This approach is justified because patients with chronic pain often require higher opioid doses over time due to tolerance, and the hospital setting allows for appropriate monitoring of increased dosing. The goal is to provide adequate pain control while maintaining safety through regular assessment and documentation of pain levels, functional status, and any adverse effects. Some key points to consider when adjusting the patient's opioid regimen include:

• Monitoring for signs of opioid overdose, such as respiratory depression
• Assessing the patient's pain levels and functional status regularly
• Documenting any adverse effects and adjusting the treatment plan as needed
• Considering alternative pain management strategies, such as non-pharmacological interventions or other medications, if the patient's pain is not adequately controlled with opioids.

From the FDA Drug Label

2.2 Initial Dosage Use of Oxycodone Hydrochloride Tablets as the First Opioid Analgesic Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain.

2.3 Titration and Maintenance of Therapy Individually titrate oxycodone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions

The patient is currently taking 5-10 mg of oxycodone every 4 hours as needed, with a maximum of 8 tablets per day. To determine a reasonable increased maximum dose, we need to consider the patient's individual needs and response to the medication.

• The current dose is within the recommended initial dosing range of 5 to 15 mg every 4 to 6 hours.
• The patient has been taking the medication for months without negative side effects, indicating a level of tolerance.
• The patient is experiencing breakthrough pain at night, suggesting the need for adjustment.

Given these factors, a conservative approach would be to increase the maximum dose by a small increment, such as 1-2 tablets per day, while closely monitoring the patient's response and adjusting as needed to minimize adverse reactions 2.

Key considerations:

• Dose titration: Individually titrate the dose to provide adequate analgesia and minimize adverse reactions.
• Monitoring: Closely monitor the patient for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases.
• Caution: Exercise caution when increasing the dose, as the patient's tolerance and response to the medication can change over time.

From the Research

Patient's Current Situation

• The patient is experiencing chronic right hip pain due to severe arthritis and hip fracture.
• The patient is currently on multimodal pain medication therapy, including oxycodone 5-10 mg q4h prn.
• The pharmacy note specifies a maximum of 8 tablets per day.
• The patient has not experienced any negative side effects after months of use but struggles with sleeping through the night due to pain.

Request to Remove the "8 Tablets Maximum" Order

• The patient is wishing for the "8 tablets maximum" order to be removed to better manage their pain.
• To determine a reasonable increased maximum dose order, it is essential to consider the patient's current dosage and the potential risks associated with oxycodone use, such as respiratory depression 3, 4, 5, 6.

Potential Risks and Considerations

• Opioid-induced respiratory depression is a potentially life-threatening condition, and the main cause of death is cardiorespiratory arrest with hypoxia and hypercapnia 4.
• The development of tolerance in the respiratory system and differences in the degree of respiratory depression caused by various opioid agonists should be considered 6.
• Studies have shown that oxycodone can cause lethal respiratory depression, but the utility functions combining wanted and unwanted endpoints were close to zero or positive over the clinical oxycodone concentration range 5.

Increased Maximum Dose Order

• Considering the patient's current dosage and the potential risks associated with oxycodone use, a reasonable increased maximum dose order could be to increase the maximum number of tablets per day, while closely monitoring the patient's response and adjusting the dosage as needed.
• However, it is crucial to weigh the benefits of increased pain management against the potential risks of respiratory depression and other adverse effects 3, 4, 5, 6.
• The decision to remove or modify the "8 tablets maximum" order should be made under the supervision of a healthcare professional, taking into account the patient's individual needs and medical history.