What can be prescribed for breakthrough pain in a 55-year-old male with a fractured left third rib, already prescribed Roxicodone (oxycodone) 30 mg extended release?

From the Guidelines

For breakthrough pain in a patient with a fractured left third rib who is already taking Roxicodone 30 mg extended release, I recommend prescribing immediate-release oxycodone 5-10 mg every 4-6 hours as needed, as this aligns with the most recent guidelines from the CDC in 2022 1. This approach is supported by the CDC's clinical practice guideline for prescribing opioids for pain, which emphasizes the importance of using the lowest effective dose and minimizing the duration of opioid use to reduce the risk of dependence and other adverse effects. The guideline also recommends using non-opioid pharmacologic and nonpharmacologic therapies as appropriate for the specific condition, which in this case could include scheduled acetaminophen 650-1000 mg every 6 hours (not exceeding 3000 mg daily) and/or ibuprofen 400-600 mg every 6 hours with food if not contraindicated. Some key points to consider when prescribing opioids for acute pain include:

• Prescribing immediate-release opioids at the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids
• Maximizing the use of non-opioid pharmacologic and nonpharmacologic therapies as appropriate for the specific condition
• Working with patients to prevent prolonged opioid use and prescribing opioids only as needed rather than on a scheduled basis
• Encouraging patients to use non-pharmacological approaches such as ice, controlled breathing during movement, and splinting the area with a pillow when coughing to manage pain
• Scheduling a follow-up appointment within 1-2 weeks to reassess pain control and begin tapering opioids as healing progresses, as the rib typically takes 4-6 weeks to heal. It's also crucial to educate the patient on the risks and benefits of opioid therapy, including the potential for dependence, overdose, and other adverse effects, as well as the importance of safe storage and disposal of opioids, and the availability of naloxone for overdose reversal 1.

From the FDA Drug Label

Administration of supplemental analgesia for breakthrough or incident pain and titration of the total daily dose of oxycodone hydrochloride tablets may be necessary, especially in patients who have disease states that are changing rapidly

The patient is already prescribed Roxicodone 30 mg extended release. For breakthrough pain, you can consider prescribing a short-acting opioid such as immediate-release oxycodone. However, the exact dosage and frequency cannot be determined from the provided information.

• The dosage of the short-acting opioid should be determined based on the patient's individual needs and response to the medication.
• It is essential to monitor the patient closely for signs of respiratory depression, especially when initiating therapy or increasing the dosage.
• The patient should be closely followed for the development of addiction, abuse, or misuse. 2 2

From the Research

Breakthrough Pain Management

The patient has been prescribed Roxicodone 30 mg extended release for a fractured left third rib. To help with breakthrough pain, the following options can be considered:

• Short-acting opioid analgesics, as they are the primary treatment for breakthrough pain 3
• Nonpharmacologic strategies to supplement pharmacologic intervention for breakthrough pain 3
• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment options for acute mild to moderate pain 4
• Topical NSAIDs for non-low back, musculoskeletal injuries 4
• Adjunctive medications, such as muscle relaxants, for specific conditions 4

Medication Options

The following medications can be prescribed for breakthrough pain:

• Short-acting oral opioids, such as oxycodone, for predictable incident breakthrough pain 3
• Rapid-onset transmucosal lipophilic opioids for unpredictable incident or idiopathic breakthrough pain 3
• Acetaminophen/opioid or NSAID/opioid combinations for severe or refractory acute pain 4
• Tramadol or tapentadol, which work on opioid and monoamine receptors, for severe or refractory acute pain 4

Multimodal Pain Management

Multimodal pain management approaches, such as simultaneous dosing of acetaminophen, celecoxib, and pregabalin, can reduce postoperative pain and opioid use 5. However, the effectiveness of acetaminophen in reducing postoperative narcotic consumption is still debated, with some studies showing no significant difference 6. Oxycodone combinations, such as with acetaminophen or NSAIDs, can provide safe and effective pain relief, but the profile of adverse effects must be determined 7.