What opioid and dosage to prescribe for acute knee pain?

Opioid Management for Acute Knee Pain

For acute knee pain, prescribe immediate-release oxycodone 5 mg with acetaminophen 325 mg every 4-6 hours as needed for pain, with a 3-day supply (maximum 12 tablets). 1, 2

Medication Selection Rationale

When selecting an opioid for acute knee pain, several factors should guide your decision:

First-Line Recommendation

• Immediate-release oxycodone with acetaminophen is recommended as an effective option for moderate to severe acute pain 1
• Starting dose: 5 mg oxycodone/325 mg acetaminophen every 4-6 hours as needed
• This combination provides effective analgesia with an NNT of 2.7 for at least 50% pain relief 3

Alternative Options (if oxycodone is unavailable or contraindicated):

• Hydrocodone 5 mg with acetaminophen 325 mg every 4-6 hours as needed
• Hydromorphone 1-2 mg every 4-6 hours as needed (for more severe pain)

Dosing Guidelines

Initial Dosing

• Start with the lowest effective dose: 5 mg oxycodone with 325 mg acetaminophen 1, 2
• For opioid-naïve patients, this represents approximately 7.5 MME per dose (using the conversion factor of 1.5 for oxycodone) 1
• This falls within the CDC-recommended starting range of 5-10 MME per dose 1

Duration of Therapy

• Prescribe for 3 days or less - this is sufficient for most acute pain conditions 1
• Maximum quantity: 12 tablets (3-day supply at 4 tablets per day)
• Avoid prescribing "just in case" pain continues longer than expected 1

Important Cautions

• Do NOT prescribe extended-release/long-acting opioids for acute pain 1
• Extended-release formulations are intended for chronic pain in opioid-tolerant patients
• Never exceed 90 MME/day without careful justification and risk assessment 1

Patient Monitoring and Safety

Risk Assessment

• Assess for risk factors for opioid misuse, abuse, or diversion 1
• Check prescription drug monitoring program before prescribing
• Consider patient's renal and hepatic function when dosing 1

Follow-up Plan

• Re-evaluate if pain persists beyond 3 days
• If continued pain requires additional opioids (rare), reassess diagnosis and consider non-opioid alternatives 1

Patient Education

• Instruct on proper storage and disposal of unused medication
• Warn about driving or operating machinery while taking opioids
• Emphasize that opioids should be discontinued when pain improves

Non-Opioid Alternatives to Consider

Before or alongside opioid therapy, consider:

• NSAIDs (e.g., ibuprofen 400-600 mg every 6 hours) - shown to be more effective than codeine combinations with fewer CNS side effects 1
• Acetaminophen 1000 mg every 6 hours (not to exceed 3000 mg/day)
• Topical NSAIDs for localized knee pain

Special Considerations

• Elderly patients: Start with lower doses (e.g., oxycodone 2.5 mg with acetaminophen 325 mg)
• Patients with renal/hepatic impairment: Reduce dose and/or frequency
• Patients on maintenance opioid therapy (e.g., methadone or buprenorphine): Consult with pain specialist or the prescribing physician 1

Remember that acute knee pain often responds well to non-opioid therapies, and opioids should be reserved for moderate to severe pain not adequately controlled with alternatives. The goal is effective pain control while minimizing the risk of long-term opioid use, which often begins with treatment of acute pain 1.