What are the guidelines for using Oxycodone (OxyContin) for pain management?

Guidelines for Using Oxycodone (OxyContin) for Pain Management

Oxycodone should only be used for the management of pain severe enough to require an opioid analgesic when alternative treatments are inadequate, and should be prescribed at the lowest effective dosage for the shortest duration consistent with individual treatment goals. 1

Indications and Patient Selection

• Oxycodone is indicated for the management of moderate to severe pain when non-opioid analgesics have not been tolerated or have not provided adequate analgesia 1
• Oxycodone should be reserved for patients for whom alternative treatment options (e.g., non-opioid analgesics or non-opioid combination products) have failed or are not expected to be effective 1
• A patient's history of addiction or substance use disorder is not an absolute contraindication but requires careful risk stratification and monitoring 2

Dosing Guidelines

Initial Dosing

• Start with immediate-release oxycodone rather than extended-release formulations for initial therapy 2
• Initial dosing range: 5-15 mg every 4-6 hours as needed for pain 1
• For opioid-naïve patients, the lowest starting dose is often equivalent to 20-30 MME/day 2
• For elderly patients or those with moderate hepatic or renal impairment, consider lower initial doses 3

Dose Titration

• Titrate dose based on individual patient response to initial dose 1
• All patients should receive around-the-clock dosing with provision of a "breakthrough dose" (usually 10-15% of total daily dose) for transient pain exacerbations 2
• If more than 4 breakthrough doses per day are necessary, adjust the baseline opioid treatment 2
• Before increasing total opioid dosage to ≥50 MME/day, carefully reassess evidence of individual benefits and risks 2

Conversion Factors

• Oxycodone has a conversion factor of 1.5 relative to morphine (multiply oxycodone dose by 1.5 to determine morphine milligram equivalent) 2
• Example: Extended-release tablets containing oxycodone 10 mg taken twice a day would contain a total of 20 mg of oxycodone daily, equivalent to 30 MME daily 2

Formulations and Administration

• Immediate-release formulations: Used for initial therapy and breakthrough pain 2
• Controlled-release formulations: For patients with chronic pain requiring around-the-clock analgesia 2
• Controlled-release tablets must be taken whole and must not be broken, chewed, or crushed 3
• For chronic pain, administer on a regularly scheduled basis rather than as needed 1

Monitoring and Safety

• Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy and following dosage increases 1
• Assess patients for risk of misuse, addiction, and diversion before and during treatment 1
• Be aware of drug interactions: Oxycodone drug levels can increase 2-3 fold with CYP3A-mediated inhibitors like ritonavir 2
• Consider obtaining an ECG in patients with increased risk of arrhythmia, especially if transitioning to methadone 2

Common Side Effects and Management

• Most common side effects: constipation, nausea, and drowsiness 3
• Less common: vomiting, pruritus, and dizziness 3
• Constipation is an expected side effect requiring use of a stool softener or laxative and adequate fluid intake 2
• Nausea or vomiting may occur in the first week but generally resolves as tolerance develops 2
• Oxycodone causes somewhat less nausea, hallucinations, and pruritus than morphine 3

Special Considerations

• Higher doses of opioids have been associated with overdose and death in several studies 2
• Patients older than 65 years typically require lower doses 4
• When converting from other opioids to oxycodone, use a conservative approach due to inter-patient variability 1
• For patients with a history of substance use disorder who require pain management, apply a risk-benefit framework and consider close monitoring and linkages to addiction treatment services 2

Limitations and Cautions

• Due to risks of addiction, abuse, and misuse, even at recommended doses, oxycodone should be prescribed with caution 1
• Avoid co-administration with medications or substances that could alter pharmacokinetics or increase sedation 2
• Opioid-induced hypogonadism is a potential adverse effect requiring monitoring in symptomatic patients 2
• Women of childbearing age should be informed of the risk of fetal physical dependence and neonatal abstinence syndrome 2