What is the maximum daily dose of oxycodone (opioid analgesic)?

Maximum Daily Dose of Oxycodone

There is no absolute maximum daily dose of oxycodone, but doses should be carefully increased beyond 50 MME/day (approximately 33mg of oxycodone) with progressively diminishing benefits relative to risks. 1

Oxycodone Potency and Conversion

• Oxycodone is approximately 1.5 times as potent as oral morphine when calculating morphine milligram equivalents (MME) 1, 2
• For example, 20mg of oxycodone daily equals 30 MME daily 2
• When converting between opioids, the new opioid should be dosed lower than the calculated MME dose to avoid overdose due to incomplete cross-tolerance 1

Dosing Recommendations

• For opioid-naïve patients, start with the lowest effective dose, typically 5-10mg per day 1, 2
• Before increasing total opioid dosage to ≥50 MME/day (approximately 33mg of oxycodone), carefully reassess individual benefits and risks 1, 2
• If increasing beyond 50 MME/day, use caution and increase by the smallest practical amount 1
• Additional dosage increases beyond 50 MME/day yield progressively diminishing returns in benefits relative to risks 1, 2
• In clinical studies, patients have been safely titrated to doses as high as 400 mg/day for cancer pain 3, 4
• In hospice settings, mean daily doses of 78.6 mg have been used, with some patients receiving up to 231.1 mg daily 5

Risk Considerations

• Risks of opioid use, including overdose and death, increase continuously with dosage, with no single threshold below which risks are eliminated 1, 2
• In one study of patients with chronic pain who were prescribed opioids, the mean prescribed daily opioid dosage among patients who died from opioid overdose was 98 MME (median: 60 MME), compared with mean prescribed daily opioid dosage of 48 MME (median: 25 MME) among patients not experiencing fatal overdose 1
• Use additional caution in patients aged ≥65 years and patients with renal or hepatic insufficiency due to potentially smaller therapeutic window 1, 2

Opioid Tolerance Definition

• According to the FDA, opioid-tolerant patients are defined as those taking at least 30 mg oral oxycodone/day (or equivalent doses of other opioids) for one week or longer 1
• Opioid-tolerant patients may require higher doses for adequate pain control 1

Monitoring and Safety

• For patients on higher doses, more frequent monitoring of respiratory rate, sedation level, and other vital signs is recommended 2
• Consider evaluation by a pain specialist at relatively high dosages 2
• Dosage recommendations are not intended as rigid standards of care but as guideposts to inform clinical decision-making 1

Breakthrough Pain Management

• For breakthrough pain, prescribe a "breakthrough dose" typically equivalent to 10-20% of the total daily dose 1, 2
• If more than 4 breakthrough doses per day are necessary, the baseline opioid treatment should be adjusted 2

Special Considerations

• If opioid adverse effects become significant, consider opioid rotation to achieve an improved balance between analgesia and adverse effects 1
• Concurrent use of oxycodone with other central nervous system depressants increases risk of respiratory depression and requires dose adjustment 2
• Always implement prophylactic bowel regimens to manage constipation, which can almost always be anticipated with opioid treatment 1