What is the most common prescription pain medication?

Most Common Prescription Pain Medications

Hydrocodone combination products are the most commonly prescribed opioid pain medications in the United States. 1

Common Prescription Pain Medications by Pain Severity

For Mild Pain (WHO Step I)

• Non-opioid analgesics are first-line for mild pain, including acetaminophen/paracetamol and NSAIDs 1
• Acetaminophen is commonly used due to its favorable safety profile, with a maximum daily dose of 4000 mg 1
• NSAIDs like ibuprofen, diclofenac, and naproxen are effective for inflammatory pain but require caution due to gastrointestinal and cardiovascular risks 1

For Moderate Pain (WHO Step II)

• Hydrocodone combination products (typically with acetaminophen) are the most commonly prescribed opioids for moderate pain 1, 2
• Other common moderate pain medications include:
  • Codeine combined with acetaminophen 1
  • Tramadol (alone or in combination with acetaminophen) 1
  • Low-dose oxycodone with acetaminophen 1, 3

For Severe Pain (WHO Step III)

• Morphine is generally considered the standard preferred starting drug for severe pain in opioid-naïve patients 1
• Other commonly used strong opioids include:
  • Oxycodone (alone or in combination formulations) 1
  • Hydromorphone for patients who cannot tolerate morphine 1, 4
  • Fentanyl (typically reserved for opioid-tolerant patients, often in transdermal form) 1

Morphine Milligram Equivalent (MME) Conversion Factors

The CDC provides conversion factors to compare potency of different opioids 1:

• Hydrocodone: 1.0
• Oxycodone: 1.5
• Morphine: 1.0
• Hydromorphone: 4-5
• Codeine: 0.15
• Tramadol: 0.2
• Fentanyl transdermal: 2.4 (mcg/hr)

Important Considerations for Opioid Prescribing

Dosing Guidelines

• For opioid-naïve patients, start with the lowest effective dose 1
• Initial doses for opioid-naïve patients are typically equivalent to 20-30 MME/day 1
• Use caution when prescribing opioids at any dosage, and avoid dosage increases when possible 1
• Careful reassessment is needed before increasing total opioid dosage to ≥50 MME/day 1

Safety Concerns

• Hydrocodone and other opioid products carry risks of dependence, addiction, and abuse 2
• Drug-seeking behavior is common in persons with substance use disorders 2
• Physical dependence can develop during chronic opioid therapy, requiring gradual tapering when discontinuing 2

Common Pitfalls to Avoid

• Failing to recognize that codeine's effectiveness varies due to CYP2D6 enzyme polymorphism, with some patients being poor metabolizers 1
• Using transdermal fentanyl for rapid opioid titration (it should only be used after pain is controlled by other opioids in opioid-tolerant patients) 1
• Not accounting for drug interactions, particularly with CYP3A4 inhibitors or inducers, which can significantly affect opioid levels 2
• Overlooking the potential for serotonin syndrome when opioids are combined with serotonergic drugs 2

Combination Products

• Hydrocodone is most commonly prescribed in combination with acetaminophen, with limitations due to the maximum daily acetaminophen dose 1, 2
• Oxycodone/acetaminophen combinations offer synergistic pain relief at lower individual drug doses 3, 5
• For moderate to severe acute pain, combination products like hydrocodone/ibuprofen and oxycodone/acetaminophen show similar efficacy and tolerability 6

In summary, while hydrocodone combination products are the most commonly prescribed pain medications in the United States, the choice of analgesic should be based on pain intensity, with acetaminophen or NSAIDs for mild pain, weak opioids or low-dose strong opioids for moderate pain, and potent opioids for severe pain 1.