What is the recommended dose of oxycodone (OxyContin) for acute on chronic post-operative pain (G89.18) in a patient with improved pain control on Norco (hydrocodone/acetaminophen) and failed tramadol therapy?

Oxycodone Dosing for Acute-on-Chronic Post-operative Pain

For a patient with improved pain control on Norco (hydrocodone/acetaminophen) who failed tramadol therapy, initiate immediate-release oxycodone 5 mg orally every 4-6 hours as needed for breakthrough pain, with a maximum prescription of 5-7 days. 1, 2, 3

Rationale for Dosing Strategy

Starting Dose Selection

• Begin with oxycodone 5 mg every 4-6 hours PRN as this represents the conservative lower end of the FDA-recommended initial dosing range (5-15 mg) for opioid-tolerant patients. 3
• Since the patient is already receiving hydrocodone (in Norco), they have some opioid tolerance, but a conservative approach is safer than overestimating requirements. 3
• The patient's improved pain control on scheduled Norco suggests baseline pain is adequately managed; oxycodone serves as breakthrough coverage for nighttime pain exacerbations. 2

Formulation Requirements

• Use immediate-release oxycodone only—modified-release preparations (including OxyContin) should be avoided without specialist pain consultation. 1, 2
• Prescribe oxycodone separately from acetaminophen to allow independent dose titration and avoid acetaminophen-induced hepatotoxicity with higher opioid requirements. 1

Duration and Quantity Limits

Prescription Duration

• Limit prescription to 5 days, with a maximum of 7 days of oxycodone supply at discharge. 1
• The discharge letter must explicitly state the recommended dose, total amount supplied, and planned duration of use. 1
• Oxycodone should never be added to repeat prescription templates—only prescribed as acute medication requiring review at each issue. 1

Multimodal Regimen Continuation

Non-Opioid Foundation

• Continue scheduled acetaminophen and NSAIDs (if not contraindicated) as the foundation of the multimodal regimen. 1, 4
• Multimodal analgesia decreases total opioid requirements and improves overall pain control. 1, 4

Bowel Protocol

• Maintain prophylactic bowel regimen with scheduled stool softeners and stimulant laxatives while on opioid therapy. 2

Monitoring Parameters

Safety Monitoring

• Record sedation scores alongside respiratory rate at each nursing assessment to detect opioid-induced ventilatory impairment risk. 2
• Monitor for constipation, excessive sedation, or inadequate pain control after medication adjustment. 2
• Reassess pain scores after physical therapy sessions and nightly. 2

Functional Assessment

• Evaluate functional pain relief rather than pain scores in isolation—the goal is adequate analgesia for sleep and rehabilitation activities, not complete pain elimination. 1, 2

Dosing Adjustments

If Inadequate Relief

• May titrate upward to 10 mg every 4-6 hours if 5 mg proves insufficient, but reassess for alternative causes of increased pain. 3
• Consider that acute-on-chronic pain may require higher doses at shorter intervals due to baseline opioid tolerance. 1

Weaning Strategy

• When analgesic requirements decrease, follow reverse analgesic ladder: wean opioids first, then stop NSAIDs, finally stop acetaminophen. 2
• Scheduled dosing is preferred over PRN during the acute phase to prevent pain reemergence. 1

Critical Precautions

Renal Function Consideration

• Assess renal function before prescribing—oxycodone dosing should be reduced in renal impairment, and alternative opioids may be more appropriate in elderly patients or those with significant renal dysfunction. 2, 3

Patient Education

• Provide clear written instructions on safe opioid administration, storage (particularly important to prevent diversion), and disposal of unused medication at a pharmacy. 1, 2
• Warn about dangers of driving or operating machinery while taking opioids. 1, 2
• Encourage patients to keep a written record of analgesics taken, as this improves pain control outcomes. 1

Follow-up Triggers

Red Flags Requiring Reassessment

• If patient continues requiring opioids beyond 90 days post-operatively, this warrants medical evaluation for chronic post-surgical pain and potential referral to pain specialist. 1
• Pain-related readmissions should be reported to the inpatient pain team. 1

Tramadol Discontinuation

• Tramadol discontinuation is appropriate given patient-reported ineffectiveness—there is evidence that tramadol may not provide statistically significant pain reduction compared to placebo in some postoperative contexts. 1