What's the next step for a patient with persistent pain after ACL surgery who hasn't responded to hydrocodone (acetaminophen and hydrocodone) or oxycodone (oxycodone hydrochloride)?

Post-ACL Surgery Pain Management After Opioid Failure

You should immediately reassess this patient's pain management strategy by implementing multimodal analgesia with scheduled NSAIDs and acetaminophen, increasing the oxycodone dose based on total 24-hour consumption, and evaluating for undertreated pain versus other postoperative complications. 1

Immediate Assessment Steps

Before escalating opioid therapy, you must determine:

• Actual medication adherence and dosing schedule - Confirm the patient is taking oxycodone on a regular schedule (every 4-6 hours) rather than PRN, as around-the-clock dosing is essential for continuous postoperative pain 1, 2
• Total 24-hour opioid consumption - Calculate how much hydrocodone and oxycodone the patient has actually taken, including all breakthrough doses 1
• Pain severity using numerical rating scale - Document current pain score (0-10 scale) to establish baseline 1
• Presence of surgical complications - New or worsening pain may indicate infection, hematoma, or other postoperative complications requiring evaluation rather than more opioids 1

Multimodal Analgesia Implementation

Add or optimize non-opioid analgesics immediately - This is the cornerstone of postoperative pain management and should have been initiated from the start:

• Acetaminophen 1000 mg every 6-8 hours (maximum 4000 mg/day) - Should be given at the beginning of postoperative analgesia and continued regularly, not PRN 1
• NSAIDs (if no contraindications) - Ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily reduces opioid requirements and improves outcomes 1, 3
• Ice, elevation, and physical therapy modalities as appropriate for ACL surgery 1

Opioid Dose Optimization

If pain remains uncontrolled despite multimodal therapy:

Calculate total opioid dose increase based on 24-hour consumption:

• Add up all scheduled and breakthrough doses taken in the previous 24 hours 1, 4
• Increase both around-the-clock and PRN doses by 25-50% based on this total 1, 2
• Provide rescue doses of 10-20% of the new 24-hour total dose available every 4 hours as needed 1, 4
• Reassess within 24-48 hours after any dose adjustment 1

For example, if the patient took oxycodone 5 mg every 6 hours (20 mg/day) plus three 5 mg breakthrough doses (15 mg), the total is 35 mg/day. Increase to approximately 45-50 mg/day divided into scheduled doses.

Common Pitfalls to Avoid

Do not simply switch to a "stronger" opioid without dose calculation - Hydrocodone and oxycodone have similar efficacy when properly dosed; the issue is likely inadequate dosing or lack of scheduled administration 5, 3

Do not prescribe opioids alone without non-opioid adjuncts - Multimodal analgesia reduces total opioid requirements and side effects 1

Do not assume the patient needs long-acting/extended-release opioids - For acute postoperative pain, short-acting opioids on a scheduled basis are appropriate; ER/LA formulations are not indicated for acute pain 1, 2

Do not continue escalating opioids indefinitely - If pain persists beyond expected recovery timeline (typically improving by 3-7 days post-ACL surgery), re-evaluate for complications or consider referral to orthopedic surgeon or pain specialist 1

Specific Dosing Algorithm

1. Confirm scheduled dosing: Oxycodone 5-10 mg every 4-6 hours (not PRN) 2
2. Add acetaminophen 1000 mg every 6 hours 1
3. Add ibuprofen 600 mg every 6 hours (if no contraindications) 1
4. Provide oxycodone 5 mg every 2-4 hours PRN for breakthrough pain 1
5. If patient requires ≥4 breakthrough doses in 24 hours, increase scheduled baseline dose by 25-50% 1, 4
6. Reassess pain scores and function within 24 hours 1

Patient Education Requirements

Provide explicit written instructions including: 1

• Exact dosing schedule for each medication (scheduled vs. PRN)
• Expected timeline for pain improvement (typically 3-7 days for acute postoperative pain) 1
• Warning signs requiring immediate callback: uncontrolled pain despite medications, fever, increased swelling, numbness, or inability to bear weight 1
• Constipation prevention with scheduled stool softeners/laxatives while on opioids 1
• Specific phone number to reach provider if pain not improving within 24-48 hours 1