What are the guidelines for prescribing oxycodone (opioid analgesic) for pain management?

Oxycodone Prescribing Guidelines for Pain Management

Start opioid-naïve patients on oxycodone 5-10 mg every 4-6 hours as needed, with a maximum initial daily dose of 20-30 morphine milligram equivalents (MME), and avoid increasing beyond 50 MME/day without careful reassessment of benefits versus risks. 1, 2

Initial Dosing for Opioid-Naïve Patients

• Begin with oxycodone 5-15 mg every 4-6 hours as needed for pain, using the lower end of this range (5 mg) for elderly patients or those with comorbidities 2, 3
• The lowest starting dose for opioid-naïve patients typically equals 5-10 MME per single dose or 20-30 MME/day total 1
• Oxycodone has a conversion factor of 1.5 relative to morphine, meaning 10 mg of oxycodone equals 15 MME 1
• For chronic pain requiring around-the-clock dosing, administer oxycodone on a regularly scheduled basis every 4-6 hours rather than as-needed to prevent pain recurrence 2

Indications and Patient Selection

• Reserve oxycodone for pain severe enough to require an opioid analgesic when alternative treatments (non-opioid analgesics, combination products) have failed or are inadequate 2
• Consider oxycodone as second- or third-line treatment for chronic non-neuropathic pain only after first-line therapies have been unsuccessful 1
• For patients with moderate to severe pain and functional impairment unresponsive to first-line therapies, initiate a time-limited trial of opioid analgesics 1

Dose Escalation and Maintenance

• Pause and carefully reassess before increasing total opioid dosage to ≥50 MME/day, as many patients do not experience additional benefit in pain or function at higher doses but face progressively increasing risks 1
• If dose increases are necessary, increase by the smallest practical amount and monitor closely for benefits versus adverse effects 1
• Additional dosage increases beyond 50 MME/day yield diminishing returns in pain relief relative to escalating risks of respiratory depression and overdose 1
• Titrate based on individual patient response, considering severity of pain, prior analgesic experience, and risk factors for addiction, abuse, and misuse 2

Formulation Selection

• Use immediate-release oxycodone for acute pain and initial dose titration; reserve extended-release formulations only for severe, continuous chronic pain in patients already receiving ≥60 mg daily of oral morphine equivalents for at least one week 1
• Do not initiate treatment with extended-release/long-acting (ER/LA) opioids for acute or subacute pain 1
• Avoid prescribing ER/LA opioids for intermittent use 1

Combination Therapy

• Oxycodone 5 mg combined with acetaminophen 325 mg provides effective analgesia for moderate pain with a number-needed-to-treat of 2.7 and duration of action up to 10 hours at higher combination doses 4, 5
• When converting from fixed-ratio opioid/acetaminophen combinations, base the starting oxycodone dose on the most recent opioid dose and titrate according to analgesic response 2
• Approximately 97% of patients with moderate pain achieved relief with 1.61 doses of oxycodone 5 mg plus acetaminophen 325 mg 5

Special Populations

Elderly Patients

• Start with the lowest possible effective dosage (5 mg oxycodone every 4-6 hours) in elderly patients due to smaller therapeutic windows and increased risk of respiratory depression 3
• Consider formulations with lower opioid doses, such as oxycodone 5 mg with acetaminophen 325 mg, to facilitate safer dosing 3
• Use additional caution in patients with renal or hepatic dysfunction, as decreased clearance can lead to medication accumulation 1, 2

Conversion from Other Opioids

• When converting from hydrocodone to oxycodone, use a ratio of approximately 1:0.67 (e.g., 30 mg hydrocodone equals approximately 20 mg oxycodone) 6
• Reduce the calculated equianalgesic dose by 25-50% to account for incomplete cross-tolerance and individual variability 7, 6
• Provide breakthrough pain medication at 10-15% of the total daily dose 7, 6

Monitoring and Safety

• Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy or following dose increases 2
• Assess risk factors for addiction, abuse, and misuse before prescribing 2
• Document baseline heart rate and rhythm if cardiovascular concerns exist 7
• Routinely prescribe laxatives for prophylaxis and management of opioid-induced constipation 3

Opioids to Avoid Without Specialist Consultation

• Do not use methadone as a first-choice ER/LA opioid due to complex pharmacokinetics, long and variable half-life, QT prolongation risk, and disproportionate overdose deaths 1
• Avoid transdermal fentanyl for acute pain management, as it takes 8-16 hours to achieve analgesic effects and 72 hours to reach steady state 1, 7
• Only clinicians familiar with methadone's unique risk profile should prescribe it for pain, with consideration of ECG monitoring for QT prolongation 1

Critical Pitfalls to Avoid

• Never use the calculated MME dose directly when converting between opioids; always reduce the new opioid dose substantially to account for incomplete cross-tolerance 1
• Do not combine immediate-release and ER/LA opioids routinely, as this increases overdose risk 1
• Avoid dosing transdermal fentanyl in mg/day (it is dosed in mcg/hour), which can lead to fatal confusion 1
• Do not prescribe oxycodone without considering non-opioid alternatives first, given risks of addiction, abuse, and misuse even at recommended doses 2