What is the recommended initial quantity of oxycodone (opioid analgesic) to prescribe at one time for acute pain management?

Oxycodone Prescribing Quantity for Acute Pain

For opioid-naïve patients with acute pain, prescribe no more than a 3-7 day supply of immediate-release oxycodone 5 mg tablets, with a total quantity of 12-20 tablets (allowing 1-2 tablets every 4-6 hours as needed). 1, 2, 3

Starting Dose and Formulation

• Begin with oxycodone 5 mg every 4-6 hours as needed (not scheduled) for opioid-naïve patients 2, 3
• The FDA label specifies a dosing range of 5-15 mg every 4-6 hours, but the lowest dose (5 mg) should be the default starting point 3
• This 5 mg dose aligns with CDC recommendations for starting at approximately 5-10 MME per dose, and since oxycodone converts at 1.5x morphine equivalents, 5 mg oxycodone = 7.5 MME 1, 2
• Use only immediate-release formulations for initial therapy—never start with controlled-release oxycodone 2, 3

Total Daily Dose Limits

• Target a total daily dose of 20-30 MME/day for opioid-naïve patients, which translates to approximately 13-20 mg of oxycodone per day 1, 2
• If prescribing 5 mg tablets with instructions for "1-2 tablets every 4-6 hours as needed," the maximum daily dose would be 40 mg (8 tablets), but most patients should use far less 3
• Prescribe "as needed" dosing, not around-the-clock scheduled dosing, to minimize total opioid exposure 2

Quantity and Duration

• For acute pain, limit the initial prescription to 3-7 days maximum 1
• A reasonable prescription would be: "Oxycodone 5 mg, dispense 15 tablets, take 1 tablet every 4-6 hours as needed for pain, no refills" 2, 3
• This allows for 2-3 tablets per day over 5-7 days, which is appropriate for most acute pain scenarios 1, 2
• If prescribing the higher end (20 tablets), this still limits use to approximately 7 days at 3 tablets per day 1

Reassessment and Titration

• Reassess pain and side effects at 60 minutes after each oral dose 1, 2
• If pain remains unchanged after the initial 5 mg dose, the next dose can be increased by 50-100% (to 7.5-10 mg) 1, 2
• Before prescribing a total daily dose exceeding 50 MME/day (approximately 33 mg oxycodone/day), pause and carefully reassess whether benefits outweigh risks 1

Critical Safety Measures

• Prescribe a stimulant laxative (senna) and stool softener from the first dose—constipation is inevitable, not a "possible" side effect 1, 4
• Provide naloxone and overdose prevention education to the patient and household members 4
• Avoid prescribing oxycodone in elderly patients or those with renal/hepatic impairment without dose reduction; consider starting at 2.5 mg if available 2
• Never prescribe extended-release formulations for acute pain or initial opioid therapy—they cannot be rapidly titrated and carry higher overdose risk 2, 4

Common Prescribing Pitfalls

• Do not prescribe 30-day supplies for acute pain—this is the most common error and contributes to opioid diversion and long-term use 1
• Do not start with 10 mg doses in opioid-naïve patients—this unnecessarily increases overdose risk without evidence of superior pain control 1, 2
• Do not write prescriptions for "every 4 hours" scheduled dosing—always use "as needed" language to prevent automatic dose escalation 2
• Do not prescribe oxycodone/acetaminophen combinations for more than 7 days without considering acetaminophen toxicity limits (maximum 3-4 grams daily) 5

Special Populations

• For cancer pain or palliative care, different rules apply: breakthrough doses should equal 10% of total daily dose, and if more than 4 breakthrough doses are needed per day, increase the baseline long-acting formulation 1, 2
• For opioid-tolerant patients (those taking ≥30 mg oral oxycodone daily for ≥1 week), calculate the previous 24-hour requirement and increase rescue doses by 10-20% 1, 2, 3