Can oxycodone HCl (hydrochloride) 10 mg every 4 hours and OxyContin (oxycodone) ER (extended release) 12-15 mg every 12 hours be combined?

Combining Immediate-Release and Extended-Release Oxycodone

Yes, oxycodone HCl 10 mg every 4 hours (immediate-release) can be combined with OxyContin ER 15 mg every 12 hours, but this practice should generally be avoided except in specific clinical circumstances, and requires careful justification and monitoring. 1

General Principle for Combination Use

In general, avoiding the use of immediate-release opioids in combination with ER/LA opioids is preferable, given potentially increased risk and diminishing returns of such an approach for chronic pain. 1

However, guidelines acknowledge specific situations where combining these formulations may be necessary:

Acceptable Scenarios for Combination

• Transitioning patients from ER/LA opioids to immediate-release opioids by temporarily using lower dosages of both 1
• Temporary postoperative use of short-term opioids in a patient already receiving ER/LA opioids 1
• Breakthrough pain management in cancer patients on stable around-the-clock opioid therapy 1

Standard Approach for Maintenance Therapy

For continuous pain, the recommended approach is:

• Add extended-release formulation to provide background analgesia for control of chronic persistent pain once controlled on stable doses of short-acting opioids 1
• Provide rescue doses of short-acting opioids for breakthrough pain at 10%-20% of 24-hour oral dose, available every 1-2 hours as needed 1
• Use the same opioid for both short-acting and extended-release forms when possible 1

Dosage Considerations for Your Specific Regimen

Your proposed regimen totals:

• Immediate-release: 10 mg × 6 doses = 60 mg oxycodone daily
• Extended-release: 15 mg × 2 doses = 30 mg oxycodone daily
• Total daily dose: 90 mg oxycodone = approximately 135 MME 2

Critical Safety Threshold

Clinicians should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day. 1 Your proposed regimen exceeds this threshold and requires:

• Careful reassessment of individual benefits and risks 1
• Implementation of additional precautions including increased frequency of follow-up 1
• Consideration of offering naloxone 1

Appropriate Prescribing Algorithm

If combining is deemed necessary:

1. Ensure the patient is opioid-tolerant - ER/LA opioids should only be considered for patients who have received immediate-release opioids daily for at least 1 week 1

2. Calculate total daily opioid dose based on previous 24-hour consumption (both scheduled and as-needed) 1

3. Prescribe ER/LA for baseline pain - The extended-release component should provide around-the-clock analgesia 1

4. Limit immediate-release to breakthrough pain - Short-acting doses should be 10%-20% of total 24-hour dose, not scheduled every 4 hours 1

5. Monitor for persistent need - If patient persistently needs doses of as-needed opioids, increase the extended-release opioid dose rather than continuing both 1

Common Pitfalls to Avoid

• Do not initiate opioid treatment with ER/LA opioids - Start with immediate-release formulations 1
• Do not prescribe ER/LA opioids for intermittent use - They are reserved for severe, continuous pain 1
• Do not use long-acting opioids as "as-needed" analgesics - OxyContin is for opioid-tolerant patients only 1, 2
• Avoid routine scheduled dosing of both formulations simultaneously - This increases overdose risk without clear benefit 1

Safer Alternative Approach

A more appropriate regimen would be:

• OxyContin ER 20-30 mg every 12 hours for baseline pain control
• Immediate-release oxycodone 5-10 mg every 2 hours as needed for breakthrough pain (not scheduled)
• This maintains total daily dose while reducing scheduled opioid exposure and overdose risk 1