What is the protocol for oxycodone (opioid analgesic) administration in pain management?

Oxycodone Administration Protocol for Pain Management

For opioid-naïve patients with moderate to severe pain, initiate oxycodone immediate-release at 5-15 mg orally every 4-6 hours, with the same dose available for breakthrough pain, and titrate daily based on total rescue medication use over the preceding 24 hours. 1

Initial Dosing Strategy

Starting Dose Selection

• Begin with 5-10 mg every 4-6 hours for opioid-naïve patients 1, 2
• Patients previously on weak opioids (Step 2 analgesics like codeine or tramadol) typically start at 10 mg every 4-6 hours 3
• If transitioning directly from non-opioid analgesics, 5 mg every 4-6 hours is sufficient 3, 2
• Use immediate-release formulations for initial titration, not controlled-release products 3, 1

Dosing Schedule

• Administer on a scheduled around-the-clock basis every 4-6 hours for chronic pain, not as-needed 1, 4
• This prevents pain recurrence rather than treating pain after it occurs 1
• Provide the same dose as breakthrough medication (equal to the regular 4-6 hourly dose) 3

Titration Protocol

Daily Assessment and Adjustment

• Assess pain control and side effects daily during the titration phase 3, 1
• Calculate total oxycodone used in the previous 24 hours (scheduled doses plus all breakthrough doses) 3
• If pain returns consistently before the next scheduled dose, increase the regular dose rather than shortening the dosing interval 3
• Titrate upward by 25-50% increments based on total daily rescue medication requirements 3

Achieving Stable Pain Control

• Most patients achieve stable analgesia within 1-2 days when starting at appropriate doses 2
• Two-thirds of opioid-naïve cancer patients achieved adequate control without dose titration when starting at 5 mg every 12 hours 2
• Continue titration until pain intensity decreases from moderate-severe (6-8/10) to slight (2-3/10) 4

Conversion to Controlled-Release Formulations

When to Convert

• Once pain is adequately controlled on immediate-release oxycodone for 2-3 days, convert to controlled-release formulations for maintenance 3, 1
• Calculate the total daily dose of immediate-release oxycodone used over 24 hours 1
• Divide this total daily dose by 2 for every-12-hour controlled-release dosing 5

Controlled-Release Dosing

• Standard dosing is every 12 hours, but 67% of chronic pain patients require every-8-hour dosing in clinical practice 6
• Patients on every-12-hour dosing are twice as likely to require regularly scheduled short-acting supplementation 6
• Continue breakthrough medication at 10-20% of the total 24-hour dose even after stabilization on controlled-release 3

Breakthrough Pain Management

Breakthrough Dose Calculation

• Provide breakthrough doses equal to the regular 4-6 hourly immediate-release dose 3
• For patients on controlled-release: use 10-20% of total 24-hour oxycodone dose 3
• Example: Patient on 60 mg/day controlled-release should receive 10-15 mg immediate-release for breakthrough 3

Frequency Monitoring

• If more than 3-4 breakthrough doses are required per day, increase the scheduled baseline dose by 25-50% 3
• Do not simply add more PRN doses without adjusting the scheduled regimen 7

Conversion from Other Opioids

Equianalgesic Dosing

• Oral morphine to oral oxycodone ratio is approximately 1.5:1 (60 mg oral morphine = 30 mg oral oxycodone) 8
• Calculate total daily morphine-equivalent dose from current regimen 1
• Reduce the calculated equianalgesic oxycodone dose by 25-50% to account for incomplete cross-tolerance 1

Conversion Protocol

• Determine 24-hour opioid requirement from current medication 1
• Apply equianalgesic conversion ratio 8
• Reduce calculated dose by 25-50% for safety 1
• Divide into appropriate dosing intervals (every 4-6 hours for immediate-release) 1
• Provide adequate breakthrough medication during conversion period 1

Special Populations and Dose Adjustments

Renal Impairment

• Start with 25-50% of usual dose in patients with renal dysfunction 7
• Oxycodone metabolites can accumulate, though less problematic than morphine 7

Hepatic Impairment

• Start with 25-50% of usual dose and reduce dose rather than extending intervals 7
• Oxycodone undergoes hepatic glucuronidation which may be impaired 7

Common Dosing Ranges in Clinical Practice

Typical Maintenance Doses

• Median dose for twice-daily controlled-release: 80 mg total daily dose 6
• Median dose for three-times-daily controlled-release: 60 mg total daily dose 6
• Most patients with moderate pain achieve control with ≤40 mg total daily dose 4
• For moderate pain, 97% of patients achieved relief with 8 mg (1.6 doses of 5 mg) combined with acetaminophen 9

Critical Safety Considerations

Monitoring Requirements

• Monitor closely for respiratory depression, especially within the first 24-72 hours and after dose increases 1
• Use the lowest effective dosage for the shortest duration 1
• Assess for risk factors for addiction, abuse, and misuse before initiating 1

Constipation Management

• Institute prophylactic stimulant or osmotic laxative in all patients unless contraindicated 7, 3
• Constipation is universal with opioid therapy and does not resolve with continued use 3

Common Pitfalls to Avoid

• Do not start with controlled-release formulations for dose titration—they have delayed peak concentrations (2-6 hours) making rapid assessment impossible 3
• Do not increase dosing frequency to every 3 hours—increase the dose instead to maintain a 4-6 hour schedule 7
• Do not use smaller breakthrough doses than the regular scheduled dose—there is no logic to this approach 7, 3
• Do not make dose adjustments more frequently than every 24-48 hours when using controlled-release formulations 8