What is the best approach to manage a patient with a history of frequent requests for Percocet (oxycodone and acetaminophen) at every visit?

Managing Frequent PRN Percocet Requests

Distinguish between pseudoaddiction (undertreated pain driving drug-seeking behavior) and true opioid use disorder before labeling the patient, as drug-seeking behaviors may represent an appropriate response to inadequately controlled pain. 1

Initial Assessment Framework

Determine the underlying cause of repeated requests by systematically evaluating:

• Pain adequacy: Ask whether current pain relief is sustained throughout the dosing interval and whether average pain levels remain moderate to severe despite treatment 2
• Functional status: Assess whether pain interferes with work, family responsibilities, or social engagement using structured tools like the PEG scale 2
• Medication patterns: Directly ask if the patient takes medication exactly as prescribed or feels the need to take more or take it more frequently 2
• Warning signs of opioid use disorder: Screen for craving, loss of control over use, escalating consumption, and continued use despite harm 1, 2
• Therapeutic dependence: Recognize that patients with adequate pain relief may still demonstrate drug-seeking behaviors because they fear reemergence of pain or withdrawal symptoms 1

If Pain is Undertreated (Pseudoaddiction)

Switch from PRN to scheduled dosing immediately, as continuous scheduled dosing prevents unnecessary suffering and reduces patient anxiety. 1

• Prescribe oxycodone/acetaminophen on a fixed schedule (every 6-8 hours) rather than as-needed 1
• Provide breakthrough doses equivalent to the regular 4-hourly dose for episodic pain exacerbations 1
• Reassess pain control within 1-4 weeks, as patients without pain relief at 1 month are unlikely to experience benefit at 6 months 2
• Avoid combination products with fixed acetaminophen doses in patients requiring large opioid doses to prevent acetaminophen-induced hepatotoxicity; prescribe each medication separately at appropriate doses 1

If Opioid Use Disorder is Suspected

Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they will precipitate acute withdrawal. 1, 3

• Reassure the patient that their addiction history will not prevent adequate pain management 1
• Continue any existing opioid agonist therapy (methadone or buprenorphine maintenance) at the full daily dose without modification 1, 3
• Add scheduled short-acting opioids at 1.5-2 times standard doses every 3-4 hours due to cross-tolerance and increased pain sensitivity 1, 3
• Verify maintenance doses with the patient's methadone clinic or prescribing physician 1
• Notify the addiction treatment program about any controlled substances prescribed, as they will appear on routine urine drug screening 1

Alternative Non-Opioid Strategies

If opioid escalation is inappropriate or the patient prefers alternatives:

• First-line: Scheduled acetaminophen (every 6 hours) plus oral NSAIDs, which reduce pain by approximately 1 cm on a 10-cm visual analog scale at 1-7 days 1
• Topical NSAIDs: Effective for non-low back musculoskeletal injuries with similar efficacy to oral NSAIDs (pain reduction of 1.02-1.08 cm) 1, 4
• Adjunctive therapies: Consider specific acupressure (pain reduction of 2.09 cm at 1-7 days) or TENS (pain reduction of 1.18 cm) for musculoskeletal pain 1

Mandatory Safety Monitoring

Discontinue or reduce the dose if the patient experiences overdose, serious adverse events, or shows no sustained improvement in pain and function. 2

• Assess treatment efficacy, adherence, adverse effects, and signs of opioid use disorder at every follow-up visit 2
• Schedule initial follow-up within 1-4 weeks and ongoing reassessment at least every 3 months 2
• Screen for sedation, slurred speech, confusion, respiratory symptoms, syncope, or seizures at each visit 2
• Identify high-risk patients requiring more frequent monitoring: those with depression, substance use history, overdose history, dosage ≥50 MME/day, or concurrent benzodiazepines 2

Common Pitfalls to Avoid

• Never assume drug-seeking equals addiction: Pseudoaddiction from undertreated pain mimics addiction but resolves with adequate analgesia 1
• Never use PRN-only dosing for chronic pain: This causes pain to reemerge between doses, increasing suffering and tension with the treatment team 1
• Never abruptly stop opioids in physically dependent patients: This precipitates withdrawal and worsens pain sensitivity 1, 3
• Never prescribe high-dose acetaminophen/opioid combinations: Limit combination products to avoid exceeding 3-4 grams of acetaminophen daily 1, 5