How to increase the dosage of oxycodone (opioid analgesic) for a patient currently taking 30mg of oxycodone (opioid analgesic) per 24 hours, who has also used 20mg as needed (PRN - pro re nata) in the past 24 hours?

From the Guidelines

To increase the patient's oxycodone string driver, I recommend increasing the continuous infusion rate from 30mg/24h to 50mg/24h, as this accounts for the additional 20mg PRN used in the past 24 hours and follows the principle of titrating opioids based on total opioid dose taken in the previous 24 hours, as suggested by the guidelines 1. This approach is supported by the idea that the dose should be increased based on the total opioid dose taken, including both scheduled and as-needed doses, to achieve optimal pain relief without causing unmanageable side effects. The calculation for the dose increase is based on the total amount of opioid used in the past 24 hours, which includes both the continuous infusion and the PRN doses. Given that the patient used an additional 20mg PRN, it's reasonable to incorporate this into the continuous infusion to maintain more consistent pain control. Additionally, maintaining a PRN dosing option for breakthrough pain, typically at 10% of the total daily dose, as suggested by 1, is advisable. This would translate to approximately 5mg every 1-2 hours as needed, based on the new total daily dose of 50mg. Monitoring the patient closely for the first 24 hours after this adjustment is crucial to assess both pain control and potential side effects such as excessive sedation, respiratory depression, constipation, or nausea. This strategy aligns with the principles outlined in the guidelines for managing pain in patients on opioid therapy, emphasizing the importance of titrating doses to effect while minimizing side effects 1.

From the FDA Drug Label

If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the oxycodone hydrochloride tablets dosage Individually titrate oxycodone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions Incremental increases should be gauged according to side effects to an acceptable level of analgesia

To increase the dose of oxycodone for a patient currently on 30mg/24h, who used 20mg PRN in the past 24h, the following steps should be taken:

• Identify the source of increased pain: Before increasing the dose, attempt to identify the source of the increased pain.
• Titrate the dose individually: Increase the dose incrementally, gauging the increase according to side effects, to an acceptable level of analgesia.
• Monitor for adverse reactions: Continually reevaluate the patient to assess the maintenance of pain control and the relative incidence of adverse reactions. It is safer to underestimate the patient’s 24-hour oxycodone dosage than to overestimate and manage an adverse reaction due to overdose 2 2.

From the Research

Increasing Opioid Dosage

To increase a string driver currently on 30mg oxycodone / 24h, who used 20mg PRN in the past 24h, consider the following points:

• The use of "as-needed" or "PRN" range orders for opioid analgesics is a common clinical practice, providing flexibility in dosing to meet individual patients' unique analgesic requirements 3, 4, 5.
• Scheduled dosing of opioids is believed to provide more effective analgesia when compared to as needed (PRN) administration of the drug, and has been associated with decreased pain intensity ratings 6.
• When considering increasing the dosage, it is essential to evaluate the patient's response to treatment and monitor for adverse events, as oxycodone has significant abuse potential similar to heroin and morphine 7.
• Effective pain management requires careful titration of analgesics and evaluation of individual patient's responses to treatment using valid and reliable pain and pain relief assessment tools 5.

Key Considerations

• The American Society for Pain Management Nursing and the American Pain Society support safe medication practices and the appropriate use of PRN range orders for opioid analgesics in the management of pain 3, 4, 5.
• A registered nurse, competent in pain assessment and analgesic administration, can safely interpret and implement properly written ''as-needed'' or ''PRN'' range orders for analgesic medications 5.
• Oxycodone, a μ-opioid receptor agonist, has been studied extensively as a therapeutic analgesic for acute and chronic neuropathic pain, but its use requires careful consideration due to its potential for abuse 7.