What is the recommended dosage of oxycodone (OxyContin) IR for a patient with hip dislocation, considering factors such as pain level, age, weight, renal function, and medical history, including substance abuse and respiratory disease?

Oxycodone IR Dosage for Hip Dislocation

For hip dislocation in patients with renal impairment, oxycodone IR should be initiated at 2.5-5 mg every 4-6 hours as needed, with dose reductions of 50% from standard dosing and extended intervals between doses, but only after regional anesthesia (femoral or fascia iliaca nerve block) has been arranged as the primary analgesic modality and IV acetaminophen 1000 mg every 6 hours has been started. 1, 2, 3

Primary Analgesic Strategy: Regional Anesthesia First

Regional anesthesia must be the definitive first-line treatment, not opioids. The American College of Emergency Physicians and American Society of Regional Anesthesia recommend femoral nerve block or fascia iliaca compartment block as the primary analgesic modality for hip dislocation, providing superior pain control with fewer side effects compared to systemic opioids. 1, 4, 2 Continuous catheter techniques are superior to single-shot blocks for extended analgesia and significantly reduce morphine consumption. 4, 2

Foundational Non-Opioid Therapy

Before any opioid administration:

• Acetaminophen 1000 mg IV or PO every 6 hours must be started immediately as mandatory baseline treatment, significantly decreasing supplementary opioid requirements. 1, 4, 2
• Verify renal function immediately before prescribing any opioid, as approximately 40% of hip fracture patients have moderate renal dysfunction (GFR <60 mL/min/1.73m²). 5, 2
• NSAIDs are absolutely contraindicated in any degree of renal impairment. 5, 4, 2

Oxycodone IR Dosing Algorithm

For Opioid-Naïve Patients with Normal Renal Function:

• Start with 5 mg orally every 4-6 hours as needed for breakthrough pain unresponsive to regional anesthesia plus acetaminophen. 3
• Maximum initial dose should not exceed 15 mg per dose. 3

For Patients with Renal Impairment (GFR <60 mL/min):

• Reduce standard dose by 50%: start with 2.5 mg every 4-6 hours as needed. 1, 2
• Extend dosing intervals beyond the standard 4-6 hours based on clinical response. 5
• Avoid oral opioids entirely if possible; if renal dysfunction is severe, both dose and frequency of opioids should be reduced (e.g., halved). 5

For Elderly or Debilitated Patients:

• Start at the lower end of the dosing range (2.5-5 mg) regardless of renal function. 5, 3
• Monitor closely for respiratory depression, especially within the first 24-72 hours. 3

Critical Monitoring Parameters

• Pain scores at rest and on movement should be recorded before and after analgesia administration. 5
• Monitor for postoperative cognitive dysfunction, which occurs in 25% of hip fracture patients and is significantly worsened by opioids. 1, 2
• Assess for respiratory depression, particularly in elderly patients who have limited physiological reserve. 5, 3
• Concomitant antiemetic (such as haloperidol) and regular stimulant laxative (such as senna) should be prescribed with opioid therapy. 5

Substances to Avoid

• Tramadol is contraindicated in patients with renal insufficiency, particularly those with GFR <30 mL/min/1.73 m², and should be avoided entirely in ESRD. 1
• Codeine should not be administered as it is constipating, emetic, and associated with perioperative cognitive dysfunction. 5, 2
• NSAIDs are relatively contraindicated until renal function has been reviewed and confirmed adequate. 5

Common Pitfalls to Avoid

• Never use opioids as the sole analgesic in elderly hip trauma patients due to increased risk of respiratory depression and postoperative confusion. 1, 2
• Do not delay regional anesthesia while attempting to control pain with systemic opioids alone—this approach increases morbidity. 1, 4
• Avoid fixed-interval dosing initially; use as-needed dosing until pain control is established, then consider scheduled dosing for chronic pain. 3
• Do not crush, break, or chew tablets if using controlled-release formulations (though IR formulations are appropriate for acute pain). 6

Titration Strategy

• Titrate based on individual patient response to initial dose, balancing analgesia against side effects (nausea, constipation, drowsiness). 3, 6
• Supplemental analgesia for breakthrough pain may be necessary during titration, especially in patients with rapidly changing disease states. 3
• Early fracture fixation provides the most effective analgesia; opioids are a bridge to definitive treatment. 5