How to schedule oxycodone (OxyContin) for a patient with severe pain, considering their medical history and risk of addiction?

How to Schedule Oxycodone/OxyContin

Start with immediate-release oxycodone 5-15 mg every 4-6 hours as needed, not extended-release OxyContin, which should be reserved only for opioid-tolerant patients requiring around-the-clock pain management when alternatives have failed. 1, 2

Initial Prescribing: Immediate-Release First

For new opioid therapy, prescribe immediate-release oxycodone tablets, never extended-release formulations like OxyContin. 1

Starting Dose for Opioid-Naive Patients

• Begin with 5-15 mg of immediate-release oxycodone every 4-6 hours as needed for pain 2
• Use the lowest effective dosage for the shortest duration consistent with treatment goals 2
• For acute pain, prescribe no more than 1 week duration 1, 3
• Monitor closely for respiratory depression, especially within the first 24-72 hours 2

Dosing Schedule Options

• Intermittent, as-needed dosing is preferred over scheduled dosing to minimize total daily opioid exposure 1
• For severe chronic pain requiring scheduled dosing: administer immediate-release oxycodone every 4-6 hours around-the-clock to prevent pain recurrence rather than treating after it occurs 2
• Time-scheduled use increases total daily opioid dosage compared to as-needed use 1

When Extended-Release OxyContin May Be Considered

OxyContin should NEVER be used for acute pain or as first-line therapy. 1, 4

Strict Prerequisites for OxyContin

Extended-release oxycodone is only appropriate when ALL of the following criteria are met:

• Patient is already opioid-tolerant, defined as receiving at least 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic doses of other opioids for at least 1 week 1, 4
• Pain is severe enough to require daily, around-the-clock, long-term opioid treatment 1
• Alternative treatments have failed (non-opioid analgesics or immediate-release opioids are ineffective, not tolerated, or inadequate) 1
• Pain is continuous, not intermittent 1

OxyContin Dosing

• Administer every 12 hours (twice daily) 4, 5
• When converting from immediate-release to extended-release: use conservative approach and reduce total daily dose to account for incomplete cross-tolerance 1
• Never use as "as-needed" analgesic 1, 4

Critical Safety Considerations

Higher Overdose Risk with Extended-Release

• ER/LA opioids carry higher overdose risk than immediate-release, especially within the first 2 weeks of therapy 1
• No evidence that continuous ER/LA use is more effective or safer than intermittent immediate-release use 1
• No evidence that ER/LA opioids reduce risk for opioid use disorder 1

Avoid Combining Immediate-Release with Extended-Release

• Use caution when prescribing immediate-release opioids for breakthrough pain in patients on ER/LA opioids outside of cancer/palliative care, as this practice may lead to dose escalation 1
• Combining both formulations increases overdose risk 1

Special Populations Requiring Extra Caution

• Elderly patients: Start with lowest doses, increased sensitivity and fall risk 3
• Opioid-naive patients: Greatest risk for respiratory depression 3
• Respiratory conditions (asthma, COPD, sleep apnea): Avoid combination with other CNS depressants entirely 3
• Renal or hepatic dysfunction: Use longer dosing intervals due to decreased clearance 1

Monitoring Requirements

Before and During Therapy

• Check state Prescription Drug Monitoring Program (PDMP) before prescribing any Schedule II medication to identify potential diversion or doctor shopping 6
• Assess respiratory rate and oxygen saturation before and after administration 3
• Evaluate sedation level using standardized scale—progressive sedation precedes respiratory depression 3
• Review benefits and risks at least every 3 months for continued therapy 1

Patient Education

• Ensure naloxone availability for emergency reversal of opioid-induced respiratory depression 3
• Educate on signs of respiratory depression 3
• Avoid alcohol completely during treatment 3
• Never combine with benzodiazepines or other CNS depressants 3

Common Pitfalls to Avoid

• Never start with OxyContin for acute pain—this is the most critical error 1, 4
• Never prescribe ER/LA opioids to non-opioid-tolerant patients—this significantly increases overdose risk 1, 4
• Avoid routine prescribing for acute exacerbations of chronic pain in emergency settings 1
• Don't ignore "abuse-deterrent" formulation marketing—these do not prevent oral misuse or unintentional overdose 1
• Don't prescribe extended durations—limit to shortest necessary, typically 1 week maximum for acute pain 1, 3