Roxicodone (Oxycodone) Prescribing Guide
For opioid-naïve adults with acute pain, initiate Roxicodone (immediate-release oxycodone) at 5-15 mg orally every 4-6 hours as needed, starting at the lowest effective dose. 1
Recommended Dosing for Opioid-Naïve Adults
Initial Dosing
- Start with 5-15 mg orally every 4-6 hours as needed for acute pain 1
- Begin at the lowest dose (5 mg) to establish tolerance and titrate upward based on response 1
- Roxicodone is immediate-release oxycodone, classified as Schedule II 1
Titration Strategy
- Initiate as immediate-release and PRN (as needed) to establish an effective dose with early assessment and frequent titration 1
- Minimum dose increase is typically 25%-50%, but must consider patient frailty, comorbidities, and organ function 1
- Stable plasma levels are reached within 24 hours (compared to 2-7 days for morphine) 2
- Effect commences within 1 hour, with peak pain relief at 2-4 hours and duration of 4-6 hours 2, 3
Duration of Therapy
- Prescribe for the lowest practical dose for limited duration (e.g., 1 week maximum) 1
- Avoid prescribing for more than 7 days in acute injury settings, as longer duration is associated with significantly higher risk for long-term disability 1
Critical Contraindications and Precautions
Absolute Contraindications
- Never use extended-release/long-acting oxycodone (OxyContin) for acute pain or as first-line therapy 1, 4
- Extended-release formulations are for opioid-tolerant patients only (those receiving ≥30 mg daily oral oxycodone or equivalent for ≥1 week) 4
- Do not use for acute new-onset pain 1
Renal and Hepatic Impairment
- In renal impairment, oxycodone should be carefully titrated and frequently monitored for risk of accumulation of parent drug or active metabolites 1
- Perform more frequent clinical observation and dose adjustment in patients with renal or hepatic impairment 1
- No dose reduction needed in moderate hepatic or renal failure, but increased monitoring is essential 2
High-Risk Situations Requiring Additional Precautions
- Avoid or carefully justify titration to ≥90 morphine milligram equivalents (MME) per day 5, 4
- If prescribing ≥50 MME daily, consider prescribing naloxone as rescue resource 1
- Consider naloxone for patients receiving opioids with benzodiazepines, gabapentinoids, or other sedating agents 1
- For patients with substance use disorder, collaborate with palliative care, pain, and/or substance use disorder specialists 1
Management of Adverse Effects
Proactive Prevention Required
- Laxatives must be routinely prescribed for both prophylaxis and management of opioid-induced constipation 1
- Combination stimulant and softener laxative recommended as first-line 1
- Educate patients regarding expected degree of sedation during early therapy 1
Common Side Effects
- Most common: constipation, nausea, somnolence 2, 6
- Less common: vomiting, pruritus, dizziness 2
- Oxycodone causes somewhat less nausea, hallucinations, and pruritus than morphine 2
- Intensity tends to decrease over time 2
Management Strategies
- Metoclopramide and antidopaminergic drugs for opioid-related nausea/vomiting 1
- For sedation: rule out other causes (benzodiazepines, gabapentinoids), limit polypharmacy, consider methylphenidate only after other methods tried 1
- For respiratory depression: naloxone must be used promptly via intranasal or intramuscular route 1
Important Clinical Pearls
Pharmacokinetic Advantages
- Oral bioavailability 60-87% (higher than morphine) 2
- Plasma half-life 3-5 hours (half that of morphine) 2
- Metabolism is more predictable than morphine, making titration easier 2
- Two main metabolites: oxymorphone (potent analgesic) and noroxycodone (weak analgesic) 2
Equivalence and Efficacy
- Oxycodone to morphine equivalence ratio is 1:1.5-2 2
- Equianalgesic doses of opioids are equally efficacious regardless of DEA schedule classification 1
- No superiority demonstrated over other short-acting opioids for acute pain 1
Common Pitfalls to Avoid
- Do not break, chew, or crush controlled-release tablets if extended-release formulation is used (though this should not be used for acute pain) 2
- Avoid routine prescribing for acute exacerbation of chronic non-cancer pain 1
- Consider patient's risk for opioid misuse, abuse, or diversion before prescribing 1
- Check prescription drug monitoring programs for past prescription patterns 1