Can a patient with chronic hip pain taking oxycodone (OxyCODONE)-acetaminophen 5 mg - 325 mg, 2 tablets every 4 hours as needed (q4h prn), in addition to maximized adjuvants like duloxetine and pregabalin, safely increase their oxycodone dose with close monitoring?

From the Guidelines

There is limited room to increase the oxycodone dosage, and any increase should be done with extreme caution and close monitoring, considering the patient's current dosage is already moderate and the risks associated with higher doses, as recommended by the CDC guideline for prescribing opioids for chronic pain 1. The patient is currently taking approximately 40mg of oxycodone daily (10mg four times daily), which is equivalent to around 60-80 morphine milligram equivalents (MME) per day. According to the CDC guideline 1, clinicians should use caution when prescribing opioids at any dosage and carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 MME or more per day.

• Key considerations for increasing the dosage include:
  • Monitoring for side effects, including respiratory depression, constipation, and signs of tolerance or dependence
  • Tracking total acetaminophen intake to avoid exceeding the maximum recommended daily dose of 3000-4000mg
  • Implementing a structured pain contract and regular follow-up appointments
  • Conducting urine drug screening to ensure adherence to the prescribed regimen and detect potential misuse
• The goal of any dosage increase should be to improve function and quality of life while minimizing risks associated with long-term opioid therapy, as emphasized in the CDC guideline 1.
• If pain remains poorly controlled despite dose increases, reconsideration of long-acting formulations or consultation with a pain specialist may be warranted to explore alternative treatment options that can provide better pain control while minimizing risks.

From the FDA Drug Label

Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain. Titrate the dose based upon the individual patient’s response to their initial dose of oxycodone hydrochloride tablets Individually titrate oxycodone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions Continually reevaluate patients receiving oxycodone hydrochloride tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse The patient is currently taking around 10 mg of oxycodone 4 times a day. The maximum dose in the initial dosing range is 15 mg every 4 to 6 hours. With close monitoring, it may be possible to titrate the dose upward to achieve adequate analgesia while minimizing adverse reactions. However, it is essential to closely monitor the patient for signs of excessive sedation and respiratory depression. The decision to increase the dose should be based on the patient's individual response and medical status, considering factors such as opioid tolerance, pain control, and adverse experiences 2.

From the Research

Patient's Current Medication Regimen

• The patient is currently taking oxyCODONE-acetaminophen 5 mg - 325 mg, 2 tablets q4h prn, which translates to a total of 10 mg oxycodone 4 times a day.
• The patient is also taking adjuvants like duloxetine and pregabalin, which are maxed out.

Potential for Increasing Oxycodone Dosage

• According to the study 3, oxycodone 10 mg plus paracetamol 650 mg provides good analgesia to half of those treated, with a duration of action of 10 hours.
• The study 4 mentions that the initial dose of controlled-release oxycodone is 10 mg b.i.d., and there is no dose reduction needed in the elderly or in cases of moderate hepatic or renal failure.
• The study 5 states that the mean daily dosage of oxycodone in trials for non-cancer pain was approximately 40 mg, with a low incidence of intolerable typical opiate side effects.
• The study 6 evaluated the adequacy of a low-dose combination of oxycodone and paracetamol in patients with multimodal, chronic, non-malignant pain, and found that oxycodone/paracetamol improved pain symptoms in the majority of compliant patients.
• The study 7 compared the efficacy and safety of controlled release oxycodone with immediate release oxycodone-acetaminophen, and found that both active treatments provided comparable pain control and sleep quality.

Considerations for Increasing Oxycodone Dosage

• The patient's current dosage of 10 mg oxycodone 4 times a day is relatively low compared to the mean daily dosage of 40 mg mentioned in the study 5.
• However, the patient has expressed concerns about increasing the dosage due to past experiences with long-acting opioids.
• Close monitoring of the patient's response to any dosage increase is crucial to minimize the risk of adverse events and ensure effective pain management.
• The patient's adjuvant medications, such as duloxetine and pregabalin, are already maxed out, which may impact the patient's overall pain management strategy.