Can the dosage of oxycodone (OxyCODONE)-acetaminophen 5 milligrams (mg) - 325 mg, 2 tablets every 4 hours as needed (prn), be safely and effectively increased for a patient with chronic hip pain who has not responded to maximum doses of adjuvant medications, including pregabalin and duloxetine, and is currently taking 2 tablets 4 times a day?

From the Guidelines

Increasing the oxycodone-acetaminophen dose for this patient with chronic hip pain is not recommended due to the significant risks associated with high-dose opioid therapy, including overdose and death, as highlighted in the 2022 CDC clinical practice guideline for prescribing opioids for pain 1. The current regimen of 5 mg oxycodone/325 mg acetaminophen, 2 tablets every 4 hours as needed, already puts the patient at a significant risk for adverse effects. According to the guideline, opioid dosages of 50–90 MME/day were associated with a minimally greater improvement in mean pain intensity compared to dosages of <50 MME/day, but with no difference in mean improvement in function 1. Moreover, the risk for serious harms related to opioid therapy, including opioid misuse, overdose, and death, increases at higher opioid dosages, without a single point below which there is no risk 1. Given that the patient is already taking a significant amount of oxycodone, the focus should be on optimizing adjuvant medications, exploring alternative pain management strategies, and closely monitoring the patient for signs of opioid misuse or overdose, rather than increasing the opioid dose 1. Options for alternative pain management strategies may include physical therapy, cognitive-behavioral therapy, or interventional procedures, which can help improve function and quality of life while minimizing the risks associated with high-dose opioid therapy. Regular reassessment of pain control, function, and side effects is essential to ensure that the patient's treatment plan is optimized and safe. The patient's current adjuvant medications, such as pregabalin and duloxetine, should be continued and optimized as part of a comprehensive pain management plan. Ultimately, the goal should be to find the minimum effective dose that improves function and quality of life while minimizing risks, rather than relying solely on high-dose opioid therapy 1.

From the FDA Drug Label

Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases with oxycodone hydrochloride tablets and adjust the dosage accordingly 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 already taking 2 tablets of oxycodone 4 times a day, which is a significant dose. Increasing the dose may increase the risk of respiratory depression and other adverse reactions. The FDA label recommends individualized titration and close monitoring for patients receiving oxycodone hydrochloride tablets.

• The patient's current dose is already high, and increasing it further may not be safe.
• The patient should be closely monitored for signs of respiratory depression and other adverse reactions.
• Alternative pain management strategies should be considered, such as non-pharmacological interventions or other medications.
• The patient's dose should not be increased without careful consideration of the potential risks and benefits, and close monitoring of the patient's response to the medication 2.

From the Research

Current Medication Regimen

• The patient is currently taking 2 tablets of oxycodone 5 mg - 325 mg, 4 times a day, spaced out, which is a relatively high dose of oxycodone 3.
• The patient has already maxed out on multiple other adjuvant medications like pregabalin and duloxetine, indicating a high level of chronic hip pain.

Efficacy of Oxycodone

• Studies have shown that oxycodone is an effective analgesic for chronic pain management, with a similar mechanism of action to other opioids 3, 4.
• A randomized controlled trial compared the efficacy of oxycodone/acetaminophen to acetaminophen alone for emergency department patients with musculoskeletal pain refractory to ibuprofen, and found that oxycodone/acetaminophen resulted in slightly greater pain relief, but with more medication-related adverse events 5.

Increasing Oxycodone Dosage

• There is no clear evidence to suggest that increasing the dosage of oxycodone beyond the current level would provide additional pain relief without increasing the risk of adverse effects 3, 5, 4.
• A study on patient-controlled intravenous analgesia with oxycodone or sufentanil after hip surgery found that oxycodone could achieve similar postoperative analgesia to sufentanil, but with potentially fewer adverse effects 6.

Alternative Treatment Options

• Radiofrequency ablation has been explored as a treatment option for chronic hip pain, and may be considered for patients who have contraindications to or refractory pain despite total hip arthroplasty 7.
• Other alternative treatments, such as physical therapy, oral medications, and injections, may also be considered for patients with chronic hip pain 7.