What type of oxycodone (short- or intermediate-release) would be a reasonable PRN (pro re nata) prescription for a patient with chronic pain, discharged with a Suboxone (buprenorphine and naloxone) titration prescription, in case the Suboxone titration fails to manage severe pain?

From the Guidelines

In this circumstance, short-acting immediate-release oxycodone would be the most reasonable PRN prescription, starting at a low dose of 5mg every 4-6 hours as needed for breakthrough pain, as recommended by the CDC guideline for prescribing opioids for chronic pain 1. This approach allows for quick onset of action and shorter duration, making it more appropriate for PRN use during Suboxone titration failures.

The patient must be clearly instructed to wait at least 24 hours after their last Suboxone dose before taking oxycodone to avoid precipitated withdrawal, as Suboxone contains buprenorphine which has a high affinity for opioid receptors and can block oxycodone's effects. Additionally, the patient should wait at least 24 hours after their last oxycodone dose before resuming Suboxone to prevent precipitated withdrawal.

Some key points to consider when prescribing oxycodone in this scenario include:

• The CDC guideline recommends prescribing immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids for chronic pain 1.
• The FDA has noted that ER/LA opioids are only appropriate for opioid-tolerant patients and should not be used as "as needed" pain relievers 1.
• Short-acting oral opioid formulations, such as oxycodone, can be effective for breakthrough pain, with recommended doses ranging from 5-15 mg every 4-6 hours as needed 1.
• A limited quantity (such as 10-15 tablets) with no refills would be appropriate to minimize risks while providing a safety net for severe pain episodes.

It's also important to note that the patient's pain management plan should be regularly reviewed and adjusted as needed to ensure that their pain is adequately controlled while minimizing the risks associated with opioid use. This approach balances addressing legitimate pain needs while minimizing risks of misuse, respiratory depression, and other opioid-related complications during this challenging transition period.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

Dosage and Administation: 2. 1 Important Dosage and Administration Instructions Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5)] 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 [see Warnings and Precautions (5. 1)] . 2. 2 Initial Dosage Use of Oxycodone Hydrochloride Tablets as the First Opioid Analgesic Initiate treatment with oxycodone hydrochloride tablets in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain.

The patient should be prescribed short-acting oxycodone for breakthrough pain, as there is no information provided that would necessitate the use of intermediate- or long-acting formulations in this context.

• The initial dose for short-acting oxycodone hydrochloride tablets is in the range of 5 to 15 mg every 4 to 6 hours as needed for pain 2. Given the patient's history of chronic pain and potential opioid tolerance, it is essential to titrate the dose based on individual patient response and adjust as necessary to achieve adequate analgesia while minimizing adverse reactions.

From the Research

Oxycodone Prescription for Chronic Pain Patient

• The patient is being discharged with a Suboxone titration prescription and is requesting a prn oxycodone prescription for pain management in case the Suboxone titration fails 3, 4.
• Studies suggest that buprenorphine, the active ingredient in Suboxone, has a favorable pharmacological profile for treating chronic pain, especially in patients with a history of opioid abuse 5, 6, 7.
• When considering a prn oxycodone prescription, it is essential to note that short-acting or immediate-release oxycodone may be more suitable for breakthrough pain management, as it has a faster onset of action compared to long-acting or extended-release formulations.
• However, there is limited evidence to support the use of oxycodone as a prn medication in patients taking Suboxone, and the decision should be made on a case-by-case basis, taking into account the patient's medical history, pain management needs, and potential risks of opioid misuse 3, 4.
• The dose of oxycodone prescribed should be carefully considered, as high doses may increase the risk of adverse effects and overdose, especially in patients taking other opioids like Suboxone 3, 4.
• A reasonable approach might be to prescribe a low to moderate dose of short-acting oxycodone, such as 5-10 mg, to be taken as needed for breakthrough pain, while closely monitoring the patient's response and adjusting the dose as necessary 3, 4.

Key Considerations

• The patient should be aware of the potential risks and benefits of taking oxycodone while on Suboxone, including the risk of adverse interactions and overdose 3, 4.
• Close monitoring and follow-up are crucial to ensure the patient's safety and adjust the treatment plan as needed 5, 6, 7.
• Alternative pain management strategies, such as non-pharmacological interventions or other medications, should be considered and discussed with the patient to minimize the risk of opioid misuse and optimize pain control 5, 6, 7.