Continuing Education Activity
Oxycodone is a potent opioid that can be useful when used judiciously for pain. However, it can cause physical dependence and addiction. The immediate-release formulation of oxycodone is FDA approved for the management of acute or chronic moderate to severe pain, for which the use of opioid medication is deemed appropriate and for which other pain management strategies are insufficient. The extended-release formulation is FDA approved for the management of pain severe enough to require continuous long-term opioid treatment and for which there are no alternative options to treat the pain. The oxycodone to morphine dose equivalent ratio is approximately 1 to 1.5 for immediate-release and 1 to 2 for extended-release formulations. This activity reviews the indications, side effects, and contraindications for oxycodone and highlights the role of the interprofessional team in helping patients manage their pain.
- Identify the mechanism of action of oxycodone.
- Describe the adverse effects of oxycodone.
- Review the contraindications to oxycodone.
- Summarize the importance of collaboration and communication within the interprofessional team to enhance care coordination and help patients effectively and safely manage their pain.
Oxycodone is an opioid agonist prescription medication. The oxycodone immediate-release formulation is FDA-approved for the management of acute or chronic moderate to severe pain, for which other treatments do not suffice and for which the use of opioid medication is appropriate. The extended-release formulation is FDA-approved for the management of pain severe enough to require continuous (24 hours per day) long-term opioid treatment, and for which there are no alternative options to treat the pain. The oxycodone to morphine dose equivalent ratio is approximately 1 to 1.5 for immediate-release and 1 to 2 for extended-release formulations.
Mechanism of Action
Oxycodone is a semisynthetic opioid with agonistic properties on mu, kappa, and delta-type opioid receptors, with the strongest affinity being for mu-type receptors. Upon binding to these G-protein coupled receptors, oxycodone stimulates the exchange of GDP on the G-alpha subunit for GTP, resulting in the inhibition of adenylate cyclase and a decrease in intracellular cAMP. This signal cascade leads to a consequent inhibition of the nociceptive neurotransmitters acetylcholine, dopamine, GABA, noradrenaline, and substance P and the hormones glucagon, insulin, somatostatin, and vasopressin.
As with other opioids, oxycodone causes hyperpolarization and reduced excitability of neurons in the central nervous system (CNS). This generalized CNS depression results from the agonistic effect on kappa-type receptors, which leads to a closure of N-type voltage-gated calcium channels, while stimulation of the mu and delta-type receptors opens calcium-dependent inward-rectifying potassium channels.
Oxycodone is metabolized by the hepatic enzymes CYP3A4 and CYP2D6, producing the metabolites noroxycodone and oxymorphone, respectively. These metabolites get excreted from the body via the kidneys.
Oxycodone is widely available in tablet, capsule, and oral solutions. It is currently available in 10-mg, 20-mg, 40-mg, or 80-mg pills. Manufacturers discontinued the 160-mg dose in May 2001 due to the high misuse potential. Oxycodone is available in combination with other analgesics, including acetaminophen, aspirin, or ibuprofen. In select countries, oxycodone may be available in intramuscular and/or intravenous forms as well.
- Initial recommended doses of oxycodone are in the 5 to 15 mg range, every 4 to 6 hours as needed for adequate analgesia of acute pain. Further dosing should titrate upwards as required for pain control, with attention and monitoring for potential side effects.
- For patients with chronic pain, it is recommended to titrate dosage in the same manner. However, the medication should be taken at regularly scheduled intervals to prevent the reoccurrence of pain as opposed to treating the pain after it has started.
- Tablets are intended to be taken the whole and must not be broken, chewed, crushed, or dissolved in liquid.
- Dose reduction may be necessary for the elderly and patients with hepatic or renal failure. Initiating a starting dose at one-third to one-half the usual doses and close monitoring is recommended. Titration upwards should proceed at a careful rate.
- The onset of action is 10 to 30 minutes for the immediate-release formulation and about 1 hour for controlled-release.
- Duration range is from 3 to 6 hours for immediate-release or 12 hours in controlled-release formulations.
- The plasma half-life is 3 to 5 hours, and stable plasma levels are reached within 24 to 36 hours.
The side effect profile of oxycodone is similar to that of the other opioid medications. Constipation is the most common overall side effect. The intensity of these side effects tends to decrease over time.
Most Common (more than 5%)
- Dry mouth
Other Reported Side Effects
- Abdominal pain
- Increased cerebrospinal (CSF) pressure
- Respiratory depression
Oxycodone therapy is contraindicated in patients with:
- Respiratory depression
- Bronchial asthma (in unmonitored settings)
- Hypersensitivity to oxycodone
- Known or suspected ileus or GI obstruction
While there is limited information involving studies of allergenic cross-reactivity in opioid medications, the possibility of a cross-sensitivity cannot be fully excluded. For patients with an opioid allergy, a clear description of the allergic reaction should be explored and properly documented before considering oxycodone. Patients who are found to have a true allergic reaction to other opioid medications should avoid oxycodone therapy when possible.
Pregnancy is not an absolute contraindication to oxycodone therapy; however, the FDA lists it as a US Boxed Warning. Maternal oxycodone use during pregnancy may result in serious and sometimes fatal events, as opioids can cross the placental barrier. These events may include preterm delivery, congenital abnormalities, and reduced fetal growth. With prolonged exposure, babies born to opioid-dependent mothers may suffer from potentially life-threatening neonatal withdrawal syndrome. Clinicians should discuss the neonatal risks of oxycodone therapy in pregnant women or plan to become pregnant and consider alternative treatments.
Patients taking oxycodone require monitoring for the presence of constipation, pain relief, other side effects, and appropriate usage. Their blood pressure, heart rate, and respiratory rate should also be monitored, especially for the first 24 to 72 hours after initiating therapy or increasing dosage. If pain continues to increase after stabilizing dosage, the clinician should investigate alternative causes of pain before increasing medication dosage or frequency. If adverse effects develop, consider decreasing the dosage to find an appropriate therapeutic level without unacceptable adverse effects. Patients taking oxycodone should be monitored or cautioned when starting a new medication that is a known CYP450 inhibitor. Inhibition of these enzymes can lead to potentially fatal oxycodone concentrations in the blood. This medication should not be abruptly discontinued in patients who may be opioid-dependent as this could precipitate withdrawal symptoms. If oxycodone therapy requires termination, consider decreasing in increments of 25% to 50% while monitoring for withdrawal symptoms.
Due to the high misuse potential and possibly fatal results of an oxycodone overdose, prescriptions should be written for the lowest therapeutic dose and only for the period the patient is expected to be in pain. Close follow-up should be arranged. Many hospital systems, states, and government agencies in the United States have published guidelines to help physicians with pain management and opioid prescriptions. The legislation is evolving in the United States, and in some states, state law will require signed informed consent to prescribe opioid medications to a patient. In opioid-naive patients with acute pain, long-acting opioids are not an advisable approach to pain control. For patients who require long-term opioid therapy for pain management, regularly scheduled visits should be conducted to reassess their pain level and monitor for possible indications of opioid abuse.
Signs and symptoms of an oxycodone overdose include bradycardia, hypotension, miosis, respiratory depression, somnolence, muscle flaccidity, cold and clammy skin, and death. When a person overdoses on oxycodone, an opioid antagonist such as naloxone should be administered. Clinicians should not give opioid antagonists in the absence of clinically significant respiratory or circulatory depression. Repeat dosing may be necessary as the duration of action of these drugs can vary from 30 to 120 minutes.
Enhancing Healthcare Team Outcomes
Healthcare workers who prescribe opiates should be familiar with the recent changes in their state law. Liberal prescribing of these agents is no longer recommended and can lead to legal difficulties with the DEA. Patients with pain should receive pain management with alternative means, and a pain consultant should be involved.
Nurses, pharmacists, and physicians should all educate patients about the dangers of opioids and their misuse. All interprofessional healthcare team members should be very familiar and knowledgeable about the signs of opioid misuse and overdose and report any concerns to the prescribing clinician. Pharmacists can report "doctor shopping" when they see it. They can also recommend alternative agents for pain control, as many trials are underway to seek different means to control pain that has historically been treated with opioid drugs. Nursing will also inform the prescriber of any concerns about the misuse and is a source of counsel for the patient and is often the point of contact for the pharmacist. The entire interprofessional healthcare team needs to function collaboratively to control the patient's pain and prevent potential misuse and dependence on opioid medications like oxycodone. [Level 5]
Currently, the DEA scans all healthcare workers who frequently write opiate prescriptions, and any mortality in a patient can lead to loss of the DEA certificate and even license to practice medicine.