Oxycodone


Article Author:
Nazia Sadiq
Travis Dice


Article Editor:
Therese Mead


Editors In Chief:
Donald Kushner
Annabelle Dookie


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
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Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
9/21/2019 10:13:38 PM

Indications

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.[1][2][3]

Mechanism of Action

Oxycodone is a semisynthetic opioid which has 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 thus a decrease in intracellular cAMP. This signal cascade leads to a consequent inhibition of the nociceptive neurotransmitters acetylcholine, dopamine, GABA, noradrenaline, and substance P, as well as 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 is a result of the agonistic effect on kappa-type receptors which lead to a closure of N-type voltage-gated calcium channels, while stimulation of the mu and delta-type receptors open 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.

Administration

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 immediate-release 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.

Adverse Effects

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.[4][5][6]

Most Common (more than 5%)

  • Asthenia
  • Constipation
  • Dizziness
  • Dry mouth
  • Headache
  • Nausea
  • Pruritus
  • Somnolence
  • Sweating
  • Vomiting

Other Reported Side Effects

Cardiovascular

  • Bradycardia
  • Hypotension
  • Palpitations

Dermatologic

  • Diaphoresis
  • Photosensitivity
  • Rash

Gastrointestinal

  • Anorexia
  • Abdominal pain
  • Diarrhea
  • Glossitis

Neurologic

  • Confusion
  • Drowsiness
  • Hallucinations
  • Increased cerebrospinal (CSF) pressure
  • Irritability
  • Sedation
  • Seizures

Respiratory

  • Cough
  • Respiratory depression

Contraindications

Oxycodone therapy is contraindicated in patients with: 

  • Respiratory depression
  • Bronchial asthma (in unmonitored settings)
  • Hypercarbia
  • 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 women who are pregnant or plan to become pregnant, and consider alternative treatments.

Monitoring

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 stabilization of 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 who are 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 increases of oxycodone concentration 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 level of pain and monitor for possible indications of opioid abuse.[7][8][9]

Toxicity

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 members of the healthcare team 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 by which to control pain that has historically been treated with opioid drugs. Nursing will also be able to 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 both to control the patient's pain, as well as prevent potential misuse and dependence of opioid medications like oxycodone. [Level V]

At the moment, 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.[10]


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Oxycodone - Questions

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A 62-year-old female presents to the emergency department after a fall while bathing. She states that she fell on the wet floor and is in severe pain. Her history is significant for hypertension, osteoporosis, diabetes, and a gastric ulcer. Physical examination reveals an inability of the patient to bear weight on her right hip. Radiological consult confirms a hip fracture. After appropriate management, she is discharged on Oxycodone as needed for pain. Which of the following side-effect is most common with this analgesic?



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A 22-year-old man presents to the emergency department in pain after being injured during a college baseball game. He states that he twisted his ankle while running, and fears that he has an ankle sprain. His history is significant for asthma and two episodes of depression over the past year. He admits to smoking half a pack of cigarettes daily and smoking marijuana over the weekends with his friends. On examination, his vitals include a blood pressure of 124/83 mmHg, a pulse of 89/minute, respiration of 13/minute and a temperature of 98 F. On physical examination, he is unable to bear weight on his right ankle. While waiting for radiology and orthopedic consult, he requests pain medication. Which of the following in the patient's history is the strongest contraindication to giving him oxycodone?



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A 27-year-old female presents to the emergency department due to the sudden onset of pain in her right lower quadrant. She states that the pain started near her navel and then moved to the lower part of her abdomen. On examination, there was guarding and rigidity of the abdomen. Further evaluation confirmed the diagnosis of acute appendicitis. She was immediately rushed to the operating room for surgery. On postoperative day 2, she states her pain has decreased in intensity, and she is scheduled for discharge. The provider discharges her on oxycodone 10 mg every 4-6 hours as needed for pain. What is the mechanism of action of the prescribed opioid analgesic?



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A 27-year old delivers a healthy full-term baby girl via a cesarean section with no acute complications. On postoperative day 3, she complains of occasional pain while sitting up or changing postures in bed but otherwise feels well. Her provider plans for her discharge and prescribes her Oxycodone 10 mg every 4 to 6 hours as needed for pain. The prescribed medication has two main metabolites. Which of the following answer set matches these metabolites with the appropriate enzyme?



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A 32-year-old male presents to the emergency department after a motor vehicle accident in which he was the front seat passenger. He admits that his friend and himself had several beers before heading for a drive. He states that he hit his head and knee on the dashboard. He is conscious but says that he feels drowsy. On examination, his vitals include a blood pressure of 100/71 mmHg, respiration of 10 breaths per minute, a pulse of 120 beats per minute and a temperature of 98 degrees Fahrenheit. Physical examination of the right knee reveals redness and laceration. While waiting for an emergency CT scan of the head to evaluate any internal bleeding, the patient requests pain medicine for his knee. Which of the following is an absolute contraindication for oxycodone administration in this patient?



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Oxycodone - References

References

Thigpen JC,Odle BL,Harirforoosh S, Opioids: A Review of Pharmacokinetics and Pharmacodynamics in Neonates, Infants, and Children. European journal of drug metabolism and pharmacokinetics. 2019 Apr 22;     [PubMed]
Schepens MHJ,Leusink M,de Vries SE,van Erkelens JA,Eleveld H,Prenger A,van Limbeek J,Berger MY, [Increase in opioid prescribing in extramural care in the Netherlands: assessment of use and prescription behaviour, based on claims data]. Nederlands tijdschrift voor geneeskunde. 2019 Apr 2;     [PubMed]
Torabi R,Bourn L,Mundinger GS,Saeg F,Patterson C,Gimenez A,Wisecarver I,St Hilaire H,Stalder M,Tessler O, American Society of Plastic Surgeons Member Post-Operative Opioid Prescribing Patterns. Plastic and reconstructive surgery. Global open. 2019 Mar;     [PubMed]
Remillard D,Kaye AD,McAnally H, Oxycodone's Unparalleled Addictive Potential: Is it Time for a Moratorium? Current pain and headache reports. 2019 Feb 28;     [PubMed]
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Leppert W,Zajaczkowska R,Wordliczek J, The role of oxycodone/naloxone in the management of patients with pain and opioid-induced constipation. Expert opinion on pharmacotherapy. 2019 Apr;     [PubMed]
Freedman-Weiss MR,Chiu AS,Solomon DG,Christison-Lagay ER,Ozgediz DE,Cowles RA,Caty MG,Stitelman DH, Opioid Prescribing Habits of General Versus Pediatric Surgeons After Uncomplicated Laparoscopic Appendectomy. The Journal of surgical research. 2019 Mar;     [PubMed]
Rauck RL, Mitigation of IV Abuse Through the Use of Abuse-Deterrent Opioid Formulations: An Overview of Current Technologies. Pain practice : the official journal of World Institute of Pain. 2019 Apr;     [PubMed]
Concheiro M,Chesser R,Pardi J,Cooper G, Postmortem Toxicology of New Synthetic Opioids. Frontiers in pharmacology. 2018;     [PubMed]
Piper BJ,Desrosiers CE,Fisher HC,McCall KL,Nichols SD, A New Tool to Tackle the Opioid Epidemic: Description, Utility, and Results from the Maine Diversion Alert Program. Pharmacotherapy. 2017 Jul;     [PubMed]

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