Opioid Dosing and Safety Guidelines

Introduction to Opioid Dosing

The Centers for Disease Control and Prevention (CDC) emphasizes careful reassessment before increasing dosages to ≥50 MME/day and progressive increases in risk as dosage increases 1
Dosages ≥90 MME/day have limited evidence of benefit and substantially elevated mortality risk 1

Dosing OxyContin ER every 4 hours would result in a total daily oxycodone dose of 90 mg (15 mg × 6 doses), which is equivalent to 135 MME/day (using 1.5 conversion factor) 1
The total daily oxycodone dose for oxycodone HCl IR 10 mg dosed every 4 hours is 60 mg (10 mg × 6 doses), which is equivalent to 90 MME/day (using 1.5 conversion factor) 1
The OxyContin ER regimen as written delivers 50% more total daily opioid than the immediate-release oxycodone regimen 1

Oxycodone has an equianalgesic conversion factor of 1.5 relative to morphine (meaning oxycodone is 1.5 times stronger than morphine milligram-per-milligram) 1
Dosing OxyContin ER every 4 hours places the patient at 135 MME/day, which exceeds the CDC threshold of 90 MME/day associated with significantly increased overdose risk 1

The appropriate comparison should be: Oxycodone IR 10 mg every 4 hours (60 mg/day = 90 MME/day) 1
Under correct dosing, the immediate-release regimen would be twice as strong as the extended-release regimen 1

Never increase dosing frequency of extended-release formulations—instead, increase the dose amount if pain control is inadequate 3
Modified-release formulations are designed for 12-hour intervals; more frequent dosing defeats the purpose of the extended-release mechanism and creates dangerous overdose risk 3
For breakthrough pain on a 12-hourly ER regimen, provide immediate-release oxycodone as rescue medication at 10-20% of the total daily dose, available every 1-2 hours as needed 5