The Case Against Combos

Why leading healthcare providers are turning to oxycodone monotherapy as part of multimodal pain management regimens designed to better treat pain and reduce opioid exposure for patients and families

Opioid plus acetaminophen (APAP) combination products—hydrocodone/APAP (Lortab, Norco, Vicodin) and oxycodone/APAP (Percocet)—have been among the most commonly-dispensed medications in America over the last 20 years.

Proactive, multimodal management of acute pain (such as after a surgical procedure or injury) is the new gold standard. When done appropriately, this multimodal approach often means fewer opioids are required in the initial prescription and even fewer opioid pills are used by patients.

Even in these updated protocols, combination products continue to be commonly prescribed, likely due to familiarity.

The Issue

So what’s the problem with combo products?

To answer this question, let’s look at two of the most common products:

Opioid/APAP product	Common Directions	Doses/Day
Hydrocodone 5mg/APAP 325mg	1-2 tablets every 4-6 hrs, as needed	8
Oxycodone 5mg/APAP 325mg	1 tablet every 6 hrs, as needed	4

The problems:

• Acetaminophen is dramatically underdosed.

The maximum daily dose of acetaminophen for the treatment of acute pain is 4,000 mg/day. Yet, with the regimens above, a patient would receive as little as 1,300mg/day of acetaminophen. That’s a pediatric over-the-counter dose! The result is the patient misses the full benefit of non-opioid, non-addictive pain management.

• Acetaminophen is not scheduled for consistent, around-the-clock dosing.

Physicians commonly recommend opioid products to be used only “as needed”. That means patients receive the combination acetaminophen “as needed” as well. However, the science is clear that most patients would be better off with a baseline acetaminophen dose to stay ahead of the pain, rather than experiencing peaks and troughs due to dosing every 4-6 hours.

• Combo products make stand-alone acetaminophen dosing confusing.

A stand-alone acetaminophen product around the edges of the opioid combination product could fill the gap. But how much? And how do you “set aside” a portion of the acetaminophen daily dose just in case the combo product is needed later? Most patients will not navigate this smoothly, if at all, and will choose the “easy button” option—exclusively taking the opioid combination product around-the-clock. This puts the patient at risk for opioid dependence.

The Solution

Prescribe stand-alone oxycodone as part of multimodal regimens for acute pain. Oxycodone—available as a stand-alone, generic, immediate-release product—can serve as a “break glass in case of emergency” option for patients.

With that in place, lean into the benefits of an around-the-clock multimodal regimen.

Emphasize acetaminophen (500-1,000mg every 6 hours on a scheduled basis), usually alternating with an NSAID (such as ibuprofen, naproxen, or celecoxib), for patients without baseline liver or kidney disease.

The Bottom Line 

Combination opioid products undercut the potential of multimodal regimens to maximize pain management. Look to stand-alone oxycodone (+ APAP + NSAIDs +/- other pharmacological and non-pharmacological options) as a viable option for patients requiring short protocols for pain relief.