Would you give PRN percocet and scheduled Oxycodone together?

[lunaro16]

I saw one patient receive PRN percocet and his scheduled Oxycodone PO at the same time. She is VERY dependent on this narcotic. Would you give these two meds together? Or would you give the scheduled oxycodone and later give the PRN, even if the patient asks to take them together?

After taking both at the same time, the patient's BP decreased to 90/60, and respiration rate decreased from 20 to 7 breaths per minute, her O2 sats were 88% on 2L of oxygen. She became +++somnolent and it was very difficult to wake her up, she would fall asleep right in the middle of a conversation. If her respirations dropped to 6 per min, the nurse would have called code 66. She was given narcan and was fine after all.

Obviously she had an overdose, but, would you normally give these two meds at the same time if the patient asks? Do you consider this a "bad" nursing practice?

[Mandychelle79, ASN, RN]

Another possibility is that the pt cheeked the long acting ( if it is a controlled release) or chewed it when it was administered, making the dose more of an immediate effect vs a long acting effect.

[BD-RN, BSN, RN]

Even if it's extended release, I don't mix two sedating medications together, whether it's a tolerant patient, dependent patient, or opiate naive patient. If the patient is c/o acute pain, and the oxycontin is due, I usually give the immediate release first so the patient has some relief, then I'll give the scheduled med about 30 minutes later. Remember standard nursing practice is you have 30 minutes on each end of the scheduled time to administer a med, sometimes 60-90 minutes depending on your hospital policy. Holding a medication (especially a sedating one) is nursing judgement.

Same thing with patients who have scheduled ambien and are complaining of pain, or requesting both; I tell them if they're in pain I'd like to treat that now, and then I'll give the ambien when they're more comfortable and ready to sleep.

[BrandonLPN, LPN]

I wouldn't give together. It's the same narcotic.

Which is why we assess things like respiratory rate, LOC and past tolerance to determine if giving the two together would be appropriate or not.

Also the wording of the PRN order is important. I interpret "for breakthrough pain" as meaning "if the scheduled med doesn't work". So in that case, no, I probably wouldn't give both together, I would most likely give the scheduled a chance to work.

[LadyFree28, BSN, LPN, RN]

Which is why we assess things like respiratory rate, LOC and past tolerance to determine if giving the two together would be appropriate or not.

Also the wording of the PRN order is important. I interpret "for breakthrough pain" as meaning "if the scheduled med doesn't work". So in that case, no, I probably wouldn't give both together, I would most likely give the scheduled a chance to work.

This.

Depending on my assessment, I would give the short acting first, then the long/acting about an hour later; I'm not a fan of "chasing pain",

especially if the medication is

affective per the pt and above all, my assessment.

[Mr. Murse]

It's completely relative to the situation and patient. If it were me, I would avoid giving the two together as a rule, but exceptions could be made. I have seen opioid tolerant patients get ridiculous amounts of pain meds and be perfectly fine. It may not be our job to feed a patient's addiction, but it's not our job to try and break their addiction either......it's our job (among other things) to keep their pain under control while they're in our care. I would look into their MAR and see if they'd gotten the two together before, and if so then look at their vitals around that time and see if the same thing had happened. If there were no history of the two meds being given together, and no other potentially sedative meds were given around the same time, then you could probably attribute the change to the medication (unless you suspect the patient of taking their own meds). Or it's possible the changes were due to whatever the patient's medical condition was.

Either way, it's all relative.

[OhioCCRN, MSN, NP]

To the poster who said it was "the same narcotic" technically you are incorrect. there is a HUGE difference between controlled release and immediate release opioids. In my practice, I have given oxycontin and percocet or oxycodone at the same time. again refer to your pharmacist who will educate you on onset/peak/duration. It also helps that we have an acute pain management service who diligently educate us on medication and help dispel "myths". the only time i would QUESTION the medication is if SBP was below 100 and of course RR.

[toomuchbaloney]

you provide no dosages...

I don't know the patient or the particular circumstances and do not feel comfortable make a judgement.

[MunoRN, RN]

To the poster who said it was "the same narcotic" technically you are incorrect. there is a HUGE difference between controlled release and immediate release opioids. In my practice I have given oxycontin and percocet or oxycodone at the same time. again refer to your pharmacist who will educate you on onset/peak/duration. It also helps that we have an acute pain management service who diligently educate us on medication and help dispel "myths". the only time i would QUESTION the medication is if SBP was below 100 and of course RR.[/quote']

I think you mean that they have different pharmacokinetics, since they are actually the same drug just with a different peak and duration, but I get your point.

The thing to keep in mind is that the main purpose behind dose and frequency orders is that they limit both the cumulative and peak serum dosages, so understanding how those components work is what helps you follow the intent of the order.

Oxycontin, particularly in doses of 40mg or less, has a fairly flat "peak" (sometimes described as not even having a true peak). For some reason we associate the act of physically taking these two medications at the same time (swallowing them at about the same time) as what defines doubling up on the medication, even though this has little to do with how the peak and duration component combine.

Plain oxycodone peaks in about 1 hour. 1 hour after taking ocycodone CR, the level is about the same as it is 8 hours after taking it. So really, giving plain oxycodone at the same time as oxycodone CR is no different than giving plain oxycodone 8 hours after giving the CR (the cumulative active circulating dosage is the same either way).

[mmc51264, BSN, MSN, RN]

I was just going to post what a few others have: dosages please! 10 mg. 20 mg 60 mg oxycontin? 5 mg, 10mg 15 mg oxy IR?? I give CR with IR all the time BUT dosages are usually 10 CR and 5-10 IR

[lunaro16]

Her orders were:

Oxycodone CR 20mg PO q8h

Percocet (Oxycodone 5mg/Acetaminophen 325mg) 2 tabs PRN q4h

VS before: BP 115/70, 20 resp/min, 95% on room air (stable throughout her hospital stay)

VS after: BP 90/61, 7 resp/min, 88% on 2L of oxygen and +++somnolient

The next day after the incident the nurse was explaining to the patient that she was going to give her the oxycodone first and 1h later the percocet because of "what happened last night" (but I think that it wouldn't make a difference because of what some of you have mentioned: it's controlled release oxycodone). The doctors changed the order to only 1 tab PRN q4h, which made her very angry. She has been taking oxycodone for 12 years or so, and is VERY dependent on the medication. She knows when the nurses are assessing her, she starts taking deep breaths or breathing faster to have higher O2 sats or more respirations per min (she thinks this way she'll be able to get the meds).. so they had to assess her while sleeping.

Thank you for your answers!! I'm a nursing student. She wasn't my patient, she was my patient's roomate, but I was curious about the whole situation.

[morte, LPN, LVN]

?suicidal ideation? chewed the CR?

[toomuchbaloney]

It is standard practice to give a controlled release opiate at the same time as an immediate relief.

You are leaving out an important aspect of the nursing decision making process? What is the pain assessment. What is the nature? Where is it? How much? What are the patient coping measures? Is this a new dose?

You keep saying she is dependent upon the medication. Does this imply that she is abusing the medication or that she has chronic pain issues? Remember that dependence is not necessarily "bad", diabetics are dependent upon insulin, for instance.

Is it possible that she is confused and chewed the CR as morte suggested?