Will you become addicted to oxycodone after surgery?
Will you become addicted to the oxycodone your surgeon prescribed? Will you get sick when the tablets run out? And, if you do get sick, does that mean you were addicted all along?
Probably not. Addiction after a prescription taken as directed is uncommon. Physical dependence after more than a few days of use is expected. Those are two different things, and most of the fear around oxycodone comes from confusing them.
The two can occur together. Usually, they do not. So, what is in the bottle?
What is oxycodone, and why is it still legal?
Oxycodone is a semi-synthetic opioid, made from a compound in the opium poppy. It is the active ingredient in Percocet, with acetaminophen, in the extended-release tablet OxyContin, and in plain generic tablets. Under the federal Controlled Substances Act it is a Schedule II drug: an accepted medical use, and a high potential for dependence and addiction.
The drug is more than a century old, which makes it older than most of the opinions about it. Yet, oxycodone is still prescribed every day, because it works for the pain that follows surgery, injury, and cancer.
While the law draws a hard line between legal and illegal opioids, the chemistry does not. Heroin is converted to morphine in the body, and morphine is given in every hospital.
If oxycodone were outlawed tomorrow, doctors would prescribe one of the other opioids on the shelf, as they did during past shortages. So, why not keep one legal opioid and ban the rest? Because of incomplete cross-tolerance: tolerance to one opioid does not fully carry over to another, so a patient whose oxycodone has stopped working may do well on a different opioid at a lower dose than expected. That is why a prescriber wants several to choose from.
Physical dependence is not addiction.
Physical dependence is what the body does when it meets an opioid day after day. It adjusts, and when the drug is taken away, you feel sick. The oxycodone prescribing information says physical dependence may not occur to a clinically significant degree until after several days to weeks of continued use. In fact, a few days of a modest dose after surgery usually produces little or none, and a few weeks of daily use usually produces some.
Addiction is a different problem altogether. It is a pattern of behavior: obsessing over the drug, running out early, and continuing in spite of the harm it does. A surgical patient can be dependent without being addicted, and that is the usual case.
Sit through a long matinee, walk out into the afternoon sun, and your eyes hurt. Nobody calls that an eye disease. Your eyes adjusted to the dark, and they need a few minutes to adjust back.
While this is not a perfect analogy, opioid dependence works the same way, except that the readjustment takes days instead of minutes. The patient who gets sick when the tablets run out does not have a character problem. They have a dependence, and dependence has a medical treatment.
How high is the risk of addiction after a prescription?
If you take oxycodone as your surgeon prescribed it, for the pain it was prescribed for, your risk of addiction is low. Low is not zero, and even a small risk of opioid addiction deserves attention. According to the oxycodone label, the risk rises with a personal or family history of addiction, especially to opioids or alcohol, and with a history of mental illness such as major depression.
So, tell your surgeon before the prescription is written. While a history of addiction is no reason to be refused pain relief, it is a reason for a shorter prescription, closer follow-up, and a plan for the day the tablets run out.
Tell your surgeon what else you take, too. The oxycodone label carries a boxed warning against combining it with benzodiazepines, alcohol, or other sedatives, because together they can slow breathing to a dangerous degree. That combination is how a routine prescription turns into an overdose. If someone who has taken an opioid cannot be woken or is barely breathing, call 911.
What should you do with the tablets you did not take?
The bathroom medicine cabinet is the first place a visitor, a teenager, or a relative with a sore back will look. The oxycodone medication guide says to store the bottle securely, out of sight and out of reach, and a locked box is the plain way to do that.
Leftover tablets belong in a pharmacy take-back program. Flushing medicine is usually the wrong thing to do. Yet, the Food and Drug Administration lists oxycodone among the few medicines it says to flush when no take-back is available, because a tablet in the wrong hands is the greater danger. Never keep a bottle “just in case.”
What happens when the prescription runs out?
If you have taken oxycodone for a few weeks or longer and the prescription ends, you may feel it. Runny nose, yawning, sweating, aches, chills, diarrhea, insomnia, and anxiety are the common symptoms of opioid withdrawal, and they usually begin within a day of the last dose, a bit later with the extended-release tablet. Patients often call the first missed day a flu that nobody else can see.
While opioid withdrawal is rarely dangerous in a healthy adult, it is miserable enough that few people get through it without help. The worst of it usually passes within a week or so, although poor sleep, low mood, and cravings can linger.
Unfortunately, the help people find on their own is often a tablet from a friend. A tablet bought outside a pharmacy that looks like oxycodone is often a counterfeit pressed with fentanyl, and there is no way to tell by looking. Fortunately, there is a better way, and it is ordinary medicine. When a drug has a medical taper, the taper is the treatment.
When does a taper fit, and when does buprenorphine fit?
For the patient whose only problem is dependence, the answer is usually a taper: lowering the dose gradually, at a pace the body can keep up with, until the last dose is small enough to stop. It is done with the prescribing doctor, and it does not require a facility. It is the matinee again: pause in the doorway instead of stepping straight into the sun.
For the patient who has crossed into addiction, or whose taper has failed more than once, buprenorphine has the best track record. Buprenorphine, the main active ingredient in Suboxone and its generic films and tablets, is a partial opioid agonist. It holds the receptor firmly enough to keep withdrawal and cravings away while activating it only part of the way, and that ceiling makes a fatal overdose far less likely than with a full opioid.
Buprenorphine does not make withdrawal disappear in a day. The first dose, known as induction, is taken only after the last oxycodone has begun to wear off and withdrawal has started. Taken too soon, as the Suboxone prescribing information warns, it pushes the other opioid off the receptors and sets off a sudden, severe withdrawal known as precipitated withdrawal.
Buprenorphine is the gold standard for opioid addiction. It is not a cure, and nobody should promise one. Some patients taper off of it within months and some stay on it for years because it keeps them well, and either is reasonable, so long as the patient and the doctor decide it together.
How does Dr. Leeds treat oxycodone dependence?
Dr. Leeds is an osteopathic physician whose concierge practice is built around deprescribing, meaning helping patients come off of medications. He sees patients throughout Florida by telemedicine, with office visits in Fort Lauderdale.
For a patient with dependence alone, the first question at a consultation is whether a taper with the doctor who prescribed the oxycodone is enough. For a patient who needs buprenorphine treatment, induction is done at home with phone support. When fentanyl may be in the picture, which is a real possibility whenever tablets came from anywhere but a pharmacy, he can start with a low dose. Visits are monthly, and weekly when needed, for as long as treatment is helping.
There is no counseling requirement and no required group meeting. Buprenorphine is also used as a pain medicine, and for a pain patient whose oxycodone has stopped working, that is a conversation for a consultation. Dr. Leeds has written separately about buprenorphine for pain.
To ask whether a taper or buprenorphine treatment fits your situation, contact the office to request a consultation.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.