How to transition from Norco (hydrocodone) to buprenorphine?

From the Guidelines

Transitioning from Norco (hydrocodone) to buprenorphine requires careful medical supervision due to the risk of precipitated withdrawal, and the process typically begins with discontinuing Norco for at least 12-24 hours before starting buprenorphine, ensuring mild to moderate withdrawal symptoms are present. The initial buprenorphine dose is usually 2-4 mg sublingually, with additional 2-4 mg doses given every 1-2 hours as needed, up to a maximum of 8-16 mg on the first day 1. Over the next few days, the dose is adjusted to a maintenance level, typically 16-24 mg daily. This protocol is necessary because buprenorphine has a higher binding affinity for opioid receptors than hydrocodone but lower intrinsic activity, meaning it can displace hydrocodone from receptors while providing less opioid effect, potentially triggering withdrawal if started too early 1.

Some key considerations for the transition include:

• Discontinuing Norco for at least 12-24 hours before starting buprenorphine to ensure mild to moderate withdrawal symptoms are present 1
• Initiating buprenorphine with a dose of 2-4 mg sublingually, with additional doses given as needed up to a maximum of 8-16 mg on the first day 1
• Adjusting the dose over the next few days to a maintenance level, typically 16-24 mg daily 1
• Monitoring withdrawal symptoms using tools like the Clinical Opiate Withdrawal Scale (COWS) and adjusting the protocol based on individual needs 1

It's also important to note that the transition should always be managed by a healthcare provider who can assess withdrawal symptoms and adjust the protocol based on individual needs 1. Additionally, sudden cessation of opioids is not recommended, and a comfortable and safe tapering regimen should be offered to reduce or discontinue long-term opioid therapy (LTOT) 1.

From the FDA Drug Label

Patients Dependent on Methadone or Other Long-acting Opioid Products: Patients dependent upon methadone or other long-acting opioid products may be more susceptible to precipitated and prolonged withdrawal during induction than those on short-acting opioid products; therefore, the first dose of Buprenorphine Sublingual Tablets should only be administered when objective and clear signs of moderate opioid withdrawal appear, and generally not less than 24 hours after the patient last used a long-acting opioid product. Patients Dependent on Heroin or Other Short-acting Opioid Products At treatment initiation, the first dose of Buprenorphine Sublingual Tablets should be administered only when objective and clear signs of moderate opioid withdrawal appear, and not less than 4 hours after the patient last used an opioid

To transition from Norco (hydrocodone) to buprenorphine, the patient should be in a state of moderate opioid withdrawal.

• For patients dependent on short-acting opioid products like Norco, the first dose of buprenorphine should be administered not less than 4 hours after the patient last used the opioid.
• The dosing on the initial day of treatment may be given in 2 mg to 4 mg increments if preferred.
• It is recommended that an adequate treatment dose, titrated to clinical effectiveness, should be achieved as rapidly as possible 2.
• Clinical supervision is necessary during the transition process, with treatment initiated with supervised administration, progressing to unsupervised administration as the patient’s clinical stability permits 2.

From the Research

Transitioning from Norco to Buprenorphine

To transition from Norco (hydrocodone) to buprenorphine, it's essential to understand the differences between these two medications and the potential challenges associated with this transition.

• Buprenorphine is a partial mu-opioid receptor agonist used to treat opioid dependence, whereas Norco is a combination of hydrocodone (an opioid) and acetaminophen [ 3 ].
• The transition process typically involves a gradual tapering of the current opioid medication (Norco) to minimize withdrawal symptoms, followed by the initiation of buprenorphine [ 4 ].

Key Considerations

When transitioning from Norco to buprenorphine, the following factors should be considered:

• Dose and titration: The dose of buprenorphine should be titrated carefully to minimize the risk of overdose or underdose [ 3 ].
• Withdrawal symptoms: Patients may experience withdrawal symptoms during the transition process, which can be managed with medications such as clonidine [ 5 ].
• Polysubstance use: The risk of polysubstance use should be assessed, as buprenorphine may be used in combination with other substances, increasing the risk of adverse events [ 3 ].

Best Practices

Best practices for transitioning from Norco to buprenorphine include:

• Close monitoring: Patients should be closely monitored during the transition process to minimize the risk of adverse events [ 4 ].
• Individualized treatment: Treatment should be individualized to meet the unique needs of each patient, taking into account their medical history, substance use disorder, and other factors [ 6 ].
• Multidisciplinary care: A multidisciplinary approach to care, including medication management, counseling, and support services, can help patients achieve optimal outcomes [ 6 ].