How do I transition a patient from Norco (hydrocodone) to buprenorphine for pain control?

From the Guidelines

Transitioning a patient from Norco to buprenorphine for pain control requires careful timing and dosing to avoid precipitated withdrawal, and the most recent evidence suggests discontinuing all opioids the night before initiation and starting with a low buprenorphine dose of 2-4 mg, repeated at 2-hour intervals, if well tolerated, until resolution of withdrawal symptoms 1. To initiate this transition, the patient should discontinue Norco and wait until they are in mild to moderate withdrawal before starting buprenorphine, typically 12-24 hours after the last Norco dose. Some key points to consider during this transition include:

• Looking for withdrawal symptoms such as anxiety, muscle aches, runny nose, and dilated pupils (COWS score of 8-12)
• Starting with a low buprenorphine dose, such as 2mg sublingual or 75mcg transdermal patch, and titrating upward based on pain control and side effects
• Using adjunct medications like clonidine (0.1mg every 6 hours as needed), NSAIDs, or antiemetics to manage withdrawal symptoms
• Monitoring the patient closely during the first week of transition, adjusting the dose as needed for optimal pain relief while minimizing side effects It's also important to note that buprenorphine works differently than full opioid agonists like hydrocodone—it's a partial agonist with a ceiling effect on respiratory depression, making it safer for long-term pain management, as noted in studies such as 1. Additionally, the patient should be informed that they may experience dysphoria, irritability, insomnia, anhedonia, or a vague sense of being unwell months after opioid elimination, and that these symptoms must be expected, discussed with the patient, and either preempted or treated 1. The dosing for buprenorphine should be given in 3-4 daily doses, unlike treatment for opioid use disorder, and the total dose given on the first day can then be prescribed as the daily dose, with reevaluation on day 2 and increase in dose if needed, as recommended in 1.

From the FDA Drug Label

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 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.

To transition a patient from Norco (hydrocodone) to buprenorphine for pain control, wait until the patient is in moderate opioid withdrawal, which is typically at least 4 hours after the last use of a short-acting opioid like hydrocodone.

• Assess the patient's withdrawal symptoms and administer the first dose of buprenorphine when objective and clear signs of moderate opioid withdrawal appear.
• Start with a low dose of buprenorphine, such as 2-4 mg, and titrate gradually to achieve an adequate treatment dose.
• Monitor the patient closely for signs of precipitated withdrawal, especially if they were previously taking a long-acting opioid. 2

From the Research

Transitioning from Norco to Buprenorphine for Pain Control

To transition a patient from Norco (hydrocodone) to buprenorphine for pain control, consider the following steps:

• Assess the patient's current opioid dosage and medical history to determine the best approach for transition 3.
• Consider using a microdose cross-tapering strategy, which involves gradually reducing the patient's current opioid dosage while simultaneously introducing small doses of buprenorphine 4.
• Alternatively, a patient can be transitioned to buprenorphine while overlapping with a full opioid agonist, such as Norco, to minimize withdrawal symptoms and uncontrolled pain 5.
• Monitor the patient's pain intensity and opioid withdrawal symptoms closely during the transition period, using tools such as the Clinical Opioid Withdrawal Scale (COWS) 5, 6.
• Be aware of potential drug-drug interactions and pharmacogenetic variations that may affect the patient's response to buprenorphine and other opioids 7.

Key Considerations

• The patient's initial opioid dosage and medical history can predict the likelihood of successful tapering or transition to buprenorphine 3.
• Co-occurring benzodiazepine or z-drug prescriptions may increase the risk of dropout from treatment 3.
• Patterns of change in pain intensity during the transition period can be mixed, with some patients experiencing increased or decreased pain 3.
• A patient-centered approach, taking into account individual needs and circumstances, is essential for a successful transition to buprenorphine 5.