What is a good starting dose of buprenorphine for a patient on Norco (hydrocodone and acetaminophen) 7.5-325mg every 4 hours?

Starting Dose of Buprenorphine for a Patient on Norco 7.5-325mg Q4h

For a patient on Norco 7.5-325mg every 4 hours, the recommended starting dose of buprenorphine is 4-8 mg sublingual, administered when the patient is in mild to moderate withdrawal. 1

Understanding the Patient's Current Opioid Use

Before initiating buprenorphine, it's important to assess the patient's current opioid use:

• Norco 7.5-325mg every 4 hours equals approximately 45mg of hydrocodone daily
• This represents moderate opioid dependence
• The patient will need to be in mild to moderate withdrawal before starting buprenorphine to avoid precipitated withdrawal

Induction Protocol

Timing of First Dose

• Wait until patient shows objective signs of moderate opioid withdrawal
• For short-acting opioids like hydrocodone, this is typically at least 12-24 hours after last dose
• Use the Clinical Opioid Withdrawal Scale (COWS) to assess - aim for a score of at least 8-12 (mild to moderate withdrawal)

Dosing Schedule

1. Day 1:

   • Initial dose: 4mg sublingual buprenorphine
   • May give additional 2-4mg after 1-2 hours if withdrawal symptoms persist
   • Maximum Day 1 dose: 8mg 1, 2

2. Day 2:

   • Target dose: 8-16mg sublingual buprenorphine daily
   • Can be administered as a single daily dose or divided 1

Maintenance Dosing Considerations

• Most patients can be effectively maintained on 4-24mg of buprenorphine daily 2
• The recommended target maintenance dose is 16mg daily 2
• For pain management, consider divided dosing (every 6-8 hours) to maximize analgesic effect 1
• Dosing ranges of 4-16mg divided into 8-hour doses have shown benefit in patients with chronic pain 1

Monitoring and Adjustments

• Monitor for:

  • Withdrawal symptoms (indicating dose may be too low)
  • Sedation (indicating dose may be too high)
  • Respiratory depression (though buprenorphine has a ceiling effect for this)
  • Pain control

• Adjust dose based on:

  • Pain control
  • Withdrawal symptoms
  • Side effects
  • Patient function

Special Considerations

• Buprenorphine has a high affinity for μ-opioid receptors, which can block other opioids 1
• Due to its partial agonist properties, buprenorphine has a ceiling effect on respiratory depression but not necessarily on analgesia 3
• If pain control is inadequate with buprenorphine alone, consider divided dosing before adding other analgesics 1
• Have naloxone available during induction due to variable rates of buprenorphine dissociation from receptors 1

Potential Pitfalls to Avoid

• Precipitated withdrawal: Starting buprenorphine too soon after last opioid dose can cause severe withdrawal
• Inadequate initial dose: May lead to continued withdrawal symptoms and treatment failure
• Abrupt discontinuation: Can cause withdrawal; always taper gradually if discontinuation is needed
• Underestimating opioid tolerance: May require higher doses of buprenorphine for adequate pain control in opioid-tolerant patients

By following this protocol, you can safely transition a patient from Norco to buprenorphine while minimizing withdrawal symptoms and maintaining pain control.