What alternative medications can be prescribed when Hydrocodone (Hydrocodone) is ineffective?

From the Guidelines

When hydrocodone is ineffective, alternative medications such as morphine, oxycodone, or oxymorphone may be considered, but the decision should be made by a qualified healthcare provider who can evaluate the specific situation and determine the best course of treatment based on the patient's individual needs and medical history. Several factors need consideration when changing pain medications, including the type and severity of pain, patient's medical history, potential drug interactions, risk of dependence, and individual response to medications. According to the 2019 NCCN clinical practice guidelines in oncology 1, pure agonists such as morphine, oxycodone, oxymorphone, and fentanyl are commonly used in the management of cancer pain, and short half-life opioid agonists are preferred for easier titration. However, the most recent guideline from the CDC in 2022 1 emphasizes the importance of maximizing nonopioid therapies, such as NSAIDs and acetaminophen, for many common acute pain conditions, and reserving opioid therapy for severe acute pain when nonopioid therapies are contraindicated or likely to be ineffective. Some key points to consider when evaluating alternative medications include:

• The patient's underlying pain mechanism and diagnosis
• The patient's current analgesic therapy and concomitant medical illnesses
• The potential for opioid-related adverse effects, such as neurologic toxicity in patients with fluctuating renal function
• The importance of individualizing opioid starting dose, frequency, and titration to achieve a balance between pain relief and medication adverse effects. Ultimately, the decision to switch medications should be made in consultation with a qualified healthcare provider who can assess the patient's specific situation and determine the best course of treatment.

From the FDA Drug Label

Hydrocodone bitartrate and acetaminophen tablets are indicated for the management of, pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. Limitations of Use Because of the risks of addiction, abuse, and misuse, with opioids, even at recommended doses [see WARNINGS], reserve hydrocodone bitartrate and acetaminophen tablets for use in patients for whom alternative treatment options [e.g., non-opioid analgesics] Have not been tolerated, or are not expected to be tolerated, Have not provided adequate analgesia, or are not expected to provide adequate analgesia

When Hydrocodone is ineffective, alternative medications that can be prescribed include:

• Non-opioid analgesics 2 These alternatives should be considered when the patient has not tolerated or has not had adequate analgesia with other treatments.

From the Research

Alternative Medications to Hydrocodone

When Hydrocodone is ineffective, several alternative medications can be prescribed. These include:

• Tapentadol, which has demonstrated analgesic efficacy across a range of pain conditions 3
• Oxycodone, which has been compared to tapentadol in a head-to-head study for the treatment of acute low back pain 3
• Morphine, although some patients may not respond to morphine and require switching to an alternative opioid 4
• Other opioids, such as extended-release morphine or extended-release oxycodone, which may be prescribed for long-term use 5

Non-Opioid Alternatives

In some cases, non-opioid alternatives may be considered, such as:

• Antiepileptics, such as carbamazepine, oxcarbazepine, lamotrigine, gabapentin, or pregabalin, which can be used to treat neuropathic pain 6
• Tricyclic antidepressants (TCAs), such as amitriptyline, which can be used to treat chronic pain syndromes 6
• Cannabinoids, which have shown promising results in studies for the treatment of MS-related pain, although their future role is still to be determined 6

Considerations for Switching Medications

When considering switching medications, it is essential to evaluate the individual patient's response to the current medication and assess the need for an alternative opioid or non-opioid therapy. Factors such as the type and severity of pain, as well as the patient's medical history and current medications, should be taken into account 4.