How to safely discontinue Norco (hydrocodone) in patients with long-term use?

Safe Discontinuation of Norco (Hydrocodone) in Patients with Long-Term Use

Gradual tapering of Norco is essential to prevent withdrawal symptoms, psychological distress, and other serious adverse effects in patients with long-term use. 1

Understanding the Risks of Abrupt Discontinuation

Abrupt discontinuation of Norco in patients physically dependent on opioids can lead to:

• Serious withdrawal symptoms (anxiety, hypertension, tachycardia, restlessness, mydriasis, diaphoresis, tremor, nausea, abdominal cramps, diarrhea)
• Psychological distress
• Self-medication with illicit substances
• Uncontrolled pain
• Suicidality
• Return to other sources of opioids 1, 2

Recommended Tapering Protocol

Initial Assessment

1. Determine if tapering is appropriate based on:
   • Inability to achieve pain relief despite dose escalation
   • Intolerable adverse effects
   • Persistent non-adherence to treatment agreement
   • Deterioration in physical, emotional, or social functioning
   • Resolution of the painful condition 1

Tapering Speed

• For most patients: Reduce by 10% of the original dose per month 1
• For patients on very high doses: Consider initial reduction of 25-50% followed by more gradual taper
• For patients with long-term use (>1 year): Slower tapers (10% per month) are better tolerated 1

Practical Implementation

1. First phase: Reduce to the smallest available unit dosage
2. Second phase: Increase the time interval between doses 1

For example:

• For a patient on 60mg hydrocodone every 8 hours:
  • First decrease to 15mg every 8 hours
  • Then gradually increase the interval between doses 1

Managing Withdrawal Symptoms

Pharmacological Support

• α2-adrenergic agonists (clonidine, tizanidine) to reduce sympathetic symptoms of withdrawal 1
• Consider non-opioid pain medications (NSAIDs, acetaminophen) for pain management
• Avoid benzodiazepines due to their own dependence potential 1

Psychological Support

• Cognitive behavioral therapy
• Mindfulness-based cognitive therapy
• Patient education about expected withdrawal symptoms 1

Monitoring During Tapering

1. Use validated tools to assess withdrawal symptoms:

   • Clinical Opiate Withdrawal Scale (COWS)
   • Subjective Opiate Withdrawal Scale 1

2. Monitor for:

   • Signs of withdrawal
   • Changes in pain levels
   • Psychological distress
   • Drug-seeking behaviors 2

3. Be prepared to slow the taper if withdrawal symptoms are severe

Common Pitfalls to Avoid

1. Tapering too quickly: Many clinicians taper over just 4 weeks or less, which can lead to withdrawal symptoms similar to abrupt discontinuation 1

2. Confusing withdrawal symptoms with pain recurrence: Hyperalgesia may appear immediately after discontinuation but is typically brief and time-limited 1

3. Failing to provide adequate support: Patients need both psychological and pharmacological support during tapering 1

4. Not having a multimodal pain management plan: Ensure alternative pain management strategies are in place before initiating taper 2

5. Overlooking patient agreement: The tapering schedule should be agreed upon by the patient to improve likelihood of success 2

By following these evidence-based guidelines for Norco discontinuation, clinicians can minimize withdrawal symptoms and adverse outcomes while safely transitioning patients off long-term opioid therapy.