What are the guidelines for prescribing Norco (hydrocodone and acetaminophen)?

Guidelines for Prescribing Norco (Hydrocodone/Acetaminophen)

Norco (hydrocodone/acetaminophen) should be prescribed only for moderate to severe pain when nonopioid alternatives are inadequate, at the lowest effective dose of 5-15 mg hydrocodone/325 mg acetaminophen every 4-6 hours as needed, and for the shortest duration necessary. 1, 2

Appropriate Indications

Hydrocodone/acetaminophen is indicated for:

• Moderate to severe acute pain when nonopioid therapies are inadequate
• Pain related to severe traumatic injuries, invasive surgeries, or other severe acute pain when NSAIDs are contraindicated or ineffective 1

Hydrocodone/acetaminophen is NOT first-line for:

• Mild pain
• Chronic low back pain
• Musculoskeletal injuries (sprains, strains)
• Minor surgical procedures
• Dental pain
• Kidney stone pain
• Headaches 1

Dosing Guidelines

• Initial dose: Hydrocodone/acetaminophen 5mg/325mg, 1 tablet every 4-6 hours as needed 1, 3
• Maximum daily acetaminophen: 4000mg (approximately 12 tablets of 325mg per day) 3
• Schedule: Prescribe as needed (PRN) rather than on a scheduled basis 1
• Duration: For acute pain, prescribe only for the expected duration of severe pain, typically 3-7 days 1

Prescribing Process

1. Verify indication: Ensure patient has moderate to severe pain that warrants opioid therapy
2. Check PDMP: Review prescription drug monitoring program before prescribing
3. Assess risk factors: Screen for history of substance abuse, mental health conditions, sleep apnea
4. Document: Record pain assessment, rationale for opioid therapy, and risks/benefits discussion
5. Prescribe: Write prescription with specific instructions (e.g., "Take 1 tablet by mouth every 4-6 hours as needed for moderate to severe pain")
6. Educate patient: Discuss risks, proper storage, disposal, and not to combine with alcohol or benzodiazepines 2

Important Considerations

• Hydrocodone is Schedule II controlled substance requiring proper DEA documentation 1
• Norco contains acetaminophen limited to 325mg per tablet by FDA regulations 3
• Equianalgesic doses of opioids are equally efficacious in relieving pain, so selection should be based on patient factors 1
• Avoid prescribing with benzodiazepines due to increased risk of respiratory depression 2
• Consider offering naloxone for patients at higher risk of overdose 1

Common Side Effects to Monitor

• Constipation (most common)
• Nausea and vomiting
• Sedation and dizziness
• Respiratory depression (serious)
• Risk of physical dependence with prolonged use 2

Pitfalls to Avoid

1. Overprescribing: Prescribing more tablets than needed increases risk of diversion and misuse
2. Inadequate monitoring: Failure to reassess pain and function after initiating therapy
3. Automatic refills: Continuing opioid therapy without reassessment
4. Ignoring red flags: Missing signs of misuse or diversion
5. Combining with CNS depressants: Increases risk of respiratory depression and death 2

Hydrocodone/acetaminophen can be effective for appropriate pain conditions when prescribed responsibly, but should always be considered after maximizing nonopioid and nonpharmacologic approaches to pain management 1.