Alternative Pain Medications for Patients with Lortab Allergy
For patients allergic to Lortab (hydrocodone/acetaminophen), several alternative pain medications can be safely prescribed, including non-opioid analgesics, pure opioids without acetaminophen, or different opioid combinations.
Non-Opioid Alternatives
- NSAIDs such as naproxen, ibuprofen, or diclofenac can be effective first-line treatments for many common pain conditions, including musculoskeletal pain, minor surgical pain, and dental pain 1
- Acetaminophen alone (without hydrocodone) may be an option if the allergy is specifically to the hydrocodone component of Lortab 1
- For mild to moderate pain, non-pharmacologic approaches should be maximized, including ice, heat, elevation, rest, immobilization, or exercise as appropriate for the specific condition 1
Opioid Alternatives
Pure Opioids (Without Acetaminophen)
- Morphine: 15-30 mg PO every 4-6 hours as needed (Schedule II) 1
- Oxycodone: 5-15 mg PO every 4-6 hours as needed (Schedule II) 1
- Hydromorphone: 2-4 mg PO every 4-6 hours as needed (Schedule II) 1
- Oxymorphone: 10-20 mg PO every 4-6 hours as needed (Schedule II) 1
Alternative Opioid Combinations
- Oxycodone/acetaminophen: 5-15 mg/325 mg PO every 4-6 hours as needed (Schedule II) if the allergy is to hydrocodone specifically 1
- Codeine/acetaminophen: 30-60 mg/325 mg PO every 4-6 hours as needed (Schedule III) if the allergy is to hydrocodone specifically 1
- Tramadol: 50-100 mg PO every 4-6 hours as needed (up to 400 mg daily) 1
Decision Algorithm Based on Pain Severity
For Mild Pain (1-4 on a 10-point scale):
- Start with non-opioid analgesics (NSAIDs or acetaminophen alone) 1
- Add non-pharmacologic approaches (ice, heat, elevation) 1
For Moderate Pain (5-7 on a 10-point scale):
- Consider codeine/acetaminophen or tramadol if not allergic to these components 1
- Consider low-dose pure opioids (morphine, oxycodone) if non-opioid options are ineffective 1
For Severe Pain (8-10 on a 10-point scale):
- Pure opioids without acetaminophen (morphine, oxycodone, hydromorphone) 1
- Consider oxycodone/acetaminophen if the allergy is specifically to hydrocodone 1
Important Considerations
- Determine the specific component causing the allergy: If the allergy is to hydrocodone specifically, acetaminophen-containing products may still be used; if allergic to acetaminophen, pure opioids or opioid/NSAID combinations may be appropriate 1, 2
- Prescribe the lowest effective dose for the shortest duration to minimize risks of dependence, tolerance, and side effects 1
- Immediate-release formulations should be used initially to establish effective dosing before considering extended-release formulations 1
- Avoid prescribing opioids on a scheduled basis; instead, prescribe as needed (e.g., "one tablet not more frequently than every 4 hours as needed for moderate to severe pain") 1, 2
- Monitor for side effects common to all opioids, including constipation, nausea, sedation, and respiratory depression 1
Evidence Comparison
- Studies comparing oxycodone/acetaminophen with hydrocodone/ibuprofen have shown similar efficacy in treating acute low back pain 3
- Comparison studies between codeine/acetaminophen and hydrocodone/acetaminophen for cancer pain showed comparable efficacy and tolerability profiles 4
- Two-tablet doses of hydrocodone/ibuprofen have shown greater efficacy than codeine/acetaminophen in some chronic pain studies, suggesting alternative combination products may be effective 5
Cautions and Contraindications
- NSAIDs should be used with caution in patients with renal impairment, cardiovascular disease, or history of gastrointestinal bleeding 1, 6
- Codeine may be less effective in patients with CYP2D6 polymorphism (more common among Asians) 1
- Tramadol has limitations in dose titration related to neurotoxicity and potential drug interactions 1
- Methadone should only be prescribed by clinicians experienced with its use due to its complex pharmacokinetics 1