What is the recommended starting dose of Norco (hydrocodone and acetaminophen) for pain management?

Recommended Starting Dose of Norco (Hydrocodone/Acetaminophen) for Pain Management

The recommended starting dose of Norco for pain management is hydrocodone 5 mg/acetaminophen 325 mg, one tablet every 4-6 hours as needed for pain, with a maximum daily limit of 8 tablets. 1, 2

Initial Dosing Recommendations

• For opioid-naïve patients, start with hydrocodone 5 mg/acetaminophen 325 mg, one tablet every 4-6 hours as needed for moderate to severe pain 2, 1
• Prescribe on an "as needed" basis rather than on a scheduled basis (e.g., one tablet not more frequently than every 4 hours as needed for moderate to severe pain) 2, 3
• The total daily dosage should not exceed 8 tablets of the 5 mg/325 mg formulation 1
• For higher strength formulations (7.5 mg/325 mg or 10 mg/325 mg), the maximum daily dosage should not exceed 6 tablets 1

Appropriate Clinical Context for Norco Use

• Norco should not be used as first-line therapy for many common acute pain conditions 2

• Nonopioid therapies (NSAIDs, acetaminophen) are at least as effective as opioids for many common acute pain conditions, including:

  • Low back pain
  • Neck pain
  • Musculoskeletal injuries (sprains, strains, tendonitis)
  • Minor surgeries with minimal tissue injury
  • Dental pain
  • Kidney stone pain
  • Headaches 2

• Norco has an appropriate role for acute pain related to:

  • Severe traumatic injuries (including crush injuries and burns)
  • Invasive surgeries with moderate to severe postoperative pain
  • Other severe acute pain when NSAIDs and other therapies are contraindicated or likely ineffective 2

Dosing Considerations and Precautions

• Use the lowest effective dose for the shortest duration consistent with treatment goals 1
• Consider patient-specific factors when determining initial dose:
  • Severity of pain
  • Patient response
  • Prior analgesic experience
  • Risk factors for addiction, abuse, and misuse 1
• Monitor patients closely for respiratory depression, especially within the first 24-72 hours 1
• Calculate the morphine milligram equivalent (MME) dose when prescribing:
  • Hydrocodone has a conversion factor of 1.0 (5 mg hydrocodone = 5 MME) 2
  • Exercise caution when approaching or exceeding 50 MME/day 2

Acetaminophen Safety Considerations

• The maximum daily acetaminophen dose from all sources should not exceed 4 grams to avoid hepatotoxicity 3
• Be aware that approximately 15% of patients taking hydrocodone/acetaminophen have been found to exceed the FDA-recommended maximum daily limit of acetaminophen 4
• Consider all sources of acetaminophen when prescribing, including over-the-counter medications 3

Duration of Therapy

• Prescribe only for the expected duration of pain severe enough to require opioids 2
• If Norco is taken around the clock for more than a few days, implement a taper to minimize withdrawal symptoms 2, 3
• Avoid abrupt discontinuation in patients who may be physically dependent 1

Special Populations

• For elderly patients or those with hepatic or renal impairment:
  • Start with lower doses
  • Use careful titration
  • Monitor more frequently for adverse effects 3
• For patients with renal impairment, use reduced doses and frequency 3

Common Pitfalls to Avoid

• Prescribing Norco as first-line therapy when nonopioid alternatives may be effective 2, 3
• Using scheduled dosing rather than as-needed dosing 2, 3
• Failing to taper Norco if used around the clock for more than a few days 2, 3
• Exceeding the maximum daily acetaminophen limit of 4 grams 3
• Prescribing long-term therapy without appropriate monitoring and reassessment 4

Comparative Efficacy

• Recent evidence suggests that the combination of ibuprofen and acetaminophen may provide similar pain relief to opioid/acetaminophen combinations for acute extremity pain 5
• When opioids are necessary, hydrocodone/acetaminophen has shown comparable efficacy to codeine/acetaminophen for chronic pain management 6