What is the recommended dosing for Norco (hydrocodone and acetaminophen) for pain management?

Norco Dosing for Pain Management

For acute moderate to severe pain, start with Norco 5/325 mg (hydrocodone 5 mg/acetaminophen 325 mg) one to two tablets every 4-6 hours as needed, not exceeding 8 tablets daily, or use the 7.5/325 mg or 10/325 mg formulations with maximum 6 tablets daily. 1

Standard Dosing Regimens

Initial Dosing by Formulation Strength

• Norco 5/325 mg: One to two tablets every 4-6 hours as needed; maximum 8 tablets per day 1
• Norco 7.5/325 mg: One tablet every 4-6 hours as needed; maximum 6 tablets per day 1
• Norco 10/325 mg: One tablet every 4-6 hours as needed; maximum 6 tablets per day 1

Critical Acetaminophen Safety Limit

Never exceed 4000 mg of acetaminophen per day from all sources combined to prevent hepatotoxicity. 2, 3 In patients with liver disease or chronic alcohol use, consider limiting acetaminophen to 2000-3000 mg daily. 3

Clinical Context and Comparative Efficacy

Position in Pain Management Hierarchy

Hydrocodone/acetaminophen combinations are classified as WHO Level II analgesics for moderate pain. 2 They should be considered after non-opioid analgesics (acetaminophen alone or NSAIDs) have proven inadequate. 2, 3

NSAIDs are superior to codeine/acetaminophen combinations for mild-moderate acute pain (NNT 2.7 for naproxen vs 4.4 for codeine/acetaminophen), and this principle extends to hydrocodone combinations as first-line therapy. 2

Comparative Opioid Efficacy

Research shows minimal clinically significant differences between hydrocodone/acetaminophen and oxycodone/acetaminophen at equivalent doses:

• Acute extremity pain: No statistically or clinically significant difference between hydrocodone/acetaminophen 5/300 mg and oxycodone/acetaminophen 5/325 mg (both reduced pain by approximately 50% at 2 hours) 4, 5
• Chronic pain: Hydrocodone 7.5 mg/ibuprofen 200 mg (2 tablets) was more effective than codeine 30 mg/acetaminophen 300 mg (2 tablets), but single-tablet doses were equivalent 6
• Cancer pain: Codeine/acetaminophen and hydrocodone/acetaminophen showed comparable efficacy and tolerability over 23 days 7

Dosing for Specific Clinical Scenarios

Acute Pain Management

• Start conservatively: Use lowest effective dose for shortest duration (typically 1 week maximum for acute pain) 3
• Monitor closely: Assess for respiratory depression within first 24-72 hours, especially after dose increases 1
• Breakthrough dosing: If using scheduled extended-release opioids, rescue doses should be 10-20% of total 24-hour oral dose 2

Chronic Pain Considerations

Norco is intended for short-term use; long-term therapy with immediate-release hydrocodone/acetaminophen is problematic. 8 If chronic opioid therapy is necessary:

• Consider conversion to extended-release formulations after stabilization 2, 1
• Implement opioid treatment agreements and monitoring (urine drug testing, prescription monitoring programs) 3
• Regularly reassess need for continued therapy 3

Dose Titration

Titrate upward only if pain remains uncontrolled at peak effect or end of dosing interval. 2 If patients require more than 4 breakthrough doses daily, increase the baseline scheduled dose rather than continuing frequent as-needed dosing. 2

High-Risk Populations Requiring Dose Adjustment

Hepatic Impairment

• Reduce acetaminophen component or avoid entirely in severe liver disease 3
• Monitor liver function tests if chronic use is necessary 2

Renal Impairment

• Use lower starting doses and careful titration 3
• Avoid in severe renal failure due to risk of metabolite accumulation 2

Elderly Patients

• Start with lower doses and titrate slowly 3
• Increased risk of respiratory depression and cognitive effects

Opioid-Naive Patients

• Begin with single-tablet doses of lower strengths (5/325 mg) 1
• Assess response before increasing dose or frequency

Critical Safety Warnings

Absolute Contraindications to Dose Escalation

• Do not abruptly discontinue in physically dependent patients; taper gradually to avoid withdrawal 1
• Do not combine with mixed agonist-antagonists (e.g., pentazocine, nalbuphine, butorphanol) as this may precipitate withdrawal 2
• Do not use extended-release formulations for acute pain management 3

Common Prescribing Errors to Avoid

• Exceeding acetaminophen limits: Approximately 15% of patients prescribed hydrocodone/acetaminophen receive total daily acetaminophen exceeding 4 grams 8
• Inappropriate long-term use: Only 1.7% of patients should continue beyond 90 days, yet large numbers receive chronic therapy 8
• Inadequate monitoring: Screen all patients for opioid misuse risk before prescribing 3

Monitoring Requirements

• Baseline assessment of pain severity, liver function, and substance use history 2
• Reassess pain control and adverse effects at each follow-up 1
• For chronic use: liver function tests every 3 months 2

Conversion from Norco to Other Opioids

When converting to extended-release formulations or other opioids:

• Calculate total 24-hour hydrocodone dose from current Norco use 2
• Reduce equianalgesic dose by 25-50% to account for incomplete cross-tolerance 2
• Monitor closely during conversion period for inadequate analgesia or excessive sedation 1