Postoperative Norco Management in Patients on Chronic Subutex
Continue the patient's chronic Subutex (buprenorphine) at their preoperative dose and add Norco (hydrocodone) at higher-than-typical doses for breakthrough pain, while maximizing non-opioid multimodal analgesia. 1
Core Management Strategy
Continue buprenorphine throughout the perioperative period rather than discontinuing it, as stopping buprenorphine risks withdrawal, increased pain sensitivity, and relapse in patients with opioid use disorder. 1, 2, 3
Why This Approach Works
- Buprenorphine does not completely block full mu-opioid agonists like hydrocodone at clinically relevant doses; they can work synergistically rather than antagonistically. 2, 3
- Continuing buprenorphine provides a protective effect against respiratory depression while maintaining stability of the underlying condition (whether chronic pain or opioid use disorder). 1
- Discontinuation destabilizes pre-existing treatment and increases relapse risk without improving pain control. 1
Specific Dosing Approach for Norco
Expect to use 2-4 times the typical hydrocodone dose to achieve adequate analgesia due to competitive receptor dynamics with buprenorphine. 3
Practical Implementation
- Start with standard Norco dosing but anticipate the need for more frequent dosing intervals or higher doses. 1
- Consider dividing the patient's daily buprenorphine dose into every 6-8 hours rather than once daily to provide more consistent baseline analgesia. 3
- Monitor pain scores closely and titrate hydrocodone upward as needed without hesitation. 1
Essential Multimodal Analgesia
Maximize non-opioid adjuncts as the cornerstone of treatment before escalating opioid doses. 1, 3
Specific Adjuncts to Use
- NSAIDs and acetaminophen: First-line agents that should be scheduled, not PRN. 1, 4
- Gabapentin or pregabalin: Effective for postoperative pain, though monitor for sedation. 1, 4
- Ketamine: Consider for moderate-to-severe pain scenarios. 1
- Regional anesthesia techniques: Use whenever anatomically feasible as they are highly effective in buprenorphine patients. 1, 3
Critical Monitoring Considerations
Implement enhanced monitoring when combining buprenorphine with full mu-opioid agonists like hydrocodone. 1
What to Monitor
- Respiratory status and sedation level more frequently than standard postoperative patients. 3, 5
- Watch for QT-interval prolongation if the patient is on other medications that affect cardiac conduction. 2, 5
- Assess for signs of withdrawal (which suggests inadequate buprenorphine dosing) or oversedation (which suggests excessive opioid dosing). 1
Discharge Planning
Discharge the patient on both their baseline buprenorphine dose AND a short course of full mu-opioid agonist (Norco) for breakthrough pain. 1
Specific Discharge Recommendations
- Continue the patient's home buprenorphine regimen unchanged. 1, 3
- Provide a limited supply of Norco (typically 3-7 days depending on surgery type) with clear tapering instructions. 1
- Coordinate with the patient's buprenorphine prescriber before discharge to ensure continuity of care. 3
- Consider longer admission or transitional pain service involvement for complex cases. 1
Common Pitfalls to Avoid
Do not discontinue buprenorphine thinking it will improve opioid analgesia—this is the most common and harmful error. 1, 2, 3
Other Critical Errors
- Assuming hydrocodone won't work: Full mu-opioid agonists remain effective; they just require higher doses. 1, 2
- Underdosing out of fear: Patients on buprenorphine have opioid tolerance and require aggressive pain management. 1
- Failing to inform the surgical team: All providers must know about buprenorphine use for coordinated care. 2, 3
- Using buprenorphine dose reduction as first-line: Only consider reducing buprenorphine if pain remains inadequate despite maximized adjuncts and full mu-opioid agonists. 1
Special Consideration for High-Dose Buprenorphine
For patients on >12 mg sublingual buprenorphine daily with anticipated high postoperative pain, some practitioners taper to 12 mg over 2-3 days before elective surgery, though current guidelines increasingly support maintaining the current dose. 2, 3