Norco Dosing and Management for Pain
Recommended Dosing Regimen
Prescribe Norco as-needed (not scheduled) at the lowest effective dose, with a maximum of 6 tablets daily for the 10mg/325mg formulation, limiting treatment to 3-7 days for acute pain. 1, 2
Standard Dosing by Formulation
- Norco 5mg/325mg: 1-2 tablets every 4-6 hours as needed; maximum 8 tablets daily 2
- Norco 7.5mg/325mg: 1 tablet every 4-6 hours as needed; maximum 6 tablets daily 2
- Norco 10mg/325mg: 1 tablet every 4-6 hours as needed; maximum 6 tablets daily 2
Critical Safety Thresholds
- Acetaminophen limit: Total daily acetaminophen from all sources must not exceed 4,000mg to prevent hepatotoxicity 1
- MME threshold: At maximum dosing (60mg hydrocodone daily = 60 MME), you approach the 50 MME/day threshold that requires heightened monitoring and careful reassessment 3, 1
- Dose escalation caution: Before increasing total opioid dosage to ≥50 MME/day, pause and carefully reassess individual benefits and risks, as many patients do not experience benefit in pain or function beyond this threshold 3
Clinical Context for Prescribing
Only prescribe Norco when nonopioid therapies (acetaminophen, NSAIDs) have failed or are contraindicated. 1
Appropriate Indications
- Severe traumatic injuries 1
- Invasive surgeries with moderate-to-severe postoperative pain 1
- Severe acute pain when NSAIDs are contraindicated 1
Duration of Therapy
- Acute pain: Prescribe only for expected duration of severe pain, typically 3-7 days 1
- Avoid scheduled dosing: Use as-needed dosing rather than around-the-clock administration 1
Special Population Adjustments
- Elderly patients (≥65 years): Require dose reduction; start with lower end of dosing range 1
- Hepatic impairment: Reduce acetaminophen dose due to hepatotoxicity risk 1
- Renal impairment: Reduce dose due to altered hydrocodone clearance 1
Mandatory Monitoring Requirements
Before Prescribing
- Check PDMP: Review prescription drug monitoring program to identify patients at risk for opioid misuse or dangerous drug combinations 1
- Assess risk factors: Evaluate for addiction, abuse, and misuse potential 2
During Treatment
- Respiratory monitoring: Follow patients closely for respiratory depression, especially within first 24-72 hours of initiating therapy and following dosage increases 2
- Pain reassessment: Continually reevaluate to assess maintenance of pain control and relative incidence of adverse reactions 2
Conversion Considerations
When converting from other opioids to Norco, use the MME conversion factor of 1.0 for hydrocodone 3:
- Conservative approach: It is safer to underestimate a patient's 24-hour dosage than to overestimate and manage an overdose 2
- Close observation: Conversion requires monitoring for signs of excessive sedation and respiratory depression 2
Discontinuation Strategy
Never abruptly discontinue Norco in patients who may be physically dependent on opioids. 2
- Rapid discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide 2
- Taper gradually to avoid withdrawal and prevent patients from seeking illicit opioids 2
Common Pitfalls to Avoid
- Do not use as first-line therapy when nonopioid alternatives may be effective 1
- Do not prescribe scheduled dosing rather than as-needed 1
- Do not exceed acetaminophen limits when patients are taking other acetaminophen-containing products 1
- Do not combine with alcohol or benzodiazepines due to risk of severe drowsiness, respiratory depression, coma, and death 2
- Do not give to patients with: severe asthma, bowel obstruction, or known hypersensitivity to hydrocodone or acetaminophen 2
Expected Adverse Effects
Most common side effects include constipation, nausea, sleepiness, vomiting, tiredness, headache, dizziness, and abdominal pain 2. Central nervous system side effects are less common with hydrocodone than with codeine 4.