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

Norco Dosage for Pain Management

For acute pain, start with Norco 5 mg/325 mg, one to two tablets every 4-6 hours as needed (not scheduled), with a maximum of 8 tablets daily, using the lowest effective dose for the shortest duration. 1, 2

Standard Dosing by Formulation Strength

Norco 5 mg/325 mg:

• Initial dose: 1-2 tablets every 4-6 hours as needed
• Maximum: 8 tablets per day (40 mg hydrocodone/2,600 mg acetaminophen)
• This is the preferred starting strength for opioid-naïve patients 1, 2

Norco 7.5 mg/325 mg:

• Initial dose: 1 tablet every 4-6 hours as needed
• Maximum: 6 tablets per day (45 mg hydrocodone/1,950 mg acetaminophen) 2

Norco 10 mg/325 mg:

• Initial dose: 1 tablet every 4-6 hours as needed
• Maximum: 6 tablets per day (60 mg hydrocodone/1,950 mg acetaminophen)
• At maximum dosing, this equals 60 morphine milligram equivalents (MME), approaching the 50 MME/day threshold requiring heightened monitoring 3, 4

Critical Dosing Principles

Prescribe "as needed" rather than scheduled:

• Patients should take Norco only when pain is moderate to severe, not around-the-clock
• This minimizes opioid exposure and reduces risk of dependence 1, 3

Acetaminophen safety ceiling:

• Total daily acetaminophen from ALL sources (including over-the-counter products) must not exceed 4,000 mg to prevent hepatotoxicity
• When calculating total exposure, account for any other acetaminophen-containing medications the patient may be taking 1, 3, 2

Morphine milligram equivalent (MME) monitoring:

• Hydrocodone has a 1.0 conversion factor (1 mg hydrocodone = 1 MME)
• Dosages ≥50 MME/day require careful reassessment of benefits versus risks
• Dosages ≥90 MME/day show progressively diminishing returns in pain relief with escalating overdose risk 4

Special Population Adjustments

Elderly patients (≥65 years):

• Start with lower doses (e.g., 1 tablet of 5 mg/325 mg every 4-6 hours)
• Use slower titration due to smaller therapeutic window between effective analgesia and respiratory depression 1, 3

Hepatic or renal impairment:

• Reduce starting dose and frequency
• Both hydrocodone and acetaminophen clearance are affected by organ dysfunction 1

Appropriate Clinical Context

When Norco is appropriate:

• Severe traumatic injuries
• Invasive surgeries with moderate-to-severe postoperative pain
• Severe acute pain when NSAIDs are contraindicated or ineffective 1, 3

When nonopioid alternatives should be used first:

• Low back pain, neck pain, musculoskeletal injuries, minor surgeries, dental pain, kidney stone pain, and headaches respond equally well or better to nonopioid therapies
• NSAIDs (ibuprofen, naproxen) are superior to codeine-acetaminophen combinations and comparable to opioid-acetaminophen combinations for many acute pain conditions 4, 5
• A recent randomized trial found no clinically important difference between ibuprofen/acetaminophen and oxycodone/acetaminophen for acute extremity pain in the emergency department 5

Duration of Therapy

Typical acute pain duration:

• Prescribe only for the expected duration of pain severe enough to require opioids, typically 3-7 days
• Avoid prescribing more than necessary to prevent leftover pills that contribute to diversion 1, 3

Tapering requirements:

• If Norco is taken around-the-clock for more than a few days, implement a gradual taper (reducing by 10-25% of current dose) to minimize withdrawal symptoms
• Abrupt discontinuation in physically dependent patients can cause serious withdrawal, uncontrolled pain, and dangerous drug-seeking behavior 1, 2

Monitoring and Safety Measures

Before prescribing:

• Check the prescription drug monitoring program (PDMP) to identify patients at risk for opioid misuse or dangerous drug combinations 3

During therapy:

• Monitor closely for respiratory depression, especially within the first 24-72 hours and after any dosage increase 2
• Consider prescribing naloxone for overdose reversal if risk factors are present 6
• Prescribe prophylactic laxatives to prevent opioid-induced constipation 4

Dose escalation caution:

• Before increasing total opioid dosage to ≥50 MME/day, pause and carefully reassess individual benefits and risks
• If increasing dosage, use the smallest practical increment 4

Common Pitfalls to Avoid

Do not use Norco as first-line therapy when nonopioid alternatives (NSAIDs, acetaminophen alone) may be effective—opioids should be reserved for pain unresponsive to other treatments 1, 3

Do not prescribe on a scheduled basis (e.g., "take every 4 hours") rather than as-needed, as this unnecessarily increases opioid exposure and dependence risk 1, 3

Do not fail to account for total acetaminophen intake from all sources, including over-the-counter products, which can lead to inadvertent hepatotoxicity 1, 3

Do not continue prescribing without reassessment—if pain increases after dosage stabilization, identify the source of increased pain before escalating the Norco dose 2